# NTSB ERA18FA148: Piper PA34, N1101X, Bennington, VT, May 20, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 20, 2018, 14:23 local (18:23 UTC) - Place: Bennington, VT - Coordinates: 42.923889, -73.139167 - Nearby events: https://openairdocs.org/map.md?lat=42.9239&lon=-73.1392&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper Aircraft, FAA/FSDO, Continental Motors - NTSB case key (mKey): 97285 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18FA148 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97285/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97285 - Page: https://openairdocs.org/ntsb/ERA18FA148 ## Probable cause The pilot's improper decision to attempt a visual flight rules flight in instrument meteorological conditions, which resulted in a loss of control during a turn. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-34-200T, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7103406), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-34-200T, 5 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7103406), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-34-200T, 2 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=7103406), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Piper PA-34-200T, 2 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=7103406), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-34-200T, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103406), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-34-200T, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103406), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis After receiving commercial and flight instructor certificates with a designated pilot examiner (DPE), the instrument-rated commercial pilot planned to fly back to his home airport the following day. The DPE reviewed weather with the pilot and advised him to delay the flight 2 days due to poor weather; however, the following day, the pilot attempted the visual flight rules flight in instrument meteorological conditions with mountain obscuration. Before departing on the flight, the pilot received three weather briefings and all three contained information regarding instrument flight rules conditions with mountain obscuration. The pilot was receiving flight following services from air traffic control, while proceeding southeast, in clouds, below the minimum vectoring altitude, near mountainous terrain. The controller suggested a westbound turn for lower terrain and continued radar coverage. The airplane briefly turned to a westbound heading, then turned back to a southeast heading. About 4 miles later, the controller again advised the pilot that, if he continued on the present heading, radar coverage would be lost. The pilot asked again what heading he should fly and the controller responded westbound, to which the pilot responded, "westbound heading 270." Radar and radio contact were lost during the second westbound turn. The last radar target indicated an altitude of 3,500 ft msl and groundspeed of 218 knots about 1,000 ft from the accident site, which was located at an elevation about 2,625 ft msl. Examination of the accident site revealed a 60-ft debris path on a 265° course through trees, consistent with a 45° nose-down attitude at impact. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The pilot had entered clouds and was trying to fly clear of clouds. The conditions were conducive to the development of spatial disorientation; however, the extent to which spatial disorientation played a role could not be determined as the descent could have also been the result of an uncoordinated turn or distraction. ## Factual narrative The six-seat, low-wing, retractable tricycle-gear airplane was manufactured in 1975. It was powered by one Continental TSIO-360-EB and one Continental LTSIO-360-EB (counter rotating) engine, both of which were 215 horsepower and equipped with constant-speed, two-blade Hartzell propellers. The airplane's maintenance logbooks were not located and presumed destroyed in the accident. According to an airplane status sheet completed on May 19, the airplane's most recent annual inspection was completed on September 30, 2017. At that time, the airplane had accumulated 7,306 total hours. On May 20, 2018, about 1423 eastern daylight time, a Piper PA34-200T, N1101X, was destroyed during impact with wooded mountainous terrain and a postcrash fire while maneuvering near Bennington, Vermont. The commercial pilot was fatally injured. The airplane was privately owned by the pilot who was operating it under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed near the accident site, and no flight plan was filed for the personal flight to Waterbury-Oxford Airport (OXC), Oxford, Connecticut. The flight originated from Burlington International Airport (BTV), Burlington, Vermont, about 1345. According to a Federal Aviation Administration (FAA) designated pilot examiner (DPE) at BTV, the pilot had obtained a commercial pilot certificate and flight instructor certificate with multiengine land ratings on May 17 and May 19, respectively. They then reviewed weather together on May 19 for the pilot's return flight to his home airport, OXC, and the DPE advised the pilot to return on May 21 due to weather. The DPE stated that he was surprised to learn that the pilot attempted to return home on May 20. Review of air traffic control information from the FAA revealed that the pilot was receiving flight following from Albany Approach Control. The controller advised the pilot of the location of precipitation and mountainous terrain nearby. The controller subsequently solicited a pilot report from the pilot regarding cloud bases. The pilot reported that the cloud bases were at 3,000 ft; at that time, radar indicated that the accident airplane was at 3,400 ft mean sea level (msl), flying southeast. The controller then asked the pilot if he was in the clouds, and the pilot responded that he was coming out of them. The controller suggested a westbound turn for lower terrain and continued radar coverage. At that time, the accident airplane was flying between 3,200 ft and 4,000 ft msl, but the minimum vectoring altitude for that area was 5,000 ft msl. The airplane briefly turned to a westbound heading, but then turned back to a southeast heading. About 4 miles later, the controller again advised the pilot that, if he continued on the present heading, radar coverage would be lost. The pilot asked again what heading he should fly, and the controller responded westbound, to which the pilot responded, "westbound heading 270." Radar andradio contact were subsequently lost during the second westbound turn. The last radar target was recorded at 1423:41, indicating an altitude of 3,500 ft msl and groundspeed of 218 knots about 1,000 ft from the accident site, which was located on Bald Mountain, at an elevation of about 2,625 ft msl. The Vermont State Department of Health's Office of the Chief Medical Examiner, Burlington, Vermont, performed the autopsy on the pilot. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. The results were negative for drugs and alcohol. In addition to reviewing and discussing weather with the DPE on May 19, the pilot obtained three weather briefings via Foreflight on the day of the accident. The briefings were obtained at 1204, 1216, and 1226. All three briefings contained information about instrument flight rules conditions and mountain obscuration along the planned route of flight. William H Morse State Airport (DDH), Bennington, Vermont, was located about 5 miles west-southwest of the accident site. The recorded weather at DDH at 1415 included wind from 230° at 8 knots; 10 miles visibility; few clouds at 1,700 ft, broken ceiling at 3,600 ft, overcast ceiling at 4,600 ft; temperature 21°C; dew point 17°C; and an altimeter of 29.91 inches of mercury. The pilot held a commercial pilot certificate with ratings for airplane multiengine land and instrument airplane. He also held a private pilot certificate with a rating for airplane single-engine land. He held a flight instructor certificate with a rating for airplane multiengine land. His most recent FAA first-class medical certificate was issued on March 5, 2018. At that time, he reported a total flight experience of 227 hours. The pilot's logbook was not located and was presumed destroyed in the accident. Review of the pilot's application for a commercial pilot certificate, dated May 17, 2018, revealed a total flight experience of 256 hours, of which 45 hours were instrument experience; however, the application did not specify simulated or actual instrument experience or recency. A debris path was observed beginning with freshly-cut tree branches descending at an approximate 45° angle and extending about 60 ft on a magnetic heading of 265° to the main wreckage. Several of the branches exhibited cuts with black paint transfer. The main wreckage came to rest upright and was oriented about a 265° magnetic heading, with the empennage canted over the cockpit area. The left propeller separated from the left engine flange and one propeller blade separated from the hub. The blade exhibited s-bending, chordwise scratching, leading edge gouging, and tip curling, and was fractured near the blade root. The other left propeller blade was not located and presumed buried beneath the engine. The right propeller separated from the right engine flange; however, both right propeller blades remained attached to the hub. Both blades exhibiteds-bending and leading-edge gouging. The landing gear and flaps were retracted. The cockpit was consumed by fire and no readable instruments were recovered. The emergency locator transmitter was recovered, and its switch was found in the off position. The attitude indicator was recovered; its face sustained impact damage. When the attitude indicator was disassembled, its gyroscope and housing exhibited rotational scoring consistent with rotation at the time of impact. The right wing was partially consumed by fire and exhibited impact damage. The right flap remained attached; the right aileron separated and was located about 2 ft from the right wing. The left wing sustained fire damage, but exhibited less impact damage than the right wing. The left flap and left aileron remained attached to the left wing. The empennage, rudder, and stabilator remained attached. Control continuity was confirmed from the left and right wing aileron bellcranks to the mid-cabin area. Stabilator control continuity was confirmed from the stabilator to the cockpit. Rudder control continuity was confirmed from the rudder to the empennage area. Measurement of the stabilator and rudder trim jackscrews each corresponded to an approximate neutral setting. Both engines were examined following recovery of the wreckage. Due to impact and fire damage, the crankshaft could not be rotated on either engine; however, visual examination of the engines' core components through the fractured oil sumps and borescope examination of the cylinders revealed no preimpact mechanical malfunctions. Additionally, no preimpact anomalies were noted with either engine's fuel and ignition systems. ## Aircraft - Registration: [N1101X](https://openairdocs.org/deregistered/N1101X-2019-09-06), registration cancelled 2019-09-06, S/N 34-7570208, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA34 (200T) - Registry model: [Piper PA-34-200T](https://openairdocs.org/model/piper-pa-34-200t) (registry code 7103406) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17023, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34-7570208 - Year built: 1975 - Airframe hours: 7603 - Engines: CONT MOTOR TSIO-360-EB 215 horsepower reciprocating; CONT MOTOR LTSIO-360-EB 215 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 30, 2017 - Departed: BTV, Burlington, VT - Destination: OXC, Oxford, CT - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 19, 2018; seat: left; restraint: 3-point; toxicology performed; flight hours: 256 total, 30 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 3,600 ft broken - Temperature: 70 °F, dew point 63 °F - Altimeter: 29.90 inHg - Observed at: DDH, 5 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 20180520005659A](https://openairdocs.org/incident/20180520005659A), May 20, 2018: Piper PA-34-200T, Bennington, VT, Destroyed, 1 fatal. The pilot departed btv at approximately 1744 with a destination of oxc. In review of the audio and video radar, the pilot was recieving flight following from… ## Docket (7 files) The files NTSB released with the investigation on September 19, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97285. 2.6 MB in all. - Interview Summaries (item 1, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475928&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Fuel Receipt (item 2, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475929&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Excerpts from Pilot Applications (item 3, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475930&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%20Applications-Master.PDF - Aircraft Status Sheet (item 4, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475931&FileExtension=.PDF&FileName=Aircraft%20Status%20Sheet-Master.PDF - Weather Report (item 5, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475932&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Radar Data (item 6, XLSX, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475935&FileExtension=xlsx&FileName=Radar%20Data-Master - Photo Array (item 7, .PDF, 6 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475937&FileExtension=.PDF&FileName=Photo%20Array-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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.