# NTSB NYC01LA132: Piper PA-22-108, N5391Z, Falmouth, MA, January 16, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 15, 2001, 19:45 local (Jan 16, 2001, 00:45 UTC) - Place: Falmouth, MA - Coordinates: 41.560604, -70.619064 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5606&lon=-70.6191&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 1, 2003 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 50929 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC01LA132 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/50929/pdf - Page: https://openairdocs.org/ntsb/NYC01LA132 ## Probable cause The pilot's improper decision to takeoff and attempt VFR flight in IMC conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - low ceiling - planning/decision - improper, pilot in command (cause) - weather condition - drizzle/mist - vfr flight into imc - attempted, pilot in command (cause) - In flight collision with terrain/water, unknown - terrain condition - water ## Analysis According to the pilot's wife, the pilot woke up early on the day of the accident, and flew to Lawrence, Massachusetts, to look at an airplane he was considering purchasing. She talked with the pilot about 1000. The pilot stated he had landed at Norwood, Massachusetts, due to snow and the poor weather conditions and that he had hoped to complete the flight before the weather moved into the area. At that time, the pilot stated he had called for a rental car and was waiting for it to arrive, so he could drive home. She next talked to the pilot about 1430, and was informed that he was still waiting for a rental car to arrive. She stated that the pilot was "very frustrated;" and they talked about him possibly renting a room at a local hotel. The pilot stated he would call her when the rental car arrived. At approximately 1612, the pilot requested a "special visual flight rules" (SVFR) clearance to depart the airport to the southwest. The controller noted that the ceiling was 400 feet overcast, and observed, " what appeared to be up to 2 inches of slush and snow on the airplane's wings and control surfaces." The controller denied the SVFR clearance and advised the pilot of the low ceilings and snow/slush contamination he observed on the airplane. However, the pilot departed, without a clearance and turned southwest. There were no further known communications with the airplane. Several residents reported seeing and/or hearing a low-flying airplane to local authorities. The last visual sighting, and radar contact with the airplane occurred between 1930 and 2000. The body of the pilot was located in Buzzards Bay, on May 27, 2001, and as of May 8, 2002, the airplane had not been located. The pilot was instrument rated and reported 15,000 hours of total flight experience on his most recent FAA second class medical certificate. The following weather was reported at an airport in Falmouth, Massachusetts, at 1855, a visibility of 1 1/2 miles in light rain and mist, and ceilings at 300 feet broken and 500 feet overcast; at 1955, a visibility of 1 1/2 miles in light rain and mist, and a ceiling of 800 feet overcast; at 2055, a visibility of 1 1/2 miles in light rain and mist, and a ceiling of 300 feet overcast. ## Factual narrative On January 15, 2001, about 1945 eastern standard time, a Piper PA-22-108, N5391Z, was last observed in the vicinity of Falmouth, Massachusetts. The airplane departed the Norwood Memorial Airport (OWD), Norwood Massachusetts, and as of May 7, 2002, the airplane had not been located. The body of the certificated commercial pilot was located in Buzzards Bay, about 3 miles north of Cuttyhunk Island, Massachusetts, on May 27, 2001. Instrument meteorological conditions prevailed and no flight plan had been filed for the personal flight conducted under 14 CFR Part 91. According to a Federal Aviation Administration (FAA) air traffic controller at OWD, about 1612 the pilot requested a "special visual flight rules" (SVFR) clearance to depart the airport to the southwest. The controller noted that the ceiling was 400 feet overcast, and observed "what appeared to be up to 2 inches of slush and snow on the airplane's wings and control surfaces." The controller denied the SVFR clearance and advised the pilot of the low ceilings and snow/slush contamination he observed on the airplane. However, the pilot departed runway 17 without a clearance and turned southwest along Interstate I-95. The pilot reported clear of the airport's "class Delta" airspace within 5 minutes. There were no further known communications with the airplane. About 1700, a witness observed a blue and white painted airplane strike a power line on Route 28, at the Falmouth/Bourne town line. When police officers were dispatched to the scene, they observed the airplane flying just above the tree tops. Unidentified, intermittent radar targets were observed in the areas of Martha's Vineyard, Woods Hole, and Falmouth, Massachusetts. Additionally, several residents reported seeing and/or hearing a low-flying airplane to local authorities. The last visual sighting, and radar contact with the airplane was in the area of East Falmouth, between 1930 and 2000. The weather reported at OWD at 1553, was: Winds from 070 degrees at 8 knots; Visibility 3 miles in mist; Ceiling 400 feet overcast; Temperature 36 degrees F; Dew point 30 degrees F. The following weather observations were reported at Otis Airport (FMH), in Falmouth: At 1855: Winds from 360 degrees at 13 knots ; Visibility 1 1/2 miles in light rain and mist; Ceiling 300 feet broken, 500 feet overcast; Temperature and Dew Point 37 degrees F. At 1955: Winds from 30 degrees at 12 knots; Visibility 1 1/2 miles in light rain and mist; Ceiling 800 feet overcast; Temperature and Dew Point 37 degrees F. At 2055: Winds from 350 degrees at 15 knots; Visibility 1 1/2 miles in light rain and mist; Ceiling 300 feet overcast; Temperature and Dew Point 37 degrees F. During an interview, the pilot's wife stated that the pilot woke up early on the day of the accident, and flew to Lawrence, Massachusetts, to look at an airplane he was considering purchasing. She talked with the pilot via telephone at about 1000. The pilot stated he had landed at OWD due to snow and the poor weather conditions and that he had hoped to complete the flight before the weather moved into the area. At that time, the pilot stated he had called for a rental car and was waiting for it to arrive, so he could drive home. She next talked to the pilot about 1430, and was informed that he was still waiting for a rental car to arrive. She stated that the pilot was "very frustrated;" and they talked about him possibly renting a room at a local hotel. The pilot stated he would call her when the rental car arrived. The pilot's wife had no further communications with the pilot. She added that the thought of him taking off in "that kind of weather" never crossed her mind. The pilot's wife reported that the pilot was diagnosed with Chronic Lymphocyte Leukemia 7 years ago, and on the Friday prior to the accident, the pilot under went a chemotherapy treatment. The pilot did not experience any side effects from the treatment. She described the pilot's mood as "happy, and excited about buying a new plane." They had also been planning a trip to Europe during the upcoming summer. The pilot's wife reported the pilot purchased the accident airplane about 6 months prior to the accident, and that the airplane was equipped for flight in instrument meteorological conditions. The pilot had never reported any problems with the airplane to her, and maintained the airplane in "top notch shape." The pilot flew the airplane on both the Saturday and Sunday, prior to the accident. The airplane's most recent annual inspection was performed on August 28, 2000. At that time, the airplane and engine had been operated for 4,656 total hours. Additionally, the engine had been operated for 356 hours since it was overhauled on February 16, 1992. The pilot was instrument rated and also held a flight instructor certificate with single engine land and instrument ratings. The pilot's logbook was not recovered. He reported 15,000 hours of total flight experience on his most recent FAA second class medical certificate, which was issued on December 20, 1999. An autopsy was performed on the pilot, on May 27, 2001, by the Office of the Chief Medical Examiner, Pocasset, Massachusetts. (THIS ACCIDENT REPORT WAS ORIGINALLY FILED AS NYC01FAMS1) ## Aircraft - Registration: [N5391Z](https://openairdocs.org/deregistered/N5391Z-2006-09-25), registration cancelled 2006-09-25, S/N 22-9160, built 1961 (OpenAirDocs) - Reported make and model: Piper PA-22-108 - Registry model: [Piper PA-22-108](https://openairdocs.org/model/piper-pa-22-108) (registry code 7102204) (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: 22-9160 - Airframe hours: 4656 - Engines: Lycoming O-235 115 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Warner F. Hendrix - Registered owner: Warner F. Hendrix - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 28, 2000 - Departed: OWD, NORWOOD, MA - Destination: OQU, NORTH KINGSTOWN, RI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; toxicology performed; flight hours: 15,000 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 30° at 12 knots - Visibility: 1.5 statute miles - Lowest ceiling: 800 ft overcast - Temperature: 37 °F, dew point 37 °F - Altimeter: 29.92 inHg - Observed at: FMH ## 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 20010115000779A](https://openairdocs.org/incident/20010115000779A), Jan 15, 2001: Piper PA22108, Falmouth, MA, Destroyed, 1 fatal. (-23) A pilot deviation was filed when N5391Z, PA-22-108, taxied to and departed runway 17 VFR, from norwood airport ma, 1612 EST, 1/15/01, without a… 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.