# NTSB NYC99FA041: Piper PA-28R-180, N4591J, Randolph, NH, December 28, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 27, 1998, 19:40 local (Dec 28, 1998, 00:40 UTC) - Place: Randolph, NH - Location: 44.3753° N, 71.2798° W: Placed by OpenAirDocs: center of Randolph, NH, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=44.3753&lon=-71.2798&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 12, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45621 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC99FA041 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45621/pdf - Page: https://openairdocs.org/ntsb/NYC99FA041 ## Probable cause The pilot's continued VFR flight into instrument meteorological conditions which led to spatial disorientation and loss of aircraft control. Also causal was the pilot exceeded the design limits of the aircraft which resulted in an in-flight separation. Contributing to the accident were the mountainous terrain, night conditions and the pilot's lack of instrument time. ## 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 - clouds - weather forecast - obtained, pilot in command - light condition - dark night (contributing factor) - vfr flight into imc - continued, pilot in command (cause) - Loss of control - in flight, cruise - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (contributing factor) - lack of total instrument time, pilot in command (contributing factor) - Airframe/component/system failure/malfunction, descent - uncontrolled - wing - overload - design stress limits of aircraft - exceeded, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly ## Analysis The non-instrument rated pilot departed on a flight at night over mountainous terrain. After the airplane failed to arrive at the destination, a search was initiated. The airplane was located the next day on Mt. Randolph approximately 2,000 feet to the southeast of the peak, and 500 feet below it. The airplane sustained an in-flight separation. According to Flight Service records, the pilot obtained a weather briefing over the telephone that forecasted scattered clouds at 5,000 feet, and scattered to broken clouds at 10,000 feet through early morning. The last radio contact with the airplane was when the pilot reported that he was encountering haze at 7,500 feet. A satellite infrared image showed overcast clouds across New Hampshire about the time of the accident. Examination of the wreckage revealed all fracture surfaces were consistent with overload. According to a witness, the airport was in a 'black hole,' surrounded by mountainous terrain with few ground lights for reference. In the last 7 years the pilot logged 0.4 hours of simulated instrument, and 4.7 hours of night. According to the Instrument Flying Handbook, illusions in flight can be created by motion and certain visual scenes. Illusions may lead the pilot to maneuver the aircraft into a dangerous attitude. ## Factual narrative HISTORY OF FLIGHT On December 27, 1998, about 1940 eastern standard time, a Piper PA-28R-180, N4591J, was destroyed during an in-flight breakup, and subsequent collision with terrain near Randolph, New Hampshire. The certificated private pilot and passenger sustained fatal injuries. Visual meteorological conditions prevailed for the personal flight that originated from Berlin Muni Airport, Berlin, New Hampshire, destined for Central Jersey Regional Airport, Manville, New Jersey. The flight was conducted under 14 CFR Part 91, and a visual flight rules (VFR) flight plan was filed and activated. At 1707, Bangor Automated Flight Service Station (AFSS) received a call from an individual requesting a weather briefing, and using the call-sign N4591J. The briefer indicated to the caller that there were no weather advisories for the route of flight. Also, the briefer advised the caller that the lowest ceilings for his intended route would be 10,000 feet in the Worcester, Massachusetts, area. While providing initial weather information to the caller, the briefer stated the weather "looks excellent." The briefer continued by giving the caller the current weather at Berlin, which included, winds calm, clear below 12,000 feet, 10 miles of visibility, temperature 26 degrees Fahrenheit, and an altimeter of 30.21 inches of mercury. After providing the caller with current conditions, the briefer advised him that northern New Hampshire, and northern Vermont were forecasting scattered clouds at 5,000 feet, and scattered to broken clouds at 10,000 feet through early morning. The briefer added that Concord, New Hampshire, after 1900, was forecasting 5,000 feet scattered to broken, and 10,000 feet broken to overcast, adding the comment, "so that's good." The briefer then provided the next day's forecast, and while providing that information, he added, "I would recommend tonight instead of tomorrow." The caller then filed a flight fight plan for a 1935 departure. About 1930, an individual using the call-sign N4591J contacted Bangor Radio, and activated a VFR flight plan. Then, about 1935, Bangor received another transmission from N4591J. The person reported he was at 7,500 feet msl, and encountering haze. The briefer advised the individual that radar indicated high clouds with possible snow aloft. The briefer added that in "the area" ceilings were 9,000 to 11,000 feet broken to overcast, changing to scattered to broken in southern New Hampshire. The individual then asked what altitude would be required to get out of the haze, and the brief reiterate the information already provide. No other transmissions were received from N4591J after acknowledging the requested information from Bangor. After the airplane failed to arrive at Central Jersey, the Federal Aviation Administration (FAA) issued an alert notice. The first of two emergency locator transmitter signals was received at 2049, and an Army National Guard helicopter identified the wreckage about 1200, the day after the accident. The accident happened during the hours of darkness. The wreckage was located 44 degrees, 23.147 minutes north latitude, 71 degrees 19.215 minutes west longitude, and at an elevation of 2,860 feet. PERSONNEL INFORMATION The pilot held a private pilot certificate with a single engine land rating, with no instrument rating. His last FAA third class medical was dated January 1, 1998. A review of the pilot's logbook revealed a total of 526.7 hours of flight experience. In addition, the pilot logged a total of 343.8 hours of cross country flight, 141.6 hours of night, 3.6 of simulate instrument, and 17.1 hours in the accident airplane's make and model. In addition, from November 1991 to December 1998, the pilot logged a total of 25 flights. During that time frame, his logbook reflected a total of 0.4 hours of simulated instrument, and 4.7 hours of night. METEOROLOGICAL INFORMATION Examination of the NEXRAD National Mosaic Reflectivity Image for 1900, December 27, 1998, revealed an area of precipitation to the south of Berlin. Examination of the GOES 8 infrared image for 1900, on December 27, 1998, revealed overcast clouds across Vermont and New Hampshire. Moon angle at the time of the accident was 52 degrees above the horizon. Illumination was 68 percent. WRECKAGE AND IMPACT INFORMATION The main wreckage, which comprised the fuselage, left wing inboard section, right wing inboard section, and the empennage, minus the left and right stabilators, was located on Mt. Randolph, approximately 2,000 feet to the southeast of the peak, and 500 feet below it. The debris path was orientated northeast to southwest, with the outboard section of the right wing marking the start. A fragment of the right aileron attached to the inboard aileron hinge, and the right half of the horizontal stabilator were found approximately 500 feet southwest of the start of the debris path. Both of these items were located within 250 feet of one another. Approximately 400 feet further to the southwest, the vertical stabilizer, a section of the right flap, a section of the left aileron, and the outboard section of the left wing were located within 200 feet of one another. The left half of the horizontal stabilator was not located. On December 29, 1999, the wreckage was examined at the accident site. The fuselage was in one complete section, and crushed along its vertical axis. On the aft left side of the fuselage was a vertical brown scrape mark consistent with a tree impact. The right side of the carry-through spar was crushed forward. The top cap for the right wing's spar was bent, but connected. The lower spar cap was fractured, and displayed 45-degree shear planes consistent with overload. The left side of the carry-through spar was not deformed. The left wing's main spar was completely separated from the carry-through spar. The fracture surfaces displayed 45-degree shear planes, and were consistent with overload. The left wing's forward attachment point was connected, and the aft was separated. The right wing separated into two major sections. The outboard section of the right wing, including the wing tip, measured 54 inches. The inboard section measured 94 inches. The inboard section of the right wing displayed damage consistent with impact, and was severely deformed on the outboard 40 inches. The leading edge on this section also exhibited damage consistent with impact. The outboard 24 inches of the main spar top cap in this section was separated from the bottom cap, and bent forward. The lower cap was bent aft. Impact, and multiple breaks at various locations were observed on the main spar in this section. The right main landing gear remained attached to the wing, and was in the up position The right wing's flap was fractured into two pieces at the middle hinge. The leading edge of the separated flap section exhibited damage consistent with impact. Only the inboard hinge and approximately 5 inches of the right aileron were identified. The left wing also separated into two major sections. The inboard section measured 94 inches, and the outboard section measured 54 inches. This was the same as the right wing. The leading edge of the outboard section sustained little impact damage. The upper, and lower skin surfaces of this section separated along a rivet line with about 50 percent of the rivet holes exhibiting span-wise elongation. The false spar was bent rearward at a 30-degree angle, and the top two stringers, aft of the false spar, were bent up and aft. The left inboard wing section was bowed upward from the leading edge to the trailing edge, with the apex of the bow mid-chord on the underside of the wing. The pitot tube remained intact. Approximately 4 inches of the outboard section of the aileron, including the counterweight, remained attached to the outboard aileron hinge. Most of the lef ## Aircraft - Registration: [N4591J](https://openairdocs.org/deregistered/N4591J-2001-06-13), registration cancelled 2001-06-13, S/N 28R-30465 (OpenAirDocs) - Reported make and model: Piper PA-28R-180 - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30465 - Airframe hours: 1560 - Engines: Lycoming IO-360 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: 68 Arrow Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 2, 1998, 85 hours before - Departed: BML, BERLIN, NH - Destination: 47N, MANVILLE, NJ - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 563 total, 20 in this make and model, 496 as pilot in command, 10 in the last 90 days, 4 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft overcast - Temperature: 19 °F, dew point 12 °F - Altimeter: 30.00 inHg - Observed at: BML, 14 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 19981227046099A](https://openairdocs.org/incident/19981227046099A), Dec 27, 1998: Piper PA28R180, Randolph, NH, Destroyed, 2 fatal. (.4) During a telephone weather briefing, the briefer used the phrase 'looks excellent' and , 'I would recommend tonight instead of tomorrow' to describe 5,000… 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.