NTSB Factual Report

HISTORY OF FLIGHT

On March 19, 2001, about 1900 eastern standard time, a Piper PA-28-RT201 Arrow, N2380U, was destroyed during a collision with trees and terrain while on approach to runway 34R at the Manassas Regional Airport, (HEF), Manassas, Virginia. The certificated commercial pilot/owner was fatally injured. Visual meteorological conditions prevailed for the flight that originated at the St. Mary's County Airport (2W6), Leonardtown, Maryland. No flight plan was filed for the personal flight conducted under 14 CFR Part 91.

According to the pilot's son, the pilot flew to St. Mary's to drop off clothes that belonged to his granddaughter, and was returning to Manassas when the accident occurred. The pilot left a message on a telephone answering machine about 1730, saying that he would wait at St. Mary's until 1800, then depart for Manassas.

A review of an Air Traffic Control (ATC) transcript revealed that the pilot contacted the Manassas Tower for landing instructions. According to the transcript:

18:48:08 - Pilot: manassas tower piper two three eight zero uniform with romeo we're six miles east landing manassas.

18:48:14 - Tower: two three eight zero uniform piper type enter the right base three four right report two out.

18:48:20 - Pilot: report two out piper arrow eight uniform.

18:55:06 - Tower: arrow two three eight zero uniform tower.

18:55:09 - Pilot: tower arrow three eight zero uniform three miles out from three four right.

18:55:13 - Tower: okay you on the base yet?

18:55:14 - Pilot: affirmative.

18:55:28 - Tower: eight zero uniform not in sight three four right cleared to land.

The controller made five subsequent radio transmissions to the airplane, and asked another pilot to check the runway for it. The controller received no response from the accident pilot, and the search of the runway was unsuccessful. The controller did not continue the search for the airplane, nor did he initiate overdue aircraft procedures.

Examination of radar data revealed that a target was about 10 miles from the airport, at 1,400 feet msl, when the pilot called for landing instructions. The target approached the airport from the east and was oriented on an approximate right base for landing on runway 34R.

The target continued on the westerly track until it approached the extended centerline to the approach end of Runway 34R, about 6 miles south of the airport. The target then initiated a turn to the south, away from the airport, and completed about a 270-degree left turn to the north, back towards the airport.

A Safety Board air traffic specialist superimposed the airplane's radar track over the GPS Runway 34 approach chart at the Manassas Airport. The target completed the 270-degree turn oriented approximately over the intermediate approach course. The target then passed directly over Peszy intersection, the final approach fix, at 1,600 feet. The target continued towards the airport at 1,600 feet msl, approximately over the 326-degree final approach course. The target continued on that approximate heading and altitude, until 2.3 miles from the approach end of the runway, where it initiated a descent.

The target continued to descend, and disappeared after reaching 600 feet, 1.1 miles from the approach end of runway 34R. From the top of the descent, to the point where the target disappeared, the average groundspeed was 120 knots and the average rate of descent was 1,200 feet per minute.

The wreckage was located in wooded terrain on March 20, 2001, about 1800. The wreckage was 4/10 of a mile from the approach end of runway 34R at HEF, on the extended runway centerline.

The accident occurred during the hours of darkness, approximately 38 degrees, 42 minutes north latitude, and 077 degrees, 30 minutes west longitude.

PILOT INFORMATION

The pilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, and instrument airplane. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued on April 12, 1999, with no restrictions.

The pilot's logbook was located in the wreckage, and appeared to be meticulously maintained. The most recent entry was on February 13, 2001. As of that date, the pilot had logged 2,116 hours of flight experience, of which 68 hours were in the year prior to the accident. With the exception of 2.3 hours in an instrument flight simulator, all of his flight experience during the previous year was in the accident airplane.

The pilot's most recent biennial flight review (BFR) was completed October 22, 1999. The logbook entry detailed 1 hour of ground school in addition to 1.6 hours of flight time. The pilot completed an instrument competency check November 22, 1999. The flight annotated just prior to the BFR was conducted November 25, 1994.

The pilot logged 251 hours of night flight experience. The most recent logbook entry for night flight was for 1 hour on February 18, 1993. However, the pilot noted 2 takeoffs and landings at night in the remarks section of a day VFR flight logged March 4, 2000.

AIRCRAFT INFORMATION

The airplane was a 1979 Piper PA-28-RT201 Arrow. Examination of the airplane's maintenance records revealed that it was on an annual inspection program. The most recent annual inspection was completed on November 6, 2000, at 3,394 aircraft hours. At the accident site, the airplane's tachometer showed 3,404 aircraft hours.

Examination of fuel records revealed that at 1630, on the day of the accident, the airplane was "topped off" with 41.9 gallons of 100LL aviation gasoline.

METEOROLOGICAL INFORMATION

The weather reported at the Manassas Regional Airport at the time of the accident included clear skies, 10 miles of visibility, and winds from 360 degrees at 5 knots.

According to the United States Naval Observatory, official sunset was at 1822. There was no moon.

AERODROME INFORMATION

The daily field inspection for the Manassas Regional Airport for both March 19 and 20, 2001, reported all airport lights were operational. The Precision Approach Path Indicator (PAPI) lights were on continuously.

WRECKAGE INFORMATION

The wreckage was examined at the accident site on March 21, 2001. All major components of the airplane were accounted for at the scene. The wreckage path was 225 feet long and oriented 340 degrees magnetic.

The initial impact point (IIP) was a tree strike approximately 60 feet above the ground. A green navigational light and angular cut wood was found near the base of the tree.

The left side of the horizontal stabilator was located 80 feet from the IIP and 20 feet to the left of the wreckage path centerline. The stabilator displayed concave dents along and perpendicular to the leading edge. The trim tab was attached at all three of its hinges.

The outboard tip of the right wing was located 110 feet from the IIP, and 30 feet left of the centerline. This section displayed concave dents along and perpendicular to the leading edge.

The right wing, the vertical stabilator, and the right side of the horizontal stabilator were located 125 feet from the IIP, and aligned with the wreckage path. The wing was separated at the main spar and forward attach fittings.

The outboard portion of the right wing rested against a tree at a 45-degree angle to the ground. The right wing, right flap and right aileron were attached. The right flap was in the 10-degree down position. The aileron bellcrank was separated from its mounting and the bellcrank lever was found next to the landing gear strut assembly. Aileron cable continuity was established from the bellcrank to the wing root, at the point of separation. The cable end was "broomstrawed".

A concave dent perpendicular to the leading edge was located about 1 1/2 feet from the outboard end of wing, and the indentation was about 6 inches deep. A section of the wing was torn and displaced aft from the leading edge to the main spar, outboard of the fuel tank. The fuel tank was ruptured and the fuel cap was secured. The right landing gear was in the down and locked position.

The vertical stabilator came to rest underneath the right wing. The right side horizontal stabilator was attached to the vertical stabilator and displayed a concave dent 2 feet from the outboard tip. The rudder was attached to the vertical stabilator at the top hinge; the remaining portion of the rudder was displaced aft at a 45-degree angle beginning 8 inches from the top. The trim measurement was 1 1/4 inches; and the cables were displaced around the drum.

The main wreckage came to rest inverted, 225 feet from the IIP, and included the fuselage, engine, and left wing. The right door was hinged open, and the baggage compartment door on right side of fuselage was torn off and rested on a tree branch. The left wing was separated at the middle and aft attach points, but remained attached at the forward attach point. The aft main root attach bracket was pulled from the fuselage. The left wing displayed concave dents along the leading edge to a point 4 feet, 5 inches inboard from the wing tip. The outboard section of the wing was ripped at the outboard border of the fuel cell; this portion was displaced aft about 30 degrees from the rest of the wing.

Aileron cable continuity was observed from the control surface to the wing root. The aileron balance cable was "broomstrawed" at the turnbuckle. A bird's nest was noted in the aft portion of the wing. The pitot tube and static hoses were connected through the wing break. The fuel line from the fuel tank to the wing root was intact and had no stains. An odor of fuel was present; the fuel cap was secured; and the tank contained fuel. The left landing gear was in the down and locked position. The left flap was in the 10-degree down position, which correlated with the flap handle position. Visual examination of the left flap concurred with the flap actuator handle. Rudder control continuity was observed from the cockpit to the rudder bellcrank, at the point where the tail separated.

Stabilator cable continuity was observed to the stabilator bellcrank. The stabilator bellcrank bracket was broken and restricted movement of the bellcrank.

The engine was attached to the fuselage and the propeller was attached to the engine. Both blades were bent aft about 90 degrees and displayed similar twisting, bending, and chordwise scratching. The nose landing gear was in the landing gear well, but the nose gear actuator rod was in the extended position.

MEDICAL AND PATHOLOGICAL INFORMATION

The Chief Medical Examiner for the State of Virginia, Northern district, performed an autopsy on March 22, 2001.

Toxicological testing was performed at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.

Atenolol was found in the pilot's blood, kidney and urine. Atenolol is a prescription medication commonly used to control high blood pressure.

The pilot's son indicated that the pilot was also on the medications Procardia and Zocor. Procardia (generic name nifedipine) is another prescription medication, often used for the control of blood pressure.

Zocor (generic name simvastatin) is a prescription medication used for the control of elevated cholesterol.

The pilot's FAA Application for Airman Medical Certificate on September 27, 1999, indicated the use of atenolol and Norvasc (amlodipine, a drug similar to nifedipine) for the control of high blood pressure. The Aviation Medical Examiner who performed the examination issued a class 3 medical certificate to the pilot.

TESTS AND RESEARCH

The engine was examined at the Manassas Regional Airport on March 22, 2001. The engine was rotated by hand at the propeller flange, and continuity was established through the valvetrain and powertrain to the accessory section. Compression on each cylinder was confirmed using the thumb method.

Borescope examination of the cylinders, pistons, and valves revealed no mechanical defects or anomalies. Engine timing matched the manufacturer's specifications.

The left magneto produced spark at all terminal leads and the right magneto produced spark at all distributor towers. Examination of seven of the eight spark plugs revealed the electrodes were intact, and light tan and gray in color. The top spark plug in the #1 cylinder was destroyed by impact.

The gascolator and gascolator filter screen were absent of contamination or debris. The fuel inlet screen was absent of debris. The engine-driven fuel pump contained fuel and was absent of debris. The fuel drained from the pump showed trace amounts of water. The fuel pump was operational.

The engine starter gear ring and the engine starter bendix nose housing displayed rotational scoring. The engine air inlet filter housing contained several angular cut twigs that were each approximately 1 inch long.

AIR TRAFFIC CONTROL

A Safety Board Air Traffic Control Specialist reviewed ATC involvement with the accident airplane. According to the Safety Board's ATC specialist, the local controller failed to perform the overdue aircraft procedures specified in FAA Order 7110.65. As a result, the initiation of the search for the airplane and pilot was delayed 19 hours.

ADDITIONAL INFORMATION

Examination of the area surrounding the south side of the Manassas Airport revealed that it was a heavily-wooded rural/residential area, with little ground-based lighting.

A Safety Board Human Factors specialist reviewed the environmental conditions at the time of the accident. He then provided a list of potential night visual illusions that could have been encountered when approaching a brightly lit airport over dark terrain at low ambient light levels.

The Human Factors specialist cited the following:

"Hawkins, F. H. (1987). Human Factors in Flight (2nd. Ed.) Brookfield, VT: Ashgate.

Lighting intensity may influence the perception of distance. Approach and runway lights appear closer when brightly lit and farther when dimly lit. This effect is more pronounced when there are few or no surrounding lights.

When distant runway or airport lights are viewed against an intervening area of darkness, there is an illusion of height. This is referred to as the black hole phenomenon and is particularly relevant when approaching airports at night over the sea, jungle, or desert.

Runway width may be a further source of distortion in perception during landing. When the runway is wider than normal it will appear closer and the aircraft will appear lower than they really are. When the runway is narrow, it will appear farther and the aircraft will appear higher than they really are.

The windshield location of an observed object, such as airport or approach lighting can lead to a misjudgment of height. The object will appear at the same spot at a higher altitude with a low pitch angle as it will at a lower altitude with a high pitch angle. On approach a speed decay and gradual loss of altitude can result in the runway remaining in the same position in the windshield giving an impression of a stabilized approach - until touching down some distance out. This is particularly relevant to visual flying at night around airports where the surrounding terrain is without lights.

Leibowitz, H. W. (1988). The human senses in flight. In ( E. L. Wiener & D. C. Nagel, Eds.) Human Factors in Aviation. San Diego, CA: Academic Press.

At night, in clear weather conditions when approaching to land over dark terrain pilots may visually overestimate their altitude. As a consequence, they tend to fly too low, and if not aware of the error in time, they may land short of the runway. Pilots are misled into believing that their ability to estimate altitude visually is as accurate at night as during daylight and may not adequately confirm their visual estimates of altitude by reference to the altimeter, especially during periods of high workload such as during approach and landing.

FAA Aeronautical Information Manual (AIM) 8-1-5

3. Illusions Leading to Landing Errors:

(a) Various surface features and atmospheric conditions encountered in landing can c

NTSB Probable Cause

The pilot's spatial disorientation due to a night visual illusion. A factor was the dark night condition.