NTSB Factual Report

HISTORY OF THE FLIGHT

On June 7, 1995, about 0010 eastern daylight time, a Piper PA-32-260, N41481, registered to an individual, crashed near Gainesville, Florida, while on a 14 CFR Part 91 personal flight. Instrument meteorological conditions prevailed and no flight plan was filed. The airplane was destroyed and the private-rated pilot and five passengers were fatally injured. The flight last departed Adel, Georgia, on June 6, 1995, about 2310.

Members of the pilot's family stated that the flight originated from Covington, Georgia, on June 6, 1995, about 2045. There were seven passengers on board during this departure, two of them were children. The aircraft had six seats. A stop was made at Adel, where one passenger got off the airplane. The flight departed Adel, about 2310, en route to Gainesville, Florida. The pilot's daughter stated she obtained a weather briefing for the pilot from the FAA Macon Flight Service Station, before the departure from Covington. The FAA found no record of this briefing.

Radio communication transcripts showed the pilot of N41481 contacted the FAA Jacksonville Air Route Traffic Control Center at 2314:13, and reported that she was 7 miles south of Adel, en route to Gainesville, at 5,500 feet. At 2320:56, the flight was assigned transponder code 0766 and told to maintain visual flight rule (VFR) conditions at all times. At 2332:03, the controller informed the pilot that another flight had trouble keeping the Gainesville Airport in sight during a visual approach and had to perform an ILS approach to land. The controller asked the pilot of N41481 if she was qualified and equipped for instrument flight rules (IFR) flight if necessary. The pilot replied she was not qualified.

At 2342:34, the pilot reported she was beginning her descent. The controller advised her to maintain VFR. At 0000:05, while 3 miles northwest of the Gainesville Airport, the pilot reported she had the airport beacon in sight. The controller then asked "do you have the uh airport in sight now suitable that you don't need any more radar service?" The pilot replied affirmative. The pilot was then told to maintain VFR conditions and contact the FAA Gainesville Flight Service Station.

At 0000:26, the pilot attempted to contact Gainesville Flight Service. She received no response and again contacted the Jacksonville Center controller at 0004:15. The center controller contacted Gainesville Flight Service on the land line and at 0005:35, the pilot made contact with Gainesville Flight Service. The controller stated there was no traffic in the Gainesville area, the winds were 240 degrees at 8 knots, and the altimeter was 29.86 in HG. The pilot reported she was having trouble picking up the runway lights but that she had the beacon in sight. The controller reported that runways 6-24 and 10-28 were lit. He then asked what runway she would use. The pilot replied, "I'll be going in on the west I'm just trying to get my bearings here bear with me." The controller asked the pilot if she would like the runway lights turned up and she replied yes. The pilot then reported she had the runway lights. The controller then lowered the runway light intensity to medium and told the pilot to inform him if she needed them lowered further. At 0008:19, the pilot replied "thank you sir I appreciate the help." No further transmissions were received from the flight.

Recorded radar data from the Jacksonville Center showed N41481 approached the Gainesville Airport from the northwest and circled the airport clockwise two times at between 1,200 and 1,700 feet. At 0008:15, the flight proceeded northeast. At 0009:37, the flight was about 3 miles northeast of the airport at 1,300 feet, at longitude 29 degrees, 43 minutes, 13 seconds North and latitude 82 degrees, 13 minutes, 24 seconds West. No further radar data from the flight was recorded.

Search and rescue efforts were initiated and the wreckage of N41481 was located on June 7, 1995, about 1130. The wreckage was located at longitude 29 degrees, 43 minutes, 5 seconds North and latitude 82 degrees, 11 minutes, 43 seconds West. See Air Traffic Control Group Chairman Factual Report.

PERSONNEL INFORMATION

The pilot's daughter stated after the accident that to her knowledge the pilot did not maintain a pilot logbook. She stated the pilot had about 2,500-3,000 flight hours. The pilot reported to the Federal Aviation Administration on an application for a medical certificate on July 11, 1994, that she had about 700 total flight hours and that she had flown 25 hours in the previous 6 months. The pilot's flight instructor stated he gave the pilot a biennial flight review in April 1994. See First Pilot Information.

AIRCRAFT INFORMATION

Logbook records for the aircraft were not located after the accident. The aircraft mechanic that performed the annual inspections on the aircraft stated he last inspected the aircraft on September 26, 1994, at aircraft total time 2831.78 hours. The aircraft flew 29 flight hours from the time of this inspection until the accident. See Aircraft Information.

METEOROLOGICAL INFORMATION

At 2357, the Gainesville Regional Airport surface weather observation showed the ceiling was measured 600 feet broken with visibility 6 miles in haze. A pilot who departed Gainesville Regional Airport runway 24 at about 2350 reported he encountered a 500-600 foot scattered to broken layer with visibilities of 3-4 miles in haze.

Doppler weather radar data from Jacksonville, Florida showed weak weather radar returns in the area of Gainesville, at 0007 and 0013. The GOES satellite data for 0002 and 0015 showed an area of possible low stratus clouds and/or fog to the north and northwest of Gainesville.

The ATC specialist at the FAA Gainesville Flight Service Station who talked with the pilot of N41481 stated that when he arrived for work about 2358, he observed the weather to be VFR with a thin scattered layer of 3/10 coverage. He did not specify the height of the layer. The visibility was 5-6 miles.

Information obtained from a computer based sun and moon information program showed that at the time of the accident the sun was at an altitude of -34.2 degrees at bearing 341.3 degrees. The moon was at an altitude of 23.4 degrees at bearing 256.9 degrees and had 58 percent illumination.

For additional meteorological information see Weather Information, Sun and Moon Information, Meteorological Factual Report, and the Air Traffic Control Group Chairman Report.

WRECKAGE AND IMPACT INFORMATION

The aircraft crashed in a swamp area, 5 miles northeast of the Gainesville Regional Airport. Examination of the crash site showed the aircraft touched down left wing first while on a 180-degree heading. The left wing and landing gear, left aileron, left flap, left horizontal stabilizer, left cargo door, and nose landing gear were found within the first 65 feet of the wreckage path. The fuselage, engine and propeller, and right wing crossed through a brush line and over a stream. The right wing, right main landing gear, right aileron, and right flap were found together about 100 feet from the initial impact point. The fuselage continued along the wreckage path and came to rest upright, 180 feet from the initial impact point.

All components of the aircraft which are necessary for flight were located along the wreckage path. Continuity of all flight and engine controls was established. Separation points within the control systems were typical of overstress separation.

Examination of the engine showed it rotated normally. Continuity was established within the valve train, crankshaft, and accessory drives. The oil suction screen and oil filter did not contain any abnormal debris. Each cylinder produced normal compression. The spark plugs had color consistent with normal engine operation. The magnetos were timed properly to the engine and each magneto fired normally when rotated by hand. The ignition switch was found in the both position and the switch operated normally. The engine-driven fuel pump contained clean 100LL fuel and operated normally. The carburetor contained clean 100LL fuel and the inlet screen was clean. All passages within the carburetor were unobstructed. The engine air filter was found in one piece. The filter had sustained impact damage. The engine muffler baffles were in place and there was no evidence of exhaust leakage from the muffler. The cable-driven engine tachometer was found indicating 2,600 rpm.

Examination of the propeller showed the propeller remained attached to the engine after the accident. Teardown examination showed each blade had heavy gouging along the leading edge and bending and twisting damage. Each blade had rotated toward the low pitch stop and each pitch change knob had separated due to overstress. No evidence to indicate precrash malfunction of the propeller was noted. Teardown examination of the propeller governor showed it had sustained impact damage. No evidence to indicate precrash malfunction was found. See propeller teardown report.

The airframe fuel valve was found in the right tip tank position. The alternator drive belt was found in place around the drive pulleys. The belt had sustained impact damage. The landing light and instrument panel flood light bulbs were found with the elements stretched. The engine-driven vacuum pump drive shaft had continuity. The vacuum pump rotated normally and there was no damage to the interior vanes or block. The vacuum-driven directional gyro and attitude indicator gyro had not sustained extensive impact damage. No rotational scars were noted on the rotors. No rotational scars were noted on the electric turn and bank gyro.

The altimeter was found indicating 46,070 feet with a setting of 29.82. Teardown examination showed there were no marks on the altimeter face from the needles contacting the face. Both sector gear pivot points had separated. All drive gears were in place. The aneroid diaphragm tested normally. All components had normal lubrication. No indications of precrash malfunction were found.

MEDICAL AND PATHOLOGICAL INFORMATION

Post-mortem examination of the pilot and five passengers was performed by Drs. Carolyn M. Hopkins and William F. Hamilton, Office of the Medical Examiner, Gainesville, Florida. The cause of death in each case was attributed to multiple blunt traumatic injuries. No findings which could be considered causal to the accident were reported.

Post-mortem toxicology testing on specimens obtained from the pilot and three of the five passengers was performed for the Medical Examiners Office by SmithKline Beecham Clinical Laboratories, Leesburg, Florida. Tests on the pilot's specimens were negative for carbon monoxide, ethanol alcohol, and drugs. Tests on the passengers' specimens were negative for significant amounts of ethanol alcohol, carbon monoxide, or drugs.

ADDITIONAL INFORMATION

The aircraft wreckage was released to Christopher J. Sheppard, Kenn Air, Inc., Gainesville, Florida, on June 8, 1995. Components retained by NTSB for testing were returned to Don Huntington, Quality Aircraft Salvage, Groveland, Florida, on June 27, 1995 and October 31, 1995.

An ATC group was formed to review the actions of Air Traffic Controllers and Flight Service Station specialists in the handling of N41481. At 2347, the Gainesville Flight Service Station specialist, who was also the controller-in-charge (CIC), who had weather observation responsibility took a record special observation. A broken ceiling at 600 feet was measured and visibility was 6 miles in haze. This weather observation indicated that IFR conditions prevailed at the Gainesville Airport. The specialist logged the report on the weather log and put the information into the weather computer for dissemination to other facilities. The specialist did not notify the specialist working the in-flight position or the Jacksonville Center. Jacksonville Center did not receive the weather observation until about 0004, after they had told N41481 to contact Gainesville Flight Service.

This specialist stated during an interview that she believes she told the oncoming CIC that the field was IFR. She then went off duty. When she left the facility shortly after midnight she stated it was clear and that she observed an airplane flying southeasterly at a low altitude with the navigation lights on. She did not observe a landing light.

The CIC who came on duty at 2300 and took charge at 0000, stated that he was briefed by the off going CIC about 2350. He stated he was told that there was a thin layer at 600 feet and that it would probably be gone the next hour. He did not believe the airport was IFR. He stated he did not look at the weather log at this time. He stated he realized the airport was officially IFR when he looked at the weather log at 0031 to record the weather observation at that time. He stated that during briefing from the off going CIC they did not use a checklist.

The specialist who was working the in-flight position at the Gainesville Flight Service Station at the time N41481 crashed stated, he entered the facility about 0000 for his shift. He noticed coming to work that the weather was about 3/10 thin coverage with fog and haze and that the moon was out about one quarter. Based on this he concluded the weather was VFR. He went directly to the in-flight position and relieved the off going specialist. He stated a checklist was not used for the shift transfer and no briefing was given. He did not check the weather and was not made aware of the current weather conditions that made the airport IFR. After talking to N41481 and loosing radio contact he was made aware by someone else in the facility that Gainesville was currently IFR.

When asked why he was unable to hear N41481 calling for about 4 minutes he stated that he was using a handset which required that all radio frequencies being monitored be put through the speaker on the console so they could be heard. The frequency N41481 was calling on, 119.55, was selected to a headset, which was not being used, and therefore could not be heard. When he was called on the land line by Jacksonville Center he corrected the problem.

Upon making contact with the pilot of N41481 at 0005:35 the specialist gave the pilot the current winds and altimeter setting. He did not give the current ceiling and visibility.

FAA Order 7110.10K, Flight Services, requires that Flight Service Station specialist issue the ceiling and visibility to VFR aircraft when less than basic VFR conditions exist. The order further states that if an aircraft operating under VFR attempts to enter, depart, or operate contrary to 14 CFR Part 91.157 (visual flight rules), the controller should issue the ceiling and visibility and request the pilot's intentions. Procedures, direction in defining the procedures, operating requirements, and personnel responsibilities are contained in Gainesville Flight Service order 7110.1, Standard Operating Procedures. Both 7110.10K, Flight Services, and 7110.1, Standard Operating Procedures, is supplemented by Letters of Agreement, Notices, and Memoranda. See Air Traffic Control Group Chairman Factual Report.

NTSB Probable Cause

THE PILOT'S LOSS OF AIRCRAFT CONTROL DUE TO SPATIAL DISORIENTATION AFTER CONTINUING THE VFR FLIGHT INTO INSTRUMENT METEOROLOGICAL CONDITIONS. FACTORS RELATING TO THE ACCIDENT WERE: THE EXISTING WEATHER CONDITIONS AND DARK NIGHT THAT CONTRIBUTED TO THE PILOT'S SPATIAL DISORIENTATION, THE FAILURE OF THE FSS WEATHER OBSERVER TO INFORM THE IN-FLIGHT SPECIALIST AND CENTER CONTROLLER THAT THE AIRPORT WAS UNDER IFR CONDITIONS, AND THE FAILURE OF THE FSS RELIEF IN-FLIGHT SPECIALIST TO MAKE HIMSELF AWARE OF THE CURRENT OFFICIAL WEATHER OBSERVATIONS AND TO THEN INFORM THE PILOT.