NYC92FA047

NTSB accident investigation · Piper PA-23-235 · Fall River, MA · December 14, 1991

Accident · FatalField investigationFinal report
Date
December 14, 1991, 17:45 local (22:45 UTC)
Place
Fall River, MA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N4959PPiper PA-23-235
Weather
Instrument (IMC) · Night/dark
Status
Completed · report April 27, 1993
Report
Approved by Office Director
FAA report
19911214056319A
Case key
37046

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 did not follow IFR proceedures and was manuvering at too low an altitude to remain clear of the terrain. Factors in the accident were; fatigue, fog and no visual ground clues.

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.

In flight encounter with weatherMissed approach (ifr)
Weather condition - fogFactor
Missed approach - attemptedPilot in command
FatiguePilot in commandFactor
Light condition - dark nightFactor
Ifr procedure - not followedPilot in commandCause
Maneuver - improperPilot in commandCause
Proper altitude - not maintainedPilot in commandCause
In flight collision with terrain/waterMissed approach (ifr)
Terrain condition - ground

Analysis

While on an NDB approach, the pilot cancelled his IFR flight plan when he had the field in sight. Shortly after radar service was terminated the pilot reestablished radio contact with ATC and said he lost sight of the airport. ATC instructed the pilot to climb to 2000 feet, but he did not reply. The last radar return depicted the airplane turning to the left (northeast), the published missed approach is a climbing right turn to an altitude of 1900 feet MSL. The airplane impacted trees about 1 1/2 mile northeast of the airport. When the pilot started the approach he had been flying for approximately 5 hour and 40 minutes, non stop from Kentucky. The flight had been flown almost totally in IMC conditions, moderate to severe turbulence, and rime ice. The approach was attempted during the hours of darkness with low visibility and no ground references.

Aircraft

Registration
N4959P
Reported as
Piper PA-23-235
Category
Airplane
Serial number
27-560
Engine
Lycoming O-540-B1A5, 235 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Milton Novotny, doing business as Novopak Inc.
Registered owner
Milton Novotny
Airworthiness certificate
Standard, Normal
Last inspection
Unknown · January 2, 2000
Departed
BWG · Bowling Green, KY
Flight plan
IFR
Airport
FLR · Fall River Municipal, runway 24, 3,948 × 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
57
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
2,830 total · 1,900 in this make and model · 2,577 as pilot in command · 54 in the last 90 days · 22 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
220° at 16 knots
Visibility
4 statute miles
Lowest ceiling
500 ft overcast
Temperature
55 °F, dew point 55 °F
Altimeter
29.00 inHg
Observed at
EWB, 10 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.

Other investigations on N4959P · 1

Matched to the same aircraft by N-number and date.