NTSB Factual Report

HISTORY OF FLIGHT

On June 21, 2008, about 1042 eastern daylight time, a Piper PA-28-140, N8776N, was substantially damaged when it impacted a tidal flat in the vicinity of Crockett Point while maneuvering near Knox County Regional Airport (RKD), Rockland, Maine. The certificated private pilot was killed. Visual meteorological conditions were recorded at the airport, however; instrument meteorological conditions were observed in the vicinity and at the accident site. No flight plan was filed for the local personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91.

The airplane was owned and operated by the members of the Knox County Flying Club. The accident pilot had rented the airplane for a one and a half-hour block that started at 1030 with another member scheduled for the airplane at 1200. One of the members talked with the accident pilot prior to her departure. He stated that the pilot was continuously checking the weather, and waiting for the overcast cloud layer to surpass 1,000 feet above ground level, so she could take her flight, which was going to remain in the traffic pattern at the airport.

The witness observed the accident airplane take off and enter a fog bank immediately off the departure end of runway 13 near the water. The engine pitch then increased, and was followed shortly by the sound "of a thud." He along with two other ear witnesses immediately called 911 and then proceeded to find the accident scene. The airplane was found approximately 200 feet from the shoreline in about 4 feet of water, inverted in the tidal flat. The debris field was approximately 300 feet in length and was comprised of numerous boulders and scattered aircraft pieces. The left wing was separated from the fuselage by a boulder and the right wing remained attached to the fuselage.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a rating for airplane single engine land. She did not possess an instrument rating. Her most recent Federal Aviation Administration (FAA) third-class medical certificate was issued in September 8, 2006. According to the accident pilot’s last FAA medical application, she had accumulated 500 total hours of flight experience. Excerpts from the pilot's logbook revealed that she had 12 hours of flight experience in the past 12 months, which included 1.0 hour in the previous 6 months, which was flown 2 days prior to the accident flight. That flight was conducted with a Certificated Flight Instructor as part of a yearly requirement for the flying club’s insurance. Her last biennial flight review was completed on August 6, 2006.

AIRCRAFT INFORMATION

The four seat, single-engine low-wing monoplane, serial number (S/N) 28-25600, was issued an airworthiness certificate in February 1969. The airplane was equipped with a Lycoming O-320-E2A engine.

A review of the airplane’s maintenance logbooks revealed that its most recent annual inspection was completed on December 05, 2007, with a total time in service of 7,293 hours. The last 100 hour inspection on the airplane was completed on May 15, 2008 with a total time in service of 7,387.9 hours. At the time of the accident, the airplane had accumulated a total time in service of 7,401.7 hours. The engine was overhauled on March 14, 2006 with a time in service of 4,283.52 hours. The last 100 hour inspection on the engine was completed May 15, 2008 with a total time in service of 4,792.5 hours. During this inspection the muffler was inspected and no discrepancies were noted, the compression of the cylinders was checked, the engine oil and filter were replaced. The used oil filter was then opened and inspected with no discrepancies noted. The airplane also had a supplemental type certificate allowing the use of automotive gas fuel.

METEOROLOGICAL INFORMATION

The weather reported at RKD, at 1035 included winds from 100 degrees at 8 knots, visibility 6 miles, an overcast layer at 1,200 feet, temperature 15 degrees Celsius (C), dew point 13 degrees C, and an altimeter setting of 30.04 inches of mercury.

The weather reported at 1015 included an overcast layer at 1,000 feet and the 0955 observation reported an overcast layer at 800 feet. The weather reported after the accident at 1055 included a broken layer at 1,200 feet and the 1115 observation reported a broken layer at 1,000 feet.

The Maine State Police officer that responded to the scene within 15 minutes of the accident reported to the National Transportation Safety Board that there was a fog bank over the water south of the field and the horizontal visibility was estimated to be 250 feet.

WRECKAGE AND IMPACT INFORMATION

The wreckage impacted a tidal flat approximately 3,600 feet from the departure end of the runway on a course of 077 degrees magnetic. The wreckage was recovered by a local salvage company and transported to the owner’s hangar at the airport. Examination of the wreckage was conducted at the hangar by an FAA inspector who verified control continuity for all control surfaces. Fuel samples were taken from the accident airplane and the fuel storage tank, which supplied the fuel, and no contaminants were found.

The wreckage was subsequently transported to a secure salvage yard for further examination, where it was examined on July 21, 2008, under the supervision of a FAA inspector. The engine was rotated by hand and good thumb compression was noted on all cylinders. The left-hand magneto sparked on two leads when the engine was rotated. The carburetor was disassembled and the floats were intact. The vacuum pump rotated freely by hand and was then disassembled and the vanes were intact. The attitude indicator was disassembled and the rotor was removed from the housing, scoring marks were observed on the inside of the housing. No preimpact malfunctions were noted.

MEDICAL AND PATHOLOGICAL INFORMATION

The Maine Medical Examiners Office, Augusta, Maine, performed an autopsy on the pilot on June 21, 2008. The reported cause of death was "multiple blunt force trauma."

Toxicological testing was performed post mortem at the FAA’s Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for carbon monoxide, cyanide, ethanol, and drugs, legal or illegal.

ADDITIONAL INFORMATION

According to the FAA Airplane Flying Handbook, FAA-H-8083-3A (Chapter 16, Emergency Procedures), "A VFR pilot is in IMC conditions anytime he or she is unable to maintain airplane attitude control by reference to the natural horizon, regardless of the circumstances or the prevailing weather conditions."

The handbook additionally stated, "The pilot must believe what the flight instruments show about the airplane’s attitude regardless of what the natural senses tell. The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes which occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

According to the FAA Airplane Instrument Flying Handbook FAA-H-8083-15A, the definition of somatogravic illusion was "The misperception of being in a nose-up or nose-down attitude, caused by a rapid acceleration or deceleration while in flight situations that lack visual reference." It further stated in Chapter 1 that "…[accelerating] stimulates the otolith organs in the same way as tilting the head backwards. This action creates the somatogravic illusion of being in a nose-up attitude, especially in situations without good visual references. The disoriented pilot may push the aircraft into a nose-low or dive attitude."

FAA Advisory Circular 60-4A stated in part, "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments." It further states, "Tests conducted with qualified instrument pilots indicate that it can take as much as 35 seconds to establish full control by instruments after the loss of visual reference with the surface."

NTSB Probable Cause

The non-instrument rated pilot becoming spatially disorientated after inadvertently entering instrument flight conditions.