NYC03FA205

NTSB accident investigation · Cessna 182T · Concord, MA · September 27, 2003

Accident · FatalField investigationFinal report
Date
September 27, 2003, 11:03 local (15:03 UTC)
Place
Concord, MA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N963LPCessna 182T
Weather
Instrument (IMC) · Day
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration, Textron Lycoming, Cessna Aircraft Company, Massachusetts Aeronautics Commision
FAA report
20030927024379A
Case key
58010

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

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Probable cause

The pilot's failure to maintain aircraft control due to spatial disorientation. A factor was the low ceilings.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightApproach - faf/outer marker to threshold (ifr)
Weather condition - low ceilingFactor
Spatial disorientationPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The pilot of the Cessna 182 initiated an ILS approach in IMC conditions. The airplane passed over the outer marker about 550 feet high, and then entered a descent of 1,200 feet in 40 seconds, after which it entered a left turn. When questioned by the local controller, the pilot reported headings that were consistent with his radar track. The airplane completed over 360 degrees of turn prior to descending into the trees, left wing down, in a steep bank. The pilot's answer to questions from the controller were sometimes delayed and/or incomplete, and when instructed to execute a missed approach, the pilot did not know what heading to fly. Examination of one navigation radio found it set for the ILS frequency. No information was obtained from the other radio due to impact damage. There was no evidence of a mechanical failure or malfunction with the engine or airplane. A witness who initially found the airplane reported a strong smell of fuel at the accident site. An FAA inspector who administered the pilot's last flight review, and instrument competency check 13 months prior to the accident reported the pilot was adequate for his rating, and level of experience, and he was familiar with the airplane. There was no information available after that flight check, and the pilot's recency of experience, and instrument experience was not determined.

Factual narrative

History of flight

On September 27, 2003, at 1103 eastern daylight time, a Cessna 182T, N963LP, was destroyed when it struck trees in Concord, Massachusetts, while on approach to Laurence G. Hanscom Field (BED), Bedford, Massachusetts. The certificated private pilot and passenger were fatally injured. Instrument meteorological conditions prevailed for the personal flight, which departed from Oswego County Airport (FZY), Fulton, New York. The flight was operated on an instrument flight rules (IFR) flight plan under 14 CFR Part 91.

According to documents found in the airplane, the pilot filed an instrument flight rules (IFR) flight plan to Bedford (BED), at 0556, via DUATs (direct user access terminal). The proposed departure time was 0830 on September 27, 2003. The pilot contacted DUATs again at 0733, and filed an IFR flight plan from BED to Providence, Rhode Island (PVD). The proposed departure time was 0630 on September 28, 2003.

No documents were found to indicate what weather the pilot had viewed prior to departure. In addition, during the preparation of the Federal Aviation Administration (FAA) air traffic package, although it was identified that the pilot had made DUATS contact, the data was neither retrieved nor preserved.

The airplane was based at Fulton, which had a field elevation of 475 feet. The pilot departed Fulton about 0910. At 0914:50, the airplane was identified on radar by its discrete transponder code of 5307, as it climbed through 1,900 feet mean sea level (msl), 3.2 nautical miles east of the airport. The initial en route altitude was 7,000 feet, with the pilot later being assigned 9,000 feet. No problems were reported with the departure or en route phases of the flight.

As the airplane neared its destination, the pilot was instructed to contact Boston Approach Control. The pilot initiated a descent and was radar vectored for the ILS (instrument landing system) Runway 11 approach.

According to a transcript of air/ground communications from the Federal Aviation Administration (FAA) control tower at Bedford:

At 1058:22, the pilot established radio contact with the control tower. The local controller asked the pilot to report the outer marker, and also told him the runway 11 runway visual range (RVR), was greater than 6,000 feet. The pilot asked for the data to be repeated and the local controller complied.

At 1059:31, the pilot reported that he was at the outer marker. The local controller acknowledged the transmission, cleared the airplane to land, and advised the pilot that the last two airplanes broke out at minimums. The pilot did not reply.

At 1100:45, the pilot transmitted, "nine six three lima pop.....".

At 1100:50, the local controller stated, "calling tower, say again."

At 1100:57, the local controller stated, "nine six three lima pop, check your altitude, altimeter is three zero one two, minimum descent altitude three hundred eight three feet, check your altitude immediately. The pilot did not initially reply. However, at 1101:24, the pilot transmitted "and six lima pop...."

At 1101:30, the local controller told the pilot that he was on a two mile final and asked him his heading. At 1101:41, the local controller again asked the pilot his heading.

At 1101:53, the pilot reported he was on a heading of 330 degrees.

At 1102:02, the local controller transmitted, "cessna three lima pop, climb and maintain two thousand, execute a missed approach now, frequency one two four point four."

At 1102:06, the pilot replied, "missed approach, can you give me the heading?"

At 1102:09, the local controller stated, "what heading are you on now sir." At 1102:13, the pilot replied, "heading one eighty [180 degrees]."

At 1102:16, the local controller transmitted, "alright - just climb to two thousand, contact boston approach now one two four point four." The pilot replied, one two four point zero, and at 1102:20, the local controller corrected the pilot by repeating the frequency, "one two four point four."

No further transmissions were received from the pilot of N963LP.

Several witnesses heard and/or saw the airplane prior to the accident.

One witness was fishing from his boat in the Concord river. He reported that he was used to hearing airplanes on approach, and heard an airplane on approach that sounded normal. He then heard an application of power, and a few seconds later, saw a white, high wing airplane, which he described as a Cessna, operating just above the tops of the trees, heading away from the airport. He did not hear the accident. He said there was fog near the tops of the trees.

A second witness who lived near the outer marker, reported hearing an airplane and an application of power, which she described as a, "real roar." She said the weather was, "murky."

A third witness reported he could hear an airplane turning where airplanes don't normally turn. He never acquired visual contact with the airplane. However, he did say he heard the airplane until impact, and that the engine was not sputtering or missing. He then walked into the woods and found the wreckage. He reported that there was a strong smell of fuel at the accident site.

Additional interviews of pilots operating in the area at the time of the accident revealed no problems with either the localizer and/or glide slope.

The accident occurred during the hours of daylight at 42 degrees, 29.547 minutes north latitude, and 71 degrees, 21.152 minutes west longitude.

Personnel information

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. He was last issued a second class FAA airman medical certificate on March 20, 2003. The pilot received his private pilot rating on September 14, 1978. He received his instrument rating with a total flight experience of 238 hours on August 27, 1981. According to the pilot's application for the instrument rating, his total instrument flight time was 120 hours. There were no other FAA flight records on the pilot.

According to the pilot's last FAA airman medical application, he had a total flight experience of 2,600 hours, and had flown 70 hours in the preceding 6 months. In the preceding 90 days, the pilot was estimated to have flown about 30 hours, and in the preceding 30 days, he was estimated to have flown about 10 hours. Since his last FAA airman physical, the pilot was estimated to have flown about 60 hours, for a total flight experience of 2,660 hours. The pilot was estimated to have 210 hours in the accident airplane.

The pilot's last flight review was conducted in the accident airplane on August 29, 2002. This was also the last entry in the pilot's logbook. It included a flight review and an instrument competency check. The review was administered by an FAA operations inspector who reported the flight was satisfactory, and that the pilot flew commensurate for his ratings and level of experience, and was familiar with the airplane.

Aircraft information

Cessna Aircraft delivered the airplane to the leasing company that owned it on May 4, 2001. The last annual inspection was conducted on May 8, 2003, with a total airplane time of 169 hours. The airplane was estimated to have accumulated an additional 40-hour since the last annual inspection for an estimated total time of about 210 hours at the time of the accident.

The airplane was equipped with a global positioning navigation system (GPS). The display on the HSI could be selected to display either GPS, or VOR/Localizer/Glideslope data. There was a two-position push-button switch located on the top of the instrument panel, under the glare shield for selecting either GPS or navigation data to be displayed on the HSI. The display on the HSI was dependent upon the selection of the GPS/NAV switch, and not the frequencies set on the navigation radios.

Meteorological information

The 1056 r

Aircraft

Registration
N963LP
Reported as
Cessna 182T
Category
Airplane
Serial number
18280963
Airframe hours
169
Engine
Textron Lycoming IO-540-AB1A5, 230 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 8, 2003 · 40 hours before
Departed
FZY · Fulton, NY
Destination
BED · Bedford, MA
Flight plan
IFR
Airport
BED · Laurence G Hanscom Field, runway 11, 7,001 × 150 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
August 29, 2002
Seat
Left
Toxicology
Performed
Flight hours
2,660 total · 210 in this make and model · 30 in the last 90 days · 10 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
90° at 8 knots
Visibility
0.75 statute miles
Lowest ceiling
400 ft overcast
Temperature
64 °F, dew point 64 °F
Altimeter
30.11 inHg
Observed at
BED, 3 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.