ERA09FA116

NTSB accident investigation · Piper PA-28-140 · Pittstown, NJ · December 31, 2008

Accident · FatalField investigationFinal report
Date
December 30, 2008, 19:00 local (Dec 31, 2008, 00:00 UTC)
Place
Pittstown, NJ
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N95156Piper PA-28-140
Defining event
Approach-VFR pattern final: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night
Status
Completed · report March 23, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Piper, Lycoming, FAA/FSDO
FAA report
20081230853609A
Case key
73167

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's failure to maintain an adequate clearance from trees during the night landing approach and the flight instructor's inadequate remedial action.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-140: 9 casesAll aircraft: 809 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-140: 103 casesAll aircraft: 9,295 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-28-140: 8 casesAll aircraft: 792 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on operationPiper PA-28-140: 13 casesAll aircraft: 448 cases
Object/animal/substance: tree(s)Environmental issues › Physical environment · Effect on operationPiper PA-28-140: 9 casesAll aircraft: 933 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot and the flight instructor were performing a training flight toward the pilot's instrument rating and the pilot was attempting to regain night currency. After 15 minutes of flying, the pilot returned to the departure airport, which was also where the flight instructor was based. The pilot flew a practice instrument approach before entering the downwind leg of the traffic pattern for landing and recalled being about 100 feet below the published traffic pattern altitude. Though the pilot could only recall turning onto the base leg of the traffic pattern, the airplane struck trees aligned with the final approach course about 1/4 mile from the runway threshold. The trees in the vicinity of the accident site are about 150 feet tall. Examination of the airframe and engine revealed no evidence of any mechanical deficiencies, nor were any reported by the pilot.

Factual narrative

HISTORY OF FLIGHT On December 30, 2008, about 1900 eastern standard time, a Piper PA-28-140, N95156, was substantially damaged when it impacted trees and terrain while on final approach to Alexandria Airport (N85), Pittstown, Pennsylvania. The certificated private pilot/owner was seriously injured and the certificated flight instructor was fatally injured. Night visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight, which was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. During an interview, and in a written statement, the pilot stated that on the day of the accident he contacted the fixed base operator at N85 to schedule a flight with a flight instructor for the purpose of training toward an instrument rating, and for the pilot to regain his night flying currency. After departing on the accident flight, the pilot and the flight instructor flew to the west for about 15 minutes, and after it was legally night, they returned to the airport by flying a practice instrument approach to runway 8. The pilot entered the left downwind leg of the traffic pattern to land on runway 26. The pilot thought the airplane was a "little fast" at 100 knots, and that the airplane may have been about 100 feet below the published traffic pattern altitude. The pilot turned from the downwind leg to the base leg of the traffic pattern, and recalled that at some point the airplane began striking trees. The pilot could not recall any other events that transpired after that point. The pilot additionally stated that the airplane was operating "fine" during the flight, and he did not note any abnormalities. METEOROLOGICAL INFORMATION The 1854 reported weather at Doylestown Airport (DYL), Doylestown, Pennsylvania, located about 16 nautical miles south of the accident site, included clear skies, 10 statute miles visibility, winds from 250 degrees at 3 knots, temperature 2 degrees Celsius (C), dewpoint -11 degrees C, and an altimeter setting of 29.95 inches of mercury. According to the U.S. Naval Observatory, sunset occurred at 1644, and the end of civil twilight occurred at 1714. Moonset occurred at 1950, and 9 percent of the moon's visible disc was illuminated. PERSONNEL INFORMATION The pilot, age 56, held a private pilot certificate with a rating for airplane single engine land. He reported 643 total hours of flight experience, 413 hours of which were in the accident airplane make and model. He also reported 15 total hours of flight experience at night. His most recent FAA third-class medical certificate was issued on August 25, 2008. The flight instructor, age 63, held numerous certificates and ratings including an airline transport pilot certificate and a flight instructor certificate. The flight instructor possessed about 19,500 total hours of flight experience, about 6,300 of which were logged at night. The flight instructor had most recently logged 3 takeoffs and landings on the nightprior to the accident flight, at the accident airport. His most recent FAA second-class medical certificate was issued on July 3, 2008. AIRPORT INFORMATION Alexandria airport was comprised of two intersecting runways, oriented 8/26 and 13/31. Runway 8/26 was 2,550-feet-long by 50-feet-wide, and sloped 0.7-percent upward to the east. The FAA Airport Facility Directory listed that a two-light precision approach path indicator (PAPI) was installed on the left side of runway 26, which had a 4.5-degree glide slope. According to the co-owner of N85, the PAPI for runway 26 ceased functioning around the spring of 2007. At that time the airport decided not to replace the light bulbs in the system since trees off the approach end of runway 26 penetrated the approach path produced by the indicator. A review of FAA notice to airman (NOTAM) information revealed that no notices pertaining to runway 26 were issued for the date of the accident. On January 12, 2009, a NOTAM was issued stating that the runway 26 PAPI was out of service. According to the FAA Airport Master Record for N85, 63-foot tall trees were located 351 feet prior to, and 78 feet left of, the runway 26 approach end. The obstruction clearance slope was 2:1. The FAA Airport Facility Directory only listed that there were trees present at both departure ends of the runway. About 1 year prior to the accident, the State of New Jersey Department of Transportation conducted a survey of the trees in the vicinity of the accident site, located 1/4-mile from the end of runway 26, and in the vicinity of the extended runway centerline. The survey showed several trees that were over 150 feet tall. WRECKAGE AND IMPACT INFORMATION The airplane came to rest about 1/4-mile east of the approach end of runway 26 at N85. The fuselage came to rest inverted, and both wings were separated from their respective wing roots. The wreckage was subsequently recovered from the scene, and examined at a wreckage recovery facility on January 21, 2009. The outer wing panel of the left wing was separated from the inboard portion of the wing, and the left flap remained attached at the inboard hinge. The left fuel tank was crushed aft to the spar. The outboard portion of the right wing was separated from the inboard portion of the wing about 3 feet outboard of the right main landing gear. The outboard portion of the right wing exhibited a concave depression about 10 inches in diameter near the right wing tip. The empennage remained attached to the aft portion of the fuselage, with the vertical stabilizer and stabilator exhibiting relatively minor damage. Control cable continuity was traced from the cockpit area, through several overload-type separations to the ailerons, stabilator, and rudder control surfaces. The engine exhibited impact damage, and the propeller mounting flange on the engine crankshaft was bent. One of the two propeller blades exhibited leading edge gouging and chordwise scratching, while the other blade was bentslightly forward. The crankshaft was rotated, and compression was noted on all cylinders. The top four spark plugs were removed, with no anomalies noted. Rotation of both magneto driveshafts produced spark at each magneto terminal lead. The oil suction and oil filter elements were absent of debris or metal. Several small twigs were found lodged in the engine intake air filter. The carburetor screen was absent of debris, and the floats were intact. No mechanical abnormalities were noted during the examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the flight instructor by the Office of the Medical Examiner, Hunterdon County, New Jersey. The autopsy report noted the cause of death as "…injuries due to impact." The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the flight instructor. No traces of carbon monoxide, cyanide, or ethanol were detected. The drug Tamsulosin was detected in blood and urine. Review of the flight instructor's most recent application for an FAA second class medical certificate, dated July 3, 2008, noted the use of the prescription medication Flomax (a trade name for the prescription drug Tamsulosin). ADDITIONAL INFORMATION According to the FAA Airplane Flying Handbook (FAA-H-8083-3A), Chapter 10 - Night Operations, "In addition to night vision limitations, pilots should be aware that night illusions could cause confusion and concerns during night flying." The handbook went on to state, "A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orienting themselves relative to Earth. The runway can seem out of position (downsloping or upsloping) and in the worst case, results in landing short of the runway. If an electronic glide slope or visual approach slope indicator (VASI) is available, it should be used. If navigation aids (NAVAIDs) are unavailable, 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
N95156
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-25826
Airframe hours
2,524
Engine
Lycoming O-320 SERIES, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 21, 2008
Departed
N85 · Pittstown, NJ
Destination
N85 · Pittstown, NJ
Airport
N85 · Alexandria Airport, runway 26, 2,550 × 60 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
December 2, 2008
Seat
Left
Flight hours
643 total · 413 in this make and model · 503 as pilot in command · 5 in the last 90 days · 3 in the last 30 days · 1 in the last 24 hours
Role
Flight instructor
Age
63
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 1, 2007
Seat
Right
Toxicology
Performed
Flight hours
23,000 total

Weather

Conditions
Visual (VMC) · Night
Wind
250° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
36 °F, dew point 12 °F
Altimeter
29.95 inHg
Observed at
DYL, 16 nm away

Docket · 12

The files NTSB released with the investigation on December 30, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.