# NTSB NYC04FA136: Piper PA-32-300, N21072, Leominster, MA, June 2, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 1, 2004, 21:31 local (Jun 2, 2004, 01:31 UTC) - Place: Leominster, MA - Coordinates: 42.546112, -71.721664 - Nearby events: https://openairdocs.org/map.md?lat=42.5461&lon=-71.7217&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 25, 2006 - Report: Approved by Office Director - Parties: Lycoming Engines, FAA, Massachussets Aeronautics Commision, Piper Aircraft - NTSB case key (mKey): 59350 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC04FA136 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59350/pdf - Page: https://openairdocs.org/ntsb/NYC04FA136 ## Probable cause The pilot's failure to follow instrument flight procedures resulting in a collision with trees. A factor related to the accident was the low cloud ceiling, and dark night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, approach - faf/outer marker to threshold (ifr) - lack of recent experience, pilot in command - ifr procedure - not followed, pilot in command (cause) - weather condition - low ceiling (contributing factor) - light condition - dark night (contributing factor) - In flight collision with object, approach - faf/outer marker to threshold (ifr) - object - tree(s) - altitude/clearance - not maintained, pilot in command ## Analysis The airplane was destroyed after impacting terrain during an approach in instrument meteorological conditions. At the destination airport, weather was reported as 3 statute miles of visibility and mist, and an overcast cloud layer at 700 feet. The overcast ceiling was variable from 400 to 1,100 feet agl. The flight progressed without incident, and once in the vicinity of the destination airport, the pilot requested and was subsequently cleared for the GPS approach. No further transmissions were received from the pilot. The airplane struck trees, and came to rest in a wooded area, about 1-3/4 miles from the runway 32 threshold, and about 1/2-mile right of the extended centerline. A postcrash fire consumed the main wreckage. The elevation of the accident site was 563 feet msl. Review of the approach plate for the GPS approach revealed that the inbound course from the final approach fix, located about 5 miles prior to the airport, was 324 degrees. The minimums for the straight in approach to runway 32 were 1 statute mile of visibility, and a minimum decision altitude of 960 feet msl (624 feet agl). No procedure turn was required for the approach. Review of radar data revealed that after the airplane crossed the final approach fix, it turned right, away from the final approach course, and began tracking northbound for several seconds. The airplane then made a left turn and proceeded inbound towards the airport and tracked an approximate 300-degree course until the last radar return was received, where the airplane was about 1 mile southeast of the airport at 1,000 feet msl. The pilot had accumulated about 409 hours of total flight experience. Within the previous 6 months, he had accumulated 7 hours, of which 1.7 hours were conducted in simulated instrument conditions, and .7 hours were in actual instrument conditions. The pilot's most recent flight conducted in nighttime conditions was about 20 months prior to the accident. ## Factual narrative HISTORY OF FLIGHT On June 1, 2004, about 2131 eastern daylight time, a Piper PA-32-300, N21072, was destroyed after impacting terrain in Leominster, Massachusetts, during an approach to the Fitchburg Municipal Airport (FIT), Fitchburg, Massachusetts. The certificated private pilot and passenger were fatally injured. Night instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight that originated from the Manchester Airport (MHT), Manchester, New Hampshire. The personal flight was conducted under 14 CFR Part 91. According to a Federal Aviation Administration (FAA) inspector, the airplane was fueled earlier at FIT with 16.7 gallons of aviation fuel prior to departing for MHT to pick up the passenger. Upon arriving at MHT, the airplane was refueled with 14.1 gallons of aviation fuel. The flight departed from MHT about 2109, and proceeded towards FIT. Review of air traffic control data revealed that the pilot was instructed to "cross TOPTO at or above 2,500, cleared GPS 32 approach," which he acknowledged. No further transmissions were received from the pilot. Review of radar data obtained from the FAA revealed that the accident airplanes flight track began at 2108:50. The airplane was at an altitude of 900 feet in the vicinity of MHT. At 2129:34, the airplane crossed abeam CLETR, the final approach fix for the GPS RWY 32 approach at FIT. At that point the airplane had been tracking a northwesterly heading approximately 320 degrees. After passing CLETR, the airplane turned right, away from the final approach course, and began tracking northbound for several seconds. At 2129:57, the airplane made a left turn and proceeded inbound towards the airport and tracked approximately a 300-degree course. The last radar return was received at 2131:44, where the airplane was about 1 mile southeast of FIT at 1,000 feet, and a ground speed of 110 knots. The airplane came to rest on its right side, on top of a stone wall, in a wooded area, about 1-3/4 miles from the runway 32 threshold, and about 1/2-mile right of the extended centerline. A postcrash fire consumed the main wreckage. A witness, located about 1/2-mile southwest of the accident site, heard an airplane fly overhead. The airplane noise was "louder than usual." The witness looked out her window and observed an airplane flying over the tree tops, from right to left, and "the engine sounded fine. Just loud because the plane was so low." The witness then heard a sound similar to "chopping of leaves from the tree tops," followed by silence, and a few seconds later, the sound of snapping trees. The accident occurred during the hours of darkness, at 42 degrees, 32.430 minutes north longitude, 071 degrees, 43.18 minutes west latitude, at an elevation of 563 feet. PERSONNEL INFORMATION The pilot held a private pilot certificate for airplane single-engine, and instrument airplane. The pilot's most recent application for a FAA third class medical certificate was dated on December 16, 2002. Review of the pilot's logbook, which was found in the wreckage, revealed that he had accumulated about 409 hours of total flight experience. Within the previous 6 months, he had accumulated 7 hours, of which 1.7 hours were conducted in simulated instrument conditions, and .7 hours were in actual instrument conditions. The pilot's most recent flight conducted in nighttime conditions was on November 15, 2002. AIRCRAFT INFORMATION The airplane's most recent annual inspection was completed on May 6, 2004, at a total aircraft time of 3,087.9 hours. The airplane was equipped with a Garmin GPS 400 unit, and an autopilot. There were no documents recovered to confirm if the GPS unit was coupled to the autopilot. METEOROLOGICAL INFORMATION The weather reported at FIT, at 2117, included winds from 080 degrees at 4 knots; 3 statute miles of visibility; mist; an overcast cloud layer at 700 feet agl; temperature of 48 degrees Fahrenheit; dew point of 46 degrees Fahrenheit; and an altimeter setting of 29.80 inches of mercury. The overcast ceiling was variable from 400 to 1,100 feet agl. AIRPORT INFORMATION The airport elevation at FIT was 348 feet msl. AIDS TO NAVIGATION Review of the approach plate for the GPS Runway 32 approach at FIT revealed that the initial approach fix (IAF), TOPTO waypoint, was located 22.3 miles, outbound 211 degrees from the MHT VOR. The outbound course from TOPTO was 234 degrees, and continued 5 miles to the DELSO waypoint. The minimum altitude for the segment was 2,500 feet msl. The final approach course from DELSO was 324 degrees, and continued 5 miles to the final approach fix (FAF), CLETR waypoint. The minimum crossing altitude at CLETR was 2,000 feet msl. CLETR intersection was located 5 miles from the runway 32 threshold. The minimums for the straight in approach to runway 32 were 1 statute mile of visibility, and a minimum decision altitude of 960 feet msl (624 feet agl). No procedure turn was required for the approach. WRECKAGE AND IMPACT INFORMATION Examination of the accident site on June 2, 2004, revealed terrain that consisted of evergreen and hardwood trees reaching a height of about 80 feet. The foliage surrounding the accident site was wilted, consistent with being sprayed with aviation fuel and exposure to heat. The wreckage path was about 280 feet in length, and was oriented on a 050-degree heading, with the main fuselage coming to rest on a 055-degree heading. The first tree strike area was located about 250 feet prior to the main fuselage. Surrounding the tree strike area, were branches of varying diameters that were cut at 45-degree angles and displayed black and red paint transfer. Along the wreckage path were wing skin sections from the left wing and the empennage assembly. All flight control surfaces were accounted for at the accident site. When the right side of the stabilator was examined, a 3-inch deep u-shaped dent was present on the leading edge. Tree bark was observed in the dent compression mark. The 3-bladed propeller assembly was separated from the engine. All three blades broke loose from the hub assembly, and were located about 30-40 feet beyond the main wreckage. The blades displayed s-bending and leading edge nicks. One blade exhibited chord-wise scratching. The propeller blades were painted black, with red and white stripes painted on the tips. Examination of the cockpit area revealed that the fuel selector was in the "left" tank position, and that the flap handle was in retracted position. The pilot's airspeed indicator was recovered, but sustained impact damage. The airspeed indicator displayed a reading of 0 knots. The altimeter displayed a reading of 495 feet. The Kollsman window displayed an altimeter setting of 29.78 inches of mercury. The attitude indicator and directional gyro were disassembled. Evidence of rotational scoring was observed on the inside gyro rotor housings of both instruments. The remaining primary flight instruments and engine instruments; the throttle, mixture, and propeller controls were destroyed. The engine was recovered from the accident site and examined on June 3, 2004. The crankshaft was rotated through the accessory drive section. Thumb compression and valve train continuity was confirmed to the number 3 through number 6 cylinders. The number 1 cylinder head was separated from its barrel, and disintegrated. The number 2 cylinder intake and exhaust push rods were bent, which restricted the movement of the rocker arms. With the exception of the number 1 cylinder, the top and bottom spark plugs of all remaining cylinder heads were removed; their electrodes were intact and dark gray in color. When the left magneto was removed from the engine case and rotated by hand, it produced spark from all leads. The right magneto was found separated from the e ## Aircraft - Registration: [N21072](https://openairdocs.org/deregistered/N21072-2004-09-15), registration cancelled 2004-09-15, S/N 32-7840183, built 1978 (OpenAirDocs) - Reported make and model: Piper PA-32-300 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-7840183 - Airframe hours: 3089 - Engines: Lycoming IO-540 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: James P. Normandin - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2004 - Departed: MHT, Manchester, NH - Destination: FIT, Fitchburg, MA - Flight plan: IFR - Airport: FIT, Fitchburg Municipal Airport, runway 32 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review December 1, 2002; seat: left; toxicology performed; flight hours: 400 total, 4 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 80° at 4 knots - Visibility: 3 statute miles - Lowest ceiling: 700 ft overcast - Temperature: 48 °F, dew point 46 °F - Altimeter: 29.79 inHg - Observed at: FIT, 2 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 20040601011219A](https://openairdocs.org/incident/20040601011219A), Jun 1, 2004: Piper PA32300, Leominster, MA, Destroyed, 2 fatal. (-23) On June 1, 2004, about 2130 EDT, a Piper PA-32-300, N21072, was destroyed when it impacted terrain in Leominster, MA during a GPS approach to runway 32… ## Other investigations on N21072 (1) 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. - [NTSB IAD00LA060](https://openairdocs.org/ntsb/IAD00LA060), Jul 8, 2000: Piper PA-32-300 (N21072), Fitchburg, MA, substantial damage. Probable cause: pilot's inadequate compensation for the crosswind. A factor was the crosswind. 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.