# NTSB NYC01FA128: Piper PA-28-161, N8365M, Danvers, MA, May 22, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 21, 2001, 22:01 local (May 22, 2001, 02:01 UTC) - Place: Danvers, MA - Coordinates: 42.585556, -70.924446 - Nearby events: https://openairdocs.org/map.md?lat=42.5856&lon=-70.9244&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report October 17, 2001 - Report: Approved by Office Director - Parties: Textron Lycoming, New Piper Aircraft, FAA/FSDO - NTSB case key (mKey): 52321 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC01FA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52321/pdf - Page: https://openairdocs.org/ntsb/NYC01FA128 ## Probable cause The pilot's failure to maintain aircraft control. Factors in the accident were the dark night, low ceiling, reduced visibility, and the pilot's decision to attempt a visual flight rules flight in marginal weather conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - aircraft control - not maintained, pilot in command (cause) - physical impairment(visual deficiency), pilot in command - preflight planning/preparation - improper, pilot in command (contributing factor) - weather condition - low ceiling (contributing factor) - light condition - dark night (contributing factor) - weather condition - drizzle/mist (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot and two passengers departed on a night VFR flight. Weather at the time was approximately 100 foot overcast and 2 1/2 miles in mist. When the airplane was approximately 100 feet agl, the landing light went out, and the airplane entered the overcast. The airplane came out of the overcast in about a 15-degree nose low attitude, and then climbed back into the clouds. The airplane crashed shortly afterwards and a post-crash fire erupted. The airplane impacted the ground approximately 70-degrees nose low. Examination of the wreckage revealed no preimpact failures with the airplane, or any of its systems. There was no record of the pilot receiving a weather briefing on the night of the accident. The pilot had approximately 1,800 of total flight experience with approximately 13 hours being in the previous 30 days. The pilot's expired FAA medical certificate restricted him from night flight because of defective color vision. There was no record of the pilot obtaining a weather briefing prior to the flight. ## Factual narrative HISTORY OF FLIGHT On May 21, 2001, about 2201 eastern daylight time, a Piper PA-28-161 (Warrior II), N8365M, was destroyed when it impacted terrain approximately a 1/4 mile to the southwest of the Beverly Municipal Airport (BVY), Beverly Massachusetts. The certificated commercial pilot and both passengers were fatally injured. Instrument meteorological conditions (IMC) prevailed for the local flight that departed Beverly, about 2158. No flight plan was filed for the personal flight conducted under 14 CFR Part 91. According to a witness, while the airplane was taxiing to the run-up area for runway 16, he could see the airplane strobes and landing light reflecting in the mist. He also noticed the light from the airport rotating beacon, which was located on top of the control tower, reflecting in the mist. The witness then went inside to check the current weather conditions at the airport. With the airplane still in the run-up area, the witness listened to the automated surface observing system (ASOS), which was reporting a visibility of 10 miles and a ceiling of 300 feet overcast. The witness was also listening to the common traffic advisory frequency for the airport, and never heard the pilot make any radio announcements. The witness went back outside to watch the airplane depart. When the airplane was approximately 100 feet agl, the landing light went out, and the airplane began to enter the overcast. The airplane turned left near the departure end of the runway, and the witness lost sight of it in the overcast, but could still hear the engine at "full power." When the airplane was west of runway 16, and south of the windsock, it descended out of the overcast in about a 15-degree nose down attitude. The airplane then climbed back into the overcast, and the witness lost sight of it again. The witness could hear the engine, and believed the pilot was maneuvering for a left downwind to runway 9. The witness ran back inside, and while trying to contact the pilot via radio to offer assistance, he saw the flames from the post-crash fire. Before going to the accident site to render assistance, the witness checked the weather. The ASOS was then reporting a visibility of 1 mile in mist, and a ceiling of 100 feet overcast. The accident occurred during the hours of darkness. The wreckage was located at 42 degrees, 35.139 minutes north latitude, 70 degrees, 55.459 minutes west longitude, and an elevation of 70 feet msl. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with ratings for airplane single-engine-land, multi-engine-land, and airplane instrument. In addition, he held a certified flight instructor rating for airplane single-engine-land. He did not hold an instrument instructor rating. The pilot's last FAA second-class medical certificate was dated November 9, 1998, and had expired. The pilot's medical restricted him from night flight because of defective color vision, and required him to wear glasses for distant vision, and possess them for near vision. On the pilot's last medical application, he reported 1,800 hours of total flight experience. The pilot's logbook was not recovered, and presumed destroyed in the post-crash fire. No information was obtained regarding the pilot's last flight review, or actual instrument experience. According to the airplane owner's records, the pilot flew 33.1 hours from February 1, 2001, to May 20, 2001, with 13.2 hours of that being within 30 days of the accident. AIRPORT INFORMATION According to National Oceanic and Atmospheric Administration publications, Beverly Municipal was located approximately 3 miles northwest of Beverly, Massachusetts, at an elevation of 108 feet. The airport had an ATC control tower that operated from 0800 to 2100 on the day of the accident. When the control tower was open, class "D" airspace was in effect. When the tower closed, the airspace changed from class "D" to class "G." The airport was comprised of two runways, 9/27 and 16/34. Runway 9/27 was 5,001 feet long, 150 wide, and equipped with medium-intensity-runway lights (MIRL). Runway 16/34 was 4,634 feet long and 100 feet wide. Runway 16 was equipped with MIRL, medium-intensity-approach lights with runway-alignment-indicator lights, and a 3.5-degree precision-approach-path indicator. Runway 34 was equipped with MIRL and runway-end-identifier lights. AIRCRAFT INFORMATION According to the owner, the instrument panel was configured with one vacuum-driven attitude indicator, one vacuum-driven directional gyro, one electric-driven turn coordinator, one pressure altimeter, and one vertical speed indicator. The airplane was equipped with one NAV/COM radio, one LORAN, and one omni-bearing selector. The airplane did not have a glide-slope receiver, or standby vacuum source. The owner added that the airplane was not certified for IMC flight. METEOROLOGICAL INFORMATION About 8 minutes before the accident, the ASOS at Beverly Municipal recorded the wind as 120 degrees at 7 knots, visibility 10 miles, ceiling 300 feet overcast, temperature 50 degrees Fahrenheit, dew point 50 degrees Fahrenheit, and an altimeter setting of 30.15 inches of mercury. About 9 minutes after the accident, the ASOS at Beverly Municipal recorded the wind as 110 degrees at 7 knots, visibility 2 1/2 miles in mist, ceiling 100 feet overcast, temperature 48 degrees Fahrenheit, dew point 48 degrees Fahrenheit, and an altimeter setting of 30.14 inches of mercury. About 20 minutes after the accident, the ASOS at Beverly Municipal recorded the wind as 130 degrees at 7 knots, visibility 1 1/2 miles in mist, ceiling 100 feet overcast, temperature 48 degrees Fahrenheit, dew point 48 degrees Fahrenheit, and an altimeter setting of 30.14 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted the ground in the backyard of a home. The debris path was oriented on a 045-degree magnetic heading, and approximately 100 feet long. The start of the debris path was marked by freshly broken branches in a tree about 30 feet above the ground. About 45 feet past the broken branches, and on a 70-degree down angle, was an indentation in the ground. The indentation was approximately the same length as the wingspan of the airplane. In the middle of the indentation was the main crater. The crater was approximately 4 feet wide and 8 inches deep. In the crater were engine accessories and the engine propeller. About 10 feet past the main crater was the engine, and about 10 feet past that was the main wreckage. The main wreckage displayed severe impact and fire damage, and was comprised of the left and right wings, cockpit, cabin, and tail section of the airplane. All the flight control surfaces were accounted for, and control continuity from each of the control surfaces to the pilot-control column was verified. Elevator trim was approximately neutral. Inside the left wing, about 1 foot inboard of the aileron bellcrank, was a screwdriver. The screwdriver was separated from the bellcrank by a structural rib, which had lightening-holes. Examination of the aileron bellcrank revealed no repetitive scrapes, or gouges. Examination of the metal portion of the screwdriver also revealed no repetitive scrapes or gouges. The plastic handle on the screwdriver was melted and partially consumed in the post-cash fire. The engine had separated from its mounts and was lying inverted on the ground. The carburetor and engine-driven fuel pump had separated from the engine and displayed severe impact and fire damage. The electric-driven fuel pump also displayed impact and fire damage, and was attached to the firewall, which was located with the main wreckage. The left and right magnetos had separated from their respective mounts. The left magneto was intact and produced spark when its impulse-coupling drive gear was rotated ## Aircraft - Registration: [N8365M](https://openairdocs.org/deregistered/N8365M-2017-06-15), registration cancelled 2017-06-15, S/N 28-8116193, built 1981 (OpenAirDocs) - Reported make and model: Piper PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8116193 - Airframe hours: 10200 - Engines: Lycoming O-320-D3G 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: High Flight, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 12, 2001, 90 hours before - Departed: BVY, BEVERLY, MA - Airport: BVY, Beverly Muni, runway 16, 4,634 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, invalid medical for flight; seat: left; toxicology performed; flight hours: 1,800 total, 800 in this make and model ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 110° at 7 knots - Visibility: 2.5 statute miles - Lowest ceiling: 100 ft overcast - Temperature: 48 °F, dew point 48 °F - Altimeter: 30.13 inHg - Observed at: BVY, 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 20010521010169A](https://openairdocs.org/incident/20010521010169A), May 21, 2001: Piper PA28161, Beverly, MA, No damage, 3 fatal. (-23)A Piper warrior crashed three minutes after taking off from Beverly, MA airport, killing the flight instructor, paul bonaiuto 70, of [privacy data… 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.