NTSB Factual Report

HISTORY OF FLIGHT

On January 19, 1995, about 1332 eastern standard time, a Piper PA-28-236, N8423B, registered to ACJ Aviation, Inc., crashed near York, South Carolina, shortly after takeoff from the Bryant Field, Rock Hill, South Carolina, while on a 14 CFR Part 91 personal flight. Instrument meteorological conditions prevailed at the time and an IFR flight plan was filed. The airplane was destroyed and the private noninstrument-rated pilot and one passenger were fatally injured. The flight originated about 1328.

About 1136.57, an individual using the registration number of the accident airplane contacted the Anderson, South Carolina, Automated Flight Service Station (AFSS) via telephone and requested a standard weather briefing. The proposed flight was from the Rock Hill Airport, Rock Hill, South Carolina to the Washington County Airport, Washington, Pennsylvania. The briefer advised the individual in part of the flight precaution for IFR along that entire route and also for mountain obscuration. The individual was also advised that at the Charlotte/Douglas International Airport located about 15 nautical miles and 028 degrees from the departure airport, the ceiling and visibility were measured 500 feet overcast 4 miles light drizzle. The forecast ceiling and visibility at the Charlotte/Douglas International Airport at the estimated time of departure was 500 feet overcast with unrestricted visibilities with occasional 3 miles with light rain and fog. The individual asked the briefer for reports of the tops of the clouds and he was advised that earlier the tops were 4,000 to 5,000 feet.

About 1158.19, an individual using the registration number of the accident airplane again called the Anderson, South Carolina, AFSS, and filed an instrument flight rules (IFR) flight plan for the proposed flight from Rock Hill, South Carolina, to Washington, Pennsylvania. The named pilot was the accident pilot.

Both fuel tanks were filled the morning of the accident and about 1230, the FBO manager where the fuel was purchased listened to the Charlotte/Douglas International Airport, Automatic Terminal Information Service (ATIS). She stated that she heard that the ceiling was reported as 500 feet overcast and the visibility was 3 miles. She advised the accident pilot that the airport did not have a Remote Communications Outlet (RCO) but there was a direct telephone line to the Charlotte Airport Terminal Radar Approach Control (TRACON) facility.

About 1312.45, the Charlotte Air Traffic Control Tower Radar Coordinator Departure position received a call from a person who identified himself as the pilot of the accident airplane, requesting activation of his filed IFR flight plan. The flight was cleared to the destination airport as filed in the IFR flight plan. The pilot was advised to enter controlled airspace heading 300 [degrees] maintain 3,000 [feet] expect clearance on course and 9,000 [feet] 10 minutes after departure. The departure frequency, transponder code 3543, void time, and Charlotte altimeter setting of 29.90 inHg were also given to the pilot.

The flight departed and about 1329.12, the airplane was observed on the secondary radar at 1,600 feet on a heading of 307 degrees. About 1330.23, the pilot contacted the Charlotte Air Traffic Control Tower Departure Radar West controller and at 1330.48, the pilot was advised to ident. About 1330.56, radar contact was established and the flight was cleared to the destination airport as filed. About 1331.12, the pilot was advised to fly heading 340 [degrees] and climb and maintain 9,000 [feet]. The pilot responded only with "four two three bravo." About 1331.25, the pilot advised the controller that the flight was currently leaving 3,500 feet. Review of recorded radar data revealed that about that time the airplane was at 3,300 feet. The controller acknowledged the pilot's altitude report and there was no further recorded voice transmission from the accident pilot. Review of the recorded radar data revealed that about 19 seconds after the pilot was advised to fly heading 340 degrees, the airplane heading was 337 degrees. About 4 seconds later with no further heading instruction changes from the controller, the airplane heading was 357 degrees and the ground speed had increased from 130 knots to 141 knots. The aircraft heading continued changing in a clockwise direction to the last recorded heading of 061 degrees. During the change of heading the groundspeed changed from a maximum of 158 knots to a minimum of 43 knots with a continuing decrease in altitude. The last recorded altitude was 1,700 feet. The airplane collided with trees during a nose-low descent and was destroyed by impact and a postcrash fire.

PERSONNEL INFORMATION

Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. Review of the FAA airman certification records revealed that the pilot did not have an instrument rating. According to the FAA Form, Rating Certification and/or Rating Application dated October 7, 1993, the accident pilot had received 4.0 hours of instrument training for his private pilot certificate. Additionally, the accident pilot was given instrument training on two flights in instrument meteorological conditions (IMC) after his private pilot certificate was issued. The pilot-in-command of each of these flights was the recommending instructor for the accident pilot's private-pilot certificate. About 8.5 hours of instrument time was logged by the pilot-in-command who is also an instrument flight instructor. About 2 weeks before the accident, the same instructor talked with the accident pilot about starting his instrument training. According to the pilot's daughter, her father was studying for the instrument written examination and his pilot logbook was in the airplane. According to the passenger's husband, she had no flight training.

AIRCRAFT INFORMATION

Information pertaining to the airplane is contained in the NTSB Factual Report-Aviation and Supplements A & B. Additionally, review of aircraft records revealed that the altimeter and transponder tests were accomplished on January 3, 1994, and the airplane was equipped with an alternate vacuum system.

METEOROLOGICAL INFORMATION

Review of the Airport Facility Directory for information pertaining to the departure airport revealed no weather data sources available. A weather observation taken at the Charlotte/Douglas International Airport about 18 minutes after the accident was as follows: ceiling measured 300 feet overcast, visibility 3 miles fog, temperature 50 degrees, dew point 48 degrees, wind from 140 degrees at 7 knots, altimeter 29.90 inHg. The Charlotte Airport was located about 14 nautical miles and 043 degrees magnetic from the accident site.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane collided with about 40 to 50-foot tall trees while on a magnetic heading of about 095 degrees. Evidence of a ground scar indicated impact with the propeller about 100 feet forward from the initial contact with trees. Numerous pieces of severed tree trunk contacted by the propeller and components of the airplane were located along the wreckage path of the airplane. Both wings, the engine assembly, the propeller, and the right horizontal stabilizer were separated from their respective attach points but all separated components were located adjacent to the wreckage. The main body of the wreckage was located about 250 feet from the initial impact point with the trees and the cockpit and cabin area were nearly consumed by the postcrash fire. Examination of the aileron, elevator, and rudder flight controls revealed no evidence of preimpact failure of malfunction. The pilot's logbook was not located in the wreckage. The vacuum annunciator bulb was located and removed for examination which revealed that the glass envelope was broken. Examination of the filament revealed that it was not grossly deformed. The vacuum pump which was separated was found adjacent to the firewall on the ground in an area damaged by the postcrash fire. The pitch stabilization system programmer which was found near the main wreckage was removed for further examination. The separated engine, propeller, and separated engine components were transported to a facility for further examination.

Examination of the engine revealed that the vacuum pump, carburetor, governor, and engine-driven fuel pump were separated. The governor was not located. The dual magneto was separated from the accessory case but was still connected to the engine by the ignition leads. Examination of the engine revealed crankshaft, camshaft, and valve train continuity. Continuity to the accessory section was also verified. The magneto drive was rotated by hand which revealed spark at all of the ignition towers. Examination of the separated carburetor revealed that the inlet screen was clean as well as the carburetor bowl. Examination of the separated engine-driven fuel pump revealed fire damage which precluded testing. The directional gyro which was separated from the instrument panel was retained for further examination. Examination of the directional gyro revealed that the rotor housing assembly was unsecured due to impact damage. One of the two bearings for the rotor housing assembly was not located. Examination of the rotor and rotor housing assembly revealed no evidence of scoring on either the rotor or rotor housing. Examination of the separated vacuum pump revealed that the outer spline and shear coupling were not recovered. The inner spline was heat damaged. Disassembly of the vacuum pump revealed no evidence of scoring of the inside of the pump housing and the rotor vanes were intact. The rotor was found broken.

MEDICAL AND PATHOLOGICAL

Post-mortem examinations of the pilot and passenger were conducted by Clay A. Nichols, M.D., Assistant Professor of Pathology & Laboratory Medicine. The cause of death for both was listed as multiple trauma due to an airplane crash.

Toxicology testing of specimens of the pilot was conducted by the Armed Forces Institute of Pathology. The results were negative for cyanide, volatiles, and tested drugs. The carboxyhemoglobin saturation in the blood was determined to be 5 percent.

FIRE

A postcrash fire nearly consumed the cockpit and cabin area of the fuselage.

TESTS AND RESEARCH

A component of the autopilot system called the pitch stabilization system programmer was sent to the FAA to transport to the manufacturers facility for examination. Examination of the unit revealed that impact damage precluded applying power to operationally test the unit. The numerous light bulbs which indicate mode engagement were removed for microscopic examination. Examination of the bulb filaments revealed none were grossly deformed.

ADDITIONAL DATA/INFORMATION

The wreckage and all retained components were released to Mr. Marshall Dean, USAIG, April 7, 1995.

NTSB Probable Cause

THE NONINSTRUMENT-RATED PILOT'S FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE DUE TO SPATIAL DISORIENTATION WHILE CONDUCTING FLIGHT IN INSTRUMENT METEOROLOGICAL CONDITIONS (IMC). A FACTOR RELATING TO THE ACCIDENT WAS: FAILURE OF THE PILOT TO FOLLOW PROCEDURES/DIRECTIVES BY CONDUCTING FLIGHT IN IMC WHEN HE LACKED TRAINING/QUALIFICATION FOR FLIGHT IN INSTRUMENT CONDITIONS.