NTSB Factual Report

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 recorded weather from Bedford, included visibility of 3/4 mile, ceiling 400 feet overcast, winds from 090 degrees at 8 knots. Interviews with pilots operating in the area disclosed the clouds extended west to the Hudson River, and the tops of the overcast was about 7,000 feet. The base of the clouds was about 450 feet. Local area witnesses reported that clouds were at the tops of the trees.

AIDS TO NAVIGATION

The route on the pilot's flight plan was based upon navigation between VOR stations. The final approach would have required an operative localizer and glide slope receiver. The localizer and glide slope were flight checked after the accident and found to be satisfactory.

RADAR AND OTHER REMOTELY RECORDED DATA

According to the instrument approach procedure for the ILS Runway 11 approach to Bedford, the minimum en route altitude to intercept the glide slope was 1,700 feet. The inbound heading on the localizer was 113 degrees. The glide slope crossed the outer marker at 1,456 feet. The published minimums for a straight-in approach were 383 feet, and 5,000 feet of RVR. The published missed approach was to climb to 2,000 feet, and proceed to Shaker Hills non-directional radio beacon, which was located about 6 nautical miles east of the airport.

Radar data from Boston Approach Control revealed the airplane was above the glide slope and descending as it approached the outer marker. The airplane crossed the outer marker at 2,000 feet, and then performed a descent to 700 feet in about 40 seconds, during which time it passed through and descended below the glideslope. The airplane then initiated a turn to the left and started climbing. The airplane proceeded northwest, and then while climbing initiated another turn to the left. In the turn the altitude was inconsistent, and the radius of turn decreased. The airplane completed over 360 degrees of turn. However, as the radius of turn decreased, the radar contacts became closer together, and it was not possible to discern the actual movements of the airplane in the last few seconds of the flight. The last radar contact occurred at 1102:51.56, with an indicated altitude of 500 feet. At that time, the airplane was about 245 feet northwest of the accident site.

While maneuvering the local controller had twice asked the pilot his heading. When the information received from the pilot was compared with the radar tracks, they were found to be similar.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on September 27 through September 29, 2003. The accident site was in a wooded area, with a ground elevation of about 200 feet. The tops of the trees were estimated to be between 75 and 100 feet high. The accident was located about 5,700 feet north of the localizer approach course, and 2.62 nautical miles from the approach end of runway 11, on a bearing of 134 degrees magnetic to the runway. Several trees were broken at a descending flight path of 26 degrees, which led to the main impact crater. The broken trees and debris field were on a heading of 130 degrees magnetic. The length of the debris field, from first tree impact to furthest object found, was about 250 feet.

The left wing was fragmented and pieces of the wing were found between the initial tree strike and the ground impact crater. The right wing remained with the airplane. The fuel caps were not identified. However, deformation was present in the cap locks, and on the right wing where lower wing skin was pushed against the fuel cap hole, fresh scratch marks were observed.

Flight control continuity was confirmed to the rudder. The up elevator cable was intact, and the down elevator cable was separated with no puffing at the ends. Flight control continuity to the ailerons could not be verified due to the breakup. However, both aileron cables were attached to their respective aileron bellcranks. The elevator trim measured one inch of rod extension, which corresponded to 10 degrees trailing edge down on the elevator trim tab.

The engine was separated from the fuselage and found nearby. The propeller hub was attached to the engine crankshaft; however, two of the three propeller blades were not in the hub and were found in the debris field. One propeller blade exhibited "S" bending on the trailing edge of the blade. When the magnetos were rotated by hand, all leads produced spark.

The engine crankshaft was rotated, and valve train continuity was confirmed. Thumb compression was obtained in all cylinders. The oil sump was fragmented and the sump screen not identified. The oil filter was cut open and was absent of debris.

The fuel control unit was fragmented. The fuselage collector tanks were found to contain fuel with 3 ounces of fuel found in the right collector tank, and 7 ounces of fuel found in the left collector tank. The fuel samples were blue in color, clear, and absent of debris. Both the left and right fuel tanks were compromised, and no fuel was found in either tank.

Filament stretch was observed in the navigation light bulbs located on the tail, and the left wing tip. The right wing tip navigation light was destroyed.

MEDICAL AND PATHOLOGICAL INFORMATION

The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for the pilot.

On September 29, 2003, autopsies were conducted on the occupants by the Medical Examiners Office, State of Massachusetts, Boston, Massachusetts.

The Concord Police Department found a diabetic test kit, including a glucose test meter, insulin, insulin syringes, and unidentified medication in a shaving kit, in the pilot' baggage, and forwarded the items to the Safety Board.

The glucose test meter was read out at the manufacturer's facility under the supervision of an FAA airworthiness inspector. The readings were consistent with a diabetic person. However, there was no date/time information recorded on the meter, and the date of the tests could not be determined.

The pilot's daughter, a physician, reported that she did not believe that her parents (both physicians) were diabetic and suggested that her father was transporting the items to give to someone.

A review of the pilot's FAA airman medical applications from May 27, 1977, through his most recent application revealed that on each application, he had checked NO to the question if had ever been diagnosed as a diabetic, or was a diabetic.

In addition, to the drug screen, a hemoglobin A1C check was performed on the pilots blood, and the results were 6.4 percent.

TESTS AND RESEARCH

Navigation Radios

The navigation radios were examined at Honeywell, in Olathe, Kansas, under the supervision of an airworthiness inspector from the FAA. The examination revealed the radios had received impact damage. On one navigation radio, the navigation frequency was found to be 111.15 Mhz, which corresponded to the ILS frequency at Bedford. The standby frequency was found to be 110.9 Mhz. The other radio had impact damage that precluded a frequency check.

The database in the GPS was found to be expired.

Attitude Indicator and Directional Gyro

The attitude indicator and directional gyro were forwarded to the Safety Board materials laboratory in Washington, DC for examination. Rotational scoring was found with the gyro from the attitude indicator. The directional gyro was found to be a slaved unit with no internal gyro.

ADDITIONAL INFORMATION

GPS/Nav Switch Flight Test

On October 30, 2003, a flight test was conducted in an exemplar Cessna 182, which was equipped with radios similar to the accident airplane. The purpose of the flight test was to check the function of the GPS/Nav switch. According to the report from Cessna:

"...the glide slope pointer on the HSI remained out of view unless a glide slope signal was being received and the GPS/Nav switch was in the Nav position. An ILS frequency in the active window of the # 1 navigation radio did not override the GPS/Nav switch. Therefore, localizer and glide slope information was not displayed on the HSI until the GPS/Nav Switch was selected to Nav....."

According to the Aeronautical Information Manual (AIM), 8-1-5, Illusions In Flight"

"Spatial Disorientati

NTSB Probable Cause

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