# NTSB ERA09FA060: Piper PA-38-112, N2316P, Smithfield, RI, November 17, 2008

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 17, 2008, 17:03 local (22:03 UTC)
- Place: Smithfield, RI
- Coordinates: 41.905555, -71.485557
- Nearby events: https://openairdocs.org/map.md?lat=41.9056&lon=-71.4856&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report November 9, 2009
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO, Piper Aircraft, Inc.
- NTSB case key (mKey): 69459
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09FA060
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69459/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69459
- Page: https://openairdocs.org/ntsb/ERA09FA060

## Probable cause

The pilot's improper descent below the published minimum descent altitude during the approach, which resulted in controlled flight into terrain.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7103812), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7103812), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot; cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=7103812), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md)
- [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot; cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=7103812), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md)
- [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7103812), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-IFR final approach: Altitude deviation](https://openairdocs.org/ntsb-events/282); cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-events/282/sequence.md?model=7103812), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md)
- [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-38-112, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103812), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)
- [Post-impact: Explosion (post-impact)](https://openairdocs.org/ntsb-events/180); cases with it: [Piper PA-38-112, 1 case](https://openairdocs.org/ntsb-events/180/sequence.md?model=7103812), [All aircraft, 47 cases](https://openairdocs.org/ntsb-events/180/sequence.md)

## Analysis

The airplane approached the airport in night visual meteorological conditions, with an instrument-rated private pilot and a private-pilot-rated passenger. The pilot received clearance for a practice very-high-omnidirectional-range/global-positioning-system approach. At 1,900 feet mean sea level (msl) and prior to the final approach fix (FAF), the pilot was cleared for the practice approach and a frequency change was approved. There was no further communication with the accident flight. Radar data showed the accident flight on a ground track associated with the approach and in a steady descent from the FAF to 500 feet msl, or 80 feet above ground level (agl) and near the first tree strike. The accident occurred approximately 2/3 mile from the threshold of runway 33. The airplane was on the correct ground track for the approach when it initially struck trees approximately 80 feet agl. The minimum descent altitude for the approach was 980 feet msl, or 539 feet agl. No evidence of any preimpact mechanical discrepancies were found with the airframe or engine that would have prevented a successful completion of the approach. Recorded weather conditions at the airport near the time of the accident included a broken cloud layer at 8,000 feet, surface visibility 10 statute miles, and a surface wind from the northwest at 6 knots.

## Factual narrative

HISTORY OF FLIGHT On November 17, 2008, about 1703 eastern standard time, a Piper PA-38, N2316P, was substantially damaged during a practice global positioning system (GPS) approach to North Central State Airport (SFZ), Pawtucket, Rhode Island. Night visual meteorological conditions prevailed, and no flight plan was filed. The certificated private pilot and his pilot rated passenger were killed. The flight originated from Theodore Francis Green State Airport (PVD), Providence, Rhode Island, at 1654. The personal flight was conducted under 14 Code of Federal Regulations Part 91. According to fuel receipts from a fixed based operator (FBO) located at PVD, the airplane was fueled with 12.3 gallons of aviation gasoline on the morning of the accident. According to Lockheed Martin flight service station records, the pilot telephoned the Raleigh, North Carolina, automated flight service station for a weather briefing at 1626 and requested an instrument flight rules (IFR) weather briefing for a one to one and one-half hour flight in order to practice instrument approaches and remain within approximately 15 nautical miles of PVD. At the time of the weather briefing he was unsure of which airports he was going to practice the approaches at. Radar contact was lost with the accident airplane about 1702. The last recorded radar target was about 2/3 of a mile south of SFZ, at 500 feet mean sea level (msl), approximately 80 feet above ground level (agl), and a ground speed of 82 knots. Starting at 1703:12 the Rhode Island Enhanced 9-1-1 Uniform Emergency Telephone System began receiving phone calls from the residence surrounding the accident sight. Most of the callers reported hearing a "loud explosion" and seeing a "ball of fire." PERSONNEL INFORMATION The pilot, age 43, held a private pilot certificate, with a rating for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on December 3, 2007. At that time, the pilot reported a total flight experience of 1,347 hours. Several of the pilot's logbooks were located and the last entry dated April 19, 2008 revealed that the pilot had accumulated 1404.7 total hours of flight experience and more than 800 hours of flight experience in the accident airplane. The pilot rated passenger, age 64, held a private pilot certificate, with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on October 8, 2008. At that time, the pilot reported a total flight experience of 244 hours. AIRCRAFT INFORMATION The two-seat, low-wing, fixed-gear airplane, serial number 38-79A0942, was manufactured in 1979 and was issued an airworthiness certificate on April 27, 1979. It was powered by a Lycoming O-235-L2C, 118-horsepower engine, equipped with a Sensenich propeller. The airplane’s most recent annual inspection was completed on January 10, 2008. The airplane was not equipped with a radar altimeter, ground proximity warningsystem, or a terrain awareness and warning system. On September 2, 2005 the airplane was equipped with a Garmin GNS Model 430 GPS/NAV/COM. METEOROLOGICAL INFORMATION The recorded weather at SFZ, at 1715, reported wind from 310 degrees at 7 knots; visibility 10 miles, an overcast cloud layer at 8,000 feet agl, temperature 5 degrees Celsius (C); dew point minus 7 degrees C; altimeter 29.93 inches of mercury. According to the United States Naval Observatory in Washington D.C. the official sunset was at 1623. AIDS TO NAVIAGATION Review of the approach plate for the very high omni-direction range (VOR)/GPS A approach indicated that the minimum altitude at the final approach fix (FAF) was 1,900 feet msl and the minimum decision altitude for the approach was 980 feet msl, or 539 feet agl. AIRPORT INFORMATION The airport has no air traffic control tower and has two crossing runways. The airport is served by five non-precision approaches. The longest runway is 5/23 which is a 5000-foot-long and 75-foot-wide. The crossing runway is 15/33 which is a 3,210-foot-long and 75-foot-wide. Both runways are equipped with pilot activated runway lights. Runway 5 is equipped with a four-light visual approach slope indicator, runways 15 and 23 are both equipped with a four-light precision approach path indicator system. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a widely scattered residential wooded area about 1715, approximately 3,431 feet from the runway 33 threshold. The wreckage was examined on November 18 and 19, and all major components of the airplane were accounted for at the scene. An approximate 250-foot debris path was observed, that originated with several tree strikes. The debris path extended on a course of approximately 358 degrees magnetic, and terminated at the main wreckage. Freshly broken tree branches were recovered along the debris path. They varied in diameter up to about 4 inches, and were broken at various angles. The outboard one-fourth of the right wing leading edge was located approximately 56 feet from the main wreckage. The main wreckage was resting inverted nose down, and oriented on a 290-degree heading with the tail section resting against a rock wall. The cockpit area was consumed by fire. The left wing was observed by the first responders on scene to be almost perpendicular to the ground. The airplane was equipped with a fixed landing gear, and the flaps were observed in the retracted position. The empennage, including vertical stabilizer and rudder, remained intact. The right side elevator was separated from the outboard pivot point but remained attached at the inboard pivot point. Flight control continuity was confirmed from the rudder, ailerons and elevator, to the cockpit area. The propeller assembly was separated from the engine and was located approximately one foot in front of the engine. One propeller blade exhibited no spanwise or chordwise bending. The other propeller blade exhibited spanwise bending andslight chordwise bending. Both propeller blades leading edge exhibited damage similar to impact damage. An airspeed indicator, altimeter, direction gyro, and engine monitor system were recovered, but sustained fire damage. The attitude indicator was recovered and disassembled. The gyro was found intact, and exhibited signs similar to rotational scoring. The engine was separated from the airframe for inspection. The throttle butterfly valve for the engine was found partially open in an almost idle throttle position. The valve covers and sparkplugs were removed from the engine the No. 2 cylinder exhaust rocker arm exhibited a crack similar to impact damage. The top and bottom sparkplug electrodes were intact, and light gray in color. The vacuum pump from the engine was removed and disassembled, and the vanes were intact. The oil filter and fuel screens were absent of debris, and oil was noted throughout the engine. Camshaft, crankshaft, and valve train continuity was established to the rear accessory sections, and thumb compression was attained on all cylinders. Both magnetos sustained thermal damage and could not be tested. MEDICAL AND PATHOLOGICAL INFORMATION The Rhode Island Office of State Medical Examiners performed an autopsy on the pilot on November 18, 2008. The reported cause of death was blunt impact injuries. Toxicological testing was performed post mortem at the FAA’s Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for carbon monoxide, cyanide, ethanol, and drugs, legal or illegal. ADDITIONAL INFORMATION The FAA ATC facility located at PVD provided visual flight rules (VFR) radar service to the accident. The accident pilot notified the facility of his request to practice several instrument approaches at SFZ. At 1641:48 the pilot contacts PVD clearance delivery and requests VFR advisories to "shoot practice approaches at North Central." At 1642:39 ATC clearance delivery issues the pilot a departure clearance, a transponder code, and then queries what approaches the pilot would like to practice. At 1643:15 the pilot states that he wanted the "…VOR/GPS Alpha and then GPS 23." The flight received takeoff clearance from the PVD air traffic control tower at 1652:23 with an initial heading of 020 degrees. At 1656:12 the accident flight requests the "GPS Alpha to North Central then a GPS 23 approach" with the radar controller. At 1657:11 and approximately 3 miles from the final approach fix, the flight was issued a VFR approach clearance and was instructed that there was no VFR traffic separation on final. At 1658:45 the flight was told that radar service was terminated and frequency change was approved. At 1659:09 the pilot acknowledged the previous instructions issued by ATC, this was also the last transmission heard from the accident flight. At 1659:22 the accident flight was in the vicinity of the final approach fix and was transmitting an altitude of 1,900 feet msl and a groundspeed of 84knots. At 1702:43 was the last radar return for the accident flight and displayed an altitude of 500 feet msl and an 82 knot ground speed. This altitude and groundspeed was displayed for the 12 seconds preceding the final radar return. Instrument Procedures Handbook, (FAA-H-8261-1A), Chapter 1, defines controlled flight into terrain (CFIT) as "an accident in which a fully qualified and certificated crew flies a properly working airplane into the ground, water, or obstacles with no apparent awareness by the pilots." In Chapter 4 it further states in part "…inappropriate descent planning and execution during arrivals has been a contributing factor to many fatal aircraft accidents…the basic causes of CFIT accidents involve poor flight crew situational awareness…the causes of CFIT are the flight crews’ lack of vertical position awareness or their lack of horizontal position awareness in relation to the ground, water, or an obstacle. More than two-thirds of all CFIT accidents are the result of an altitude error or lack of vertical situational awareness. CFIT accidents most often occur during reduced visibility associated with instrument meteorological conditions (IMC), darkness, or a combination of both." Pilot's Handbook of Aeronautical Knowledge, (FAA-H-8083-25), Chapter 16, and Aviation Instructor Handbook, (FAA-H-8083-9), Chapter 9, both define situational awareness as "the accurate perception of the operational and environmental factors that affect the airplane, pilot, and passengers during a specific period of time." It further states that "when situationally aware, the pilot has an overview of the total operation and is not fixated on one perceived significant factor…an awareness of the environmental conditions of the flight, such as spatial orientation of the airplane, and its relationship to terrain, traffic, weather, and airspace must be maintained." Instrument Flying Handbook, (FAA-H-8083-15A), Chapter 11, further defines situational awareness as "not simply a mental picture of aircraft location; rather, it is an overall assessment of each element of the environment and how it affects a flight." The Airplane Flying Handbook (FAA-H-8083-3A); Chapter 10, states in part that when flying at night and "…when flying over terrain with only a few lights, it will make the runway recede or appear farther away. With this situation, the tendency is common to fly a lower-than-normal approach." It further states in part that "…careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed."

## Aircraft

- Registration: [N2316P](https://openairdocs.org/deregistered/N2316P-2010-07-28), registration cancelled 2010-07-28, S/N 38-79A0942, built 1979 (OpenAirDocs)
- Reported make and model: PIPER PA-38-112
- Registry model: [Piper PA-38-112](https://openairdocs.org/model/piper-pa-38-112) (registry code 7103812) (OpenAirDocs)
- Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs)
- Category: Airplane
- Serial number: 38-79A0942
- Engines: Lycoming O-235-L2C 112 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, January 10, 2008
- Departed: PVD, Providence, RI
- Destination: SFZ, Smithfield, RI
- Airport: SFZ, North Central State, runway 33, 3,210 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 43; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 1,405 total

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 310° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: 8,000 ft overcast
- Temperature: 39 °F, dew point 21 °F
- Altimeter: 29.93 inHg
- Observed at: SFZ, 1 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20081117850849A](https://openairdocs.org/incident/20081117850849A), Nov 17, 2008: Piper PA38112, Smithfield, RI, Destroyed, 2 fatal. (-23) On 17 November 2008 at 2153:30Z the accident departed t.f. green state airport (pvd) on a local flight to conduct practice instrument approaches at north…

## Docket (17 files)

The files NTSB released with the investigation on June 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69459. 7.6 MB in all.

- Maps or Charts of Accident Area, Wreckage Diagrams (item 1, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313881&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF
- North Central State Airport Weather (item 2, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313482&FileExtension=.PDF&FileName=North%20Central%20State%20Airport%20Weather-Master.PDF
- Lockheed Martin Weather and NOTAMs (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313859&FileExtension=.PDF&FileName=Lockheed%20Martin%20Weather%20and%20NOTAMs-Master.PDF
- Flight Service Station Transcript (item 4, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313857&FileExtension=.PDF&FileName=Flight%20Service%20Station%20Transcript-Redacted.PDF
- Providence Air Traffic Control Communications and Radar Files (item 5, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313869&FileExtension=.PDF&FileName=Providence%20Air%20Traffic%20Control%20Communications%20and%20Radar%20Files-Master.PDF
- ATC Transcript (Partial) (item 6, .PDF, 409 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314205&FileExtension=.PDF&FileName=ATC%20Transcript%20(Partial)-Redacted.PDF
- Fire Department Run Report (item 7, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313485&FileExtension=.PDF&FileName=Fire%20Department%20Run%20Report-Redacted.PDF
- Smithfield Police Report (item 8, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313486&FileExtension=.PDF&FileName=Smithfield%20Police%20Report-Redacted.PDF
- 911 Transcript (item 9, .PDF, 403 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314291&FileExtension=.PDF&FileName=911%20Transcript-Redacted.PDF
- Airplane Annual Inspection (item 10, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313478&FileExtension=.PDF&FileName=Airplane%20Annual%20Inspection-Redacted.PDF
- Pilot record of Maintenance Summary (item 11, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313479&FileExtension=.PDF&FileName=Pilot%20record%20of%20Maintenance%20Summary-Redacted.PDF
- Fuel receipt (item 12, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313480&FileExtension=.PDF&FileName=Fuel%20receipt-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313483&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- GPS installation paperwork (item 14, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313481&FileExtension=.PDF&FileName=GPS%20installation%20paperwork-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313487&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Toxicological Report (item 16, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313856&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF
- Photo 1: Airplane At Rest (item 17, .PDF, 904 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313865&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20At%20Rest-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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