NTSB Factual Report

HISTORY 0F FLIGHT

On January 14, 2001, about 1825 eastern standard time, a Piper PA-28R-180, N3996T, registered to an individual, struck wires and impacted with the ground while performing the published procedure turn for an ILS approach to the Pitt/Greenville Airport (PGV), Bethel, North Carolina. Instrument meteorological conditions prevailed at the time. An instrument flight rules (IFR) flight plan was filed for the approach. The personal flight was conducted under 14 CFR Part 91. The airplane was destroyed. The private-rated pilot and one passenger were fatally injured. The flight had originated from Tifton, Georgia, at 1600.

The flight departed Tifton, en route to Greenville, North Carolina, without a flight plan, or incident, until 1803:13, when the pilot of N3996T made initial radio contact with the FAA Washington, air route traffic control center (ARTCC), New Bern (R25) sector, thirty miles southwest of Seymour Johnson Air Force Base, North Carolina. The pilot filed and was given an IFR clearance to descend to 3,000 feet from 5,500 feet msl, and proceed to Alwood, the IAF (initial approach fix) for the ILS runway 20 approach. The flight was cleared for the approach, via the published procedure turn. The minimum altitude for the procedure turn was 1,600 feet.

According to the Air Traffic Control (ATC) summary of flight, at 1804, the pilot of N3996T informed R25 of his position and that he would like the ILS to PGV. The controller instructed the pilot of N3996T to contact the controller at Seymour Johnson Approach control (GSB) for an IFR clearance inbound. The GSB controller cleared N3996T direct to PGV at 3,000 feet, and issued the IFR clearance. At 1812, the pilot of N3996T was issued and acknowledged his IFR clearance. At 1814, the pilot was asked to say his altitude. He said "2,500 feet." The R25 controller told the pilot, "...you're now on an IFR clearance to maintain three thousand." The pilot was asked if he had the AWOS (Automated Weather Observing Station) at PGV and he answered "affirmative." He was then issued the PGV altimeter of 30.19. At 1817, the pilot was again asked to say his altitude and this time he replied 2,800 feet. At 1820, the flight was over the initial approach fix, and was subsequently cleared for the ILS approach to PGV, to maintain at or above 1,600 feet in the procedure turn. The pilot acknowledged, and at 1824, the pilot of N3996T was instructed to change to advisory frequency. The pilot acknowledged the frequency change, and shortly after this radio and radar contact was lost.

A radar plot prepared by NTSB Operational Factors, AS-30, revealed that after receiving his instrument flight rules clearance, the flight had descended to the assigned altitude of 3,000 feet, and stayed at 3,000 from 1812:20 to 1813:20, and then descended to 2,800 feet. From 1813:41 to 1816:33, the flight descended from 2,800 feet to a low altitude of 2,300 feet, before starting to climb. The flight ascended from 2,300 feet to 2,700 feet in 40 seconds (600 feet per minute). The radar plot showed that the flight attained an altitude of 3,000 feet only once until reaching the initial approach fix at Alwood. The radar plot showed the flight crossed near Alwood at 1820:05, at an altitude of 3,000 feet, then outbound in a northeasterly direction. Twenty seconds later at 1820:25, the flight had descended to 2,800 feet. The flight then climbed to 2,900 feet and then descended back to 2,800 feet. At 1822:06, the flight was at 2,800 and then started to descend. At 1822:57, the flight was at 2,500, at 1823:37, 2,200 feet, and the last radar plot at 1823:47, showed the flight was at 2,100 feet.

PERSONNEL INFORMATION

The pilot, held a FAA private pilot certificate, with airplane single engine land, airplane instrument, last issued on May 5, 1997, when the airplane instrument rating was added. The pilot held an FAA class 3 medical certificate issued on June 20, 2000, with the limitations the "Holder shall wear corrective lenses." The pilot received a biennial flight review, as required by 14 CFR Part 61, on August 6, 1999. The pilot received his private pilot, airplane single engine land rating August 12, 1988. As per the entries in his personal flight logbook, he had accumulated a total of 4,015 total flight hours, 4,015 total single engine flight hours, and 137 hours in this make and model aircraft. In addition, the logbooks showed that he had a total of 3,546 cross country flight hours, 324 total night flight hours, 135 simulated instrument flight hours, and 105 actual instrument flight hours.

A breakdown of the instrument flight time the pilot had logged, revealed that 2 years before the accident in 1999, he had logged a total 8.6 instrument flight hours for the entire year, and for the entire year of 2000, he had logged a total 2.0 instrument flight hours. July 12, 2000, was the last entry that showed .4 of an hour instrument flight time.

AIRCRAFT INFORMATION

The airplane was a Piper Aircraft Inc., model PA-28R-180, serial number 28R-30351, manufactured in 1967. At the time of the accident the airplane had accumulated 6,943 total flight hours. The airplane received an annual inspection on September 22, 2000, 118.56 hours before the accident. The airplane was equipped with one Lycoming IO-360-B1E, 180 horsepower engine. According to the engine logbook, the engine was put in service June 29, 1969. On June 29, 1994, the engine underwent a major overhaul, and was reinstalled on N3996T at a tachometer time of 2,875.5 hours. On September 22, 2000, at tachometer time 5,168.62 hours, an annual inspection was performed on the engine. At the time of the accident a 118.56 hours had accumulated since the annual inspection, and the total number of hours on the engine at the time of the accident was 6,703.62 (See the copy of the engine logbook, an attachment to this report)..

A write up in the airframe logbook dated November 29, 2000, by Capital Avionics, Inc., Tallahassee, Florida, stated,that "Autocontrol 2 Autopilot System INOP," and they placarded the panel with "Autopilot INOP." Work Order Number: 23020.

According to the airframe logbook, on December 22, 2000, the following entry was recorded: "Removed altimeter type SEA-2 pt # AS-4-01, installed altimeter model ALT210NF-3N Ser # 60109. R Allen 258643495 A&P." On the same day the altimeter and static system tests were performed as required by F.A.R. Part 91.411 (See the copy of the airframe logbook, an attachment to this report).

METEOROLOGICAL INFORMATION

The reported weather at PGV at 1755 was; 300 overcast, visibility 1 sm light rain, winds calm, temperature 55 degrees F, dew point 54 degrees F, and the altimeter was 30.19 inches Hg.

The reported sunset for the Greenville area was 1719, civil twilight was 1747, nautical twilight was 1818, and astro twilight was 1849.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted with two power lines about 35 feet above the ground, then impacted in an open field, located about 11.5 nautical miles north of the Greenville/Pitt Airport. The accident occurred during the hours of darkness about 35 degrees, 50 minutes north, and 078 degrees, 45 minutes west. After impact with the power lines the airplane continued on a wreckage path heading of 026 degrees. A ground scar was observed about 45 feet north of the power lines. The first piece of airplane, the right wing tip, was found about 75 feet north of the power lines, and about 10 feet east of the wreckage path. The largest of three ground scars was located on the wreckage path about 85 feet north of the power lines. About 3 feet west and adjacent to the larger ground scar was a Plexiglas windshield seal and about 3 feet north of the seal was the right stabilator tip. The right stabilator tip displayed wire strike marks. The right wing, with the main landing gear extended, was found about 5 feet west of the wreckage path and about 150 feet north of the power lines. The wreckage came to rest in a small cemetery, with about five grave sites, located in the middle of the open field, about 195 to 200 feet north of the power lines. The nose of the airplane came to rest on a heading of 200 degrees, the engine and left wing remained attached. The tail section was found lying over the top of the wreckage with the vertical stabilizer lying near the cabin area.

Examination of the left wing revealed impact damage to the outboard leading edge. The aileron had remained attached at both hinge points. Impact damage was observed on the aileron on the outboard leading edge, and about a 1-foot section of the upper skin area. The flap displayed impact damage on the inboard trailing edge. The flap remained attached to the wing at all of the hinges. The flap mechanism had separated and was found destroyed. The fuel cap was in place and secured. Before the wreckage was removed from the crash site, about 6 ounces of fuel was drained from the fuel tank. The left main landing gear was still attached, and was found in the down position.

Examination of the right wing revealed it had separated from the airframe at the wing root. The outboard leading edge displayed impact damage, and buckling. The aileron was found attached at the hinge points. The aileron displayed buckling from the mid section to the inboard section. The aileron bell crank was found separated from its attachment points. The aileron cables were found separated and the cable breaks appeared to be broom-straw and unwound. The flap displayed impact damage and had separated from its attachment points. The fuel cap was found in place and secure. The fuel tank was breached and no fuel was observed in the tank. The edge of the fuel tank displayed a vertical slice about 8 inches deep. The main landing gear was still attached and found in the down position.

The vertical stabilizer and horizontal stabilator displayed impact damage. The rudder and the stabilator stops did not display any damage. Rudder continuity was established from the rudder to the rudder control pedal. Stabilator continuity was established from the stabilator to the cabin area. The horizontal stabilator trim mechanism measured 7/8 of an inch, which equated to a neutral trim position. The Left horizontal stabilator displayed wire strike marks.

Examination of the cockpit revealed that the landing gear switch was found in the "DOWN" position. The flap lever was found in the second notch position. The flap lever was found loosened from its attachment points. The fuel selector valve was found selected to the "RIGHT" tank position. All the seats had separated from their attachment points.

The engine was removed from the crash site and examined at the facilities of Dillion Aviation, Greenville, on January 15, 2001. The examination revealed that the throttle linkage was found in the full open position, and the mixture in the full rich position. The propeller, top spark plugs, vacuum pump and number 1 rocker cover were removed. The fuel line between the engine driven fuel pump and servo was removed, and uncontaminated fuel was found. The line from the servo up to the flow divider at the servo was removed and uncontaminated fuel was found. The crankshaft rotated freely and completely. Continuity was confirmed to all gears and rocker arms. Compression and suction was confirmed on all cylinders. During the rotation of the engine, fuel was noted squirting out of the outlet fitting of the fuel pump. The inlet screen to the fuel servo was removed and found clean. Examination of the magnetos revealed that during rotation of the crankshaft the impulse coupling in the left magneto was heard clicking. Spark was confirmed to all the leads on the left magneto. The right magneto was removed and rotated freely by hand. Spark was confirmed from all the leads.

The propeller examination revealed that that the propeller and spinner were still partially attached to the engine, and the blades were found at a low blade angle. Both of the propeller blades were bent aft, one of the tips curled forward and the other tip was bent aft. The spinner was found torn open. The propeller governor was found in place and undamaged. No discrepancies were found on either the engine or the propeller. All damage was consistent with impact damage.

The vacuum pump was found still attached to the engine accessory case and was not damaged. The drive and coupling were found in place. After the pump was removed from the engine, it rotated freely by hand, and suction was noted. The vacuum pump was opened; the rotor and vanes were not damaged.

TEST AND RESEARCH

The heading, attitude and turn and bank indicators were sent to the NTSB Materials Laboratory, Washington, D.C., for examination. The examination of the heading indicator revealed that the gyroscope assembly was not damaged. There was one scoring mark on about one-third of the gyroscope rotor's circumference, but there was no corresponding scoring on the inside of the gyroscope housing.

The attitude indicator did not display any damage to the external case. Visual examination of the gyroscope assembly after it was removed from the case revealed that it was not damaged. The gyroscope assembly was removed from the indicator and disassembled. There was no rotational damage found on the gyroscope rotor or the gyroscope housing.

The electrically driven turn and bank indicator revealed that when moved, a rattling sound could be heard inside the indicator. The glass plate on the front of the instrument was undamaged. Inside of the indicator, the gyroscope assembly was not connected to the faceplate. One of the mounts that hold the assembly inside of the case was found broken. Visual examination of the gyroscope revealed that it was not damaged. One side of the gyroscope rotor was painted black, and no scratches were found on the paint. There was no rotational damage on the gyroscope rotor or the gyroscope housing (See the NTSB Materials Laboratory Factual Report, an attachment to this report).

The altimeter was also sent to the NTSB Materials Laboratory, who forwarded it to Wultrad Inc, Grayslake, Illinois, the manufacturer, for a performance test. The case leakage test showed a total 100 feet per minute, and a case leakage of 10 feet per minute. The after effect feet was 10, and all other test appeared to be within limits. (See the Wultrad Performance Test Report, an attachment to this report). The pilot of N3996T was issued the PGV altimeter of 30.19 when he was given his IFR clearance. Twice after receiving the IFR clearance and told to maintain 3,000 feet, the pilot was asked to say his altitude. The first time was at 1615, and the pilot answered 2,500 feet. The radar plot for that time confirmed that the mode "C" altitude was 2,500 feet. The second time was at 1617, and the pilot answered 2,800 feet. The radar plot for that time confirmed that the mode "C" altitude was 2,800 feet.

MEDICAL AND PATHOLOGICAL INFORMATION

Dr. Paul R. Spence performed an autopsy on the pilot, at the Medical Examiners Office, Greenville, North Carolina, on January 15, 2001. According to the autopsy report the cause of death was "…Avulsion of the cerebrum and fracture of the spine due to multiple cranial and vertebral fractures due to blunt force injuries...." No findings that could be considered causal to the accident were reported.

Toxicological tests were conducted at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol detected in Vitreous." Drugs were found in the urine and blood, to include; Doxylamine, Dextromethorphan, Pseudoephedrine, and Chlorpheniramine. (See the Federal Aviation Administration's Toxicology Report, an attachment to this report).

The FAA does not regulate the use of any specific prescription or over-the-counter medications by pilots, though the FARs do state that (Sec. 91.17): "No person may act or attempt to act as a crewmember of a civil aircraft … While using any drug that affects the person's faculties in any way contrary to safety…." FAA Aviation Medical Examiners are instructed (1999 Guide for Aviation Medical Examiners, page 22) to d

NTSB Probable Cause

the pilot's failure to maintain control of the airplane due to spatial disorientation, which resulted in an in-flight collision with power lines and the subsequent impact with terrain. A factor in this accident was: the pilot's lack of recent instrument flight experience.