NTSB Factual Report

HISTORY OF FLIGHT

On June 14, 1996, about 0240 eastern daylight time, a Piper PA-23-150, N2189P, struck trees on rising terrain after departure from the Cortland County Airport, Cortland, New York. The airplane was destroyed, and the commercial rated pilot and two passengers were fatally injured. Instrument meteorological conditions prevailed, and the personal transportation flight was operated on an instrument flight plan under 14 CFR Part 91.

The pilot had recently accepted new employment and was in the process of moving from Augusta, Maine, to Bar Harbor, Maine. She and her husband had flown from Augusta, to Bowling Green, Ohio, On June 12, 1996, to pickup a relative who would assist them in the move. En route to Bowling Green, the flight had stopped at Cortland for fuel. A witness reported that upon departure from Cortland, the pilot experienced difficulty with starting the left engine; however, once started, it ran smoothly.

At Bowling Green, on June 13, 1996, prior to departure, the pilot experienced difficulty with starting both engines. She requested help from a mechanic, who declined due to the lack of available time; however, he did loan her tools to work on the airplane. The return flight to Augusta, departed Bowling Green, on the afternoon of June 13, 1996. Upon arrival at Cortland, the flight was serviced with 66.15 gallons of automotive gasoline which was paid for at 1609.

At 1910, the pilot called the Buffalo Flight Service Station for a weather briefing for an IFR flight to Augusta, Maine. She was advised of a line of thunderstorms between Cortland and Augusta.

A local pilot transported the pilot and passengers to a motel. No mention was made of any difficulty with the airplane.

At 2001, the occupants checked into a local motel.

At 2216, the pilot called the Buffalo Flight Service Station, and was advised that the line of thunderstorms were still present.

At 0030, a wake up phone call was placed to the room the pilot and passengers were occupying.

At 0035, June 14, 1996, the pilot called the Buffalo Flight Service Station, and was advised that the line of thunderstorms were still present.

At 0130, a call was placed to a local cab company for a cab to take the occupants to the airport.

At 0134, the pilot called the Buffalo Flight Service Station, and filed an instrument flight plan (Placed from motel).

At 0223, the pilot called the Buffalo Flight Service Station, and requested her IFR clearance. She received the clearance and was given a void time of 0245.

The pilot had filed direct to the Georgetown VOR as the first navigational fix. This was located 21 nautical miles from Cortland Airport, on a heading of 068 degrees.

Several witnesses reported that they heard the sounds of an airplane engine before the sound of an impact occurred. All witnesses reported that the engine(s) sounds were steady. Two witnesses reported the visibility was about 100 feet, and one witness reported the winds were calm. The witnesses lived on the north side of a road that ran along the north side of the airport. In most cases they were less than 150 yards of the accident site, and 150 yards from the runway.

The accident occurred during the hours of darkness at location 42 degrees, 35 minutes, 45 seconds North, and 76 degrees, 12 degrees, 45 seconds West.

PERSONNEL INFORMATION

The pilot was the holder of a commercial pilot certificate with airplane single engine land, multi-engine land, and instrument airplane ratings. In addition, she held a flight instructor rating with airplane single land, and instrument airplane ratings. Her pilot log book was not recovered and her flight times were estimated, based upon her recent employment application.

The pilot had recently been employed as a pilot for "Scenic Flights" under 14 CFR Part 91, and as a flight instructor. She was undergoing 14 CFR Part 135 initial ground school at the operator's facility. According to the chief pilot, she had missed a class on the evening of June 13, 1996, and was scheduled to be on duty for scenic flights at 0900 on June 14. No flights were scheduled at that time, and she was aware that another pilot had offered to cover her flight schedule in case she was unable to return in time. She was estimated to have about 50 hours in the accident airplane.

The last known flight review and instrument proficiency flight check occurred when the pilot added her multi-engine/multi-engine instrument rating to her commercial pilot certificate on August 8, 1995, using a Piper PA-34. The pilot's recent instrument experience was not determined.

AIRCRAFT INFORMATION

The airplane was a 1956 Piper PA-23-150 Apache. Family members reported that a search of the pilot's residence for the airplane log books was unsuccessful, and they were believed to be aboard the airplane. The airplane was estimated to have been operated about 50 hours since being purchased on May 18, 1996, for an estimated total airplane time of 4293 hours at the time of the accident.

METEOROLOGICAL INFORMATION

The airport was equipped with an Automated Weather Observation System (AWOS). Weather data was recorded every 20 minutes. Following are the visibility and cloud heights recorded by the AWOS:

June 13, 1996 At 2241, the visibility dropped below 3 miles At 2301, the visibility dropped below 2 miles June 14, 1996 At 0001, low clouds, 300 feet scattered appeared, visibility was 1 1/4 miles At 0021, the clouds were reported as 300 feet broken, visibility was 1 mile At 0041, the clouds were reported as 300 feet overcast, visibility was 1 mile At 0101, the clouds were reported as 300 feet overcast, visibility was 1 mile At 0121, the clouds remained at 300 feet overcast, the visibility dropped to 1/4 mile At 0141, the clouds dropped to 100 feet overcast, the visibility dropped to less than 1/4 mile. The observations remained the same until 0521 when the visibility started to increase.

AERODROME INFORMATION

Chase Field, Cortland County Airport was an uncontrolled airport. There was a UNICOM on the airport which had a common frequency used by pilots to announce their arrivals and departures. The frequency was unmonitored, and not recorded. The runway was 3400 feet long, 75 feet wide, and had an asphalt surface. No centerline lighting was installed. The runway was equipped with medium intensity runway lights which were spaced 200 feet apart. A check of the runway lights on the day following the accident revealed all were operative. No tire track leading off the runway were observed.

The published IFR departure procedure requires an airplane to maintain runway heading until reaching 2600 feet (MSL), at which point the flight can proceed on course. There were also published takeoff minimums of a 400 foot ceiling and visibility of 2 miles. These were not required to be followed by 14 CFR Part 91 operators.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on June 14, 1996. The engines were removed to the airport for further examination on June 15, 1996.

Measurements for the wreckage diagram were made as a group effort by the investigative team including personnel from the Safety Board, The New York State Police, The Federal Aviation Administration, Lycoming, and Piper. The drawing was made by the New York State Police.

The accident occurred in a stand of trees on a hill located about 400 yards north of the departure end of runway 6. Initial contact with the trees was about 30 feet above the ground, and 80 feet above the departure end of the runway, on a heading of 360 degrees. Broken branches and trees in the initial contact area were at a 30 degree angle with the right side higher. Parts of the airplane associated with the left and right sides of the airplane were found on the left and right sides of the debris path respectively. A burn area with an approximate 50 foot radius was centered where the airplane came to rest. Several trees contained scratch marks where the bark was worn away. These marks were on the sides of trees and led to the ground impact point. Two trees with bases greater than 12 inches were uprooted and bent in the direction of travel. Several pieces of cut wood were found at the scene. The left aileron was found lodged in a tree on the left side near the beginning of the debris path, about 20 feet up in a tree. The left engine generator was found 30 feet beyond the main wreckage. No evidence of fire was found at the initial impact point.

The cockpit/cabin was destroyed by fire. The use of seatbelts could not be confirmed. No information was obtained from the flight instruments or engine power controls. Both tachometers were recovered in burn area. The left tachometer needle was at 3000 RPM. The right tachometer was found at 2700 RPM. Both needles were easily moved.

The left propeller was separated from the left engine, and found laying at the base of a tree. There were some bends on the blades. The point of failure was the lighting holes on the propeller flange. The fracture faces were at a 45 degree angle and had a granular appearance. The right propeller was found attached to its engine. "S" curves were found on both propeller blades.

On the left and right engines, the top row of spark plugs were removed. They were gray in appearance with no impact damage. The engines was rotated and compression was obtained in all cylinders. Both magnetos on the left engine were damaged by fire and no spark was obtained from them. Spark was obtained from both right engine magnetos.

The right engine carburetor venturi was in place. The venturi from the left engine carburetor was not recovered. A piece of melted metal was found in the bottom of the left engine carburetor air heat box. It was retained for examination.

Flight control continuity was not confirmed due to impact and fire damage. All failures on pushrods were found between rod ends. All flight controls were either attached to their respective cable or pushrod, or the connection had been torn from the flight control surface. The rudder trim jack screw measured 0.75 inches, which corresponds to 8 degrees tab right. The elevator jack screw had 11 threads visible on the top which corresponds to 22 percent nose up trim. The elevator and rudder trim controls were mounted on the overhead panel above the pilot seats, and were not identified. The wing flap extension cylinder measured 23.5 inches, which corresponds to 12 to 14 degrees of flap extension, however, the hydraulic system had been compromised, and the cylinder was detached from the wing flaps.

All major landing gear components were accounted for at the accident. None of the landing gear were found in a down and locked position.

Both outboard wing panels were separated outboard of the engines. The right wing main tank was found to be about 1/2 full of fuel. All others were ruptured, and/or burned with no fuel present.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were conducted on the occupants by Samuel Livingstone, MD, Pathologist, Onondaga County, on June 15, 1996.

Toxicological testing conducted on the pilot by the FAA Civil Aeromedical Institute was negative for drugs and alcohol.

TESTS AND RESEARCH

The metal recovered from the left engine carburetor air box was forwarded to the NTSB Metallurgical laboratory where it was found to contain a large amount of zinc and some aluminum. The specification drawing obtained from Precision Aeromotive, in Seattle, Washington, called for, "Die Cast Zinc (Spec 185-1).

A loose gyro rotor was found in the debris area. It was not found attached to a gyro. It was forwarded to the NTSB Metallurgical laboratory where it was examined for impact marks, and none were found.

ADDITIONAL DATA/INFORMATION

A pilot who had ridden in the airplane several times recently reported that the airplane experienced numerous electrical problems, including loss of the instrument panel lighting and overhead dome lights. In addition, he reported that the turn and back needle was always moving and was not stable even in wings level flight.

The previous owner reported that the location of the flight instruments was the same as when the airplane had been built, which did not match a "T" arrangement. The only upgrades had been to the radios which remained in the same locations, but were newer models.

The airplane used by the pilot to pass her multi-engine instrument flight check had the flight instruments arranged in a "T" configuration.

A family member reported that the pilot and her husband were under pressure from their current landlord to evacuate their present housing by the end of the day on June 14, 1996. The landlord already had the property rented as a summer rental with new occupants arriving on June 15, 1996.

The aircraft wreckage was released to the Ryan Insurance Company, on June 15, 1996.

NTSB Probable Cause

the pilot failure to maintain directional control of the airplane which resulted in the airplane striking trees. Contributing factors were the pilot's spatial disorientation, dark night conditions, fog, and the pilot's self induced pressure to reach the destination.