January 16, 2000 NTSB Incident Report on the Piper PA-28-236 at Alton, NH (IAD97FA043) |
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January 16, 2000
NTSB Identification: IAD97FA043
Accident occurred JAN-17-97 at ALTON, NH
Aircraft: Piper PA-28-236, registration: N8263Y
Injuries: 2 Fatal.
HISTORY OF FLIGHT
On January 17, 1997, at 1335 eastern standard time, a Piper PA-28-236, N8263Y, was
destroyed when it collided with trees near Alton, New Hampshire. The pilot and one
passenger were fatally injured. Visual meteorological conditions prevailed and a flight
plan was not filed. The personal flight was conducted under 14 CFR Part 91. The flight
originated from Farmingdale (FRG), New York, at approximately 1115. The intended
destination was Saranac Lake, New York.
According to Air Traffic Control (ATC) records, at 1117, the pilot radioed New York
ATC, and advised the controller that he was 4 1/2 miles north of FRG at 3,000 feet, and
requested flight following. The flight then proceeded uneventful for the next 25 minutes.
At 1139, the controller radioed the pilot and instructed him to contact the Boston Air
Route Traffic Control Center (ARTCC), but there was no response. At 1141, the pilot rated
passenger (PRP) transmitted that they were in trouble, and that the pilot was not
responding. She told the controller that she was the co-pilot, and only had pilot
experience in a Cessna 172.
At 1142, the controller advised the PRP that they were basically the same aircraft, and
that they just land a little differently. He instructed her to do a shallow left turn
southbound, and he would keep her VFR to help talk her down to an airport. He also advised
her to descend if she could, and to stay clear of the clouds.
At 1143, the PRP advised the controller that she could see the ground while making the
turn, and that the pilot was throwing up. The controller informed the PRP that she was
over the Danbury Airport, Danbury, Connecticut. During the next 16 minutes, the controller
and the pilot of another airplane (POAA) provided directions and instructions to the PRP.
At 1156, the PRP radioed that she was getting tired, and she was nauseated. At 1158,
the POAA asked the PRP to lower the nose of the airplane and to start descending, and the
PRP responded that she was trying to "activate" the pilot. At 1200, she repeated
she was very tired. The POAA told the PRP where the control wheel was, and that she should
trim the airplane. At 1204, the controller advised the POAA that the airplane had turned
northbound, and that it was slowly climbing. The controller told the POAA that the PRP was
responding with idents.
At 1207, the controller advised the POAA that the airplane was at 8,200 feet, and that
there were no further idents from the PRP. At 1209, the controller advised the POAA that
the airplane was holding it's heading and altitude of 8,800 feet. At 1210, the controller
radioed the PRP and told her to open a vent on the airplane and get some fresh air as
there might be carbon monoxide in the cockpit.
At 1212, the controller radioed the PRP and told her to lower the nose because the
airplane was probably trimmed to climb. The transmission was not acknowledged. At 1217,
the controller radioed the PRP, and told her that maybe the autopilot was on, and that was
probably why it was difficult to descend. Shortly thereafter, the controller advised the
POAA that the PRP's airplane was descending rapidly.
At 1221, the controller advised the POAA that the airplane was at 7,800 feet, and that
the bases of the clouds were around 5,000 feet. The POAA advised the controller that he
was at 5,000 feet, and that it was VFR. The controller that had coordinated the two
airplanes, contacted Bradley Approach Control, and coordinated the handover of the two
airplanes to their airspace. The airplanes were then handed off to the Boston ARTCC at
1249.
At 1313, the POAA reported that he had the airplane in sight. At 1318, the POAA
reported that he saw smoke coming out of the engine, and at 1320, the POAA reported that
nobody was sitting up, and it appeared the entire cabin was full of smoke and that the
engine was smoking.
At 1324, the POAA reported that the airplane was descending rapidly. At 1326, the POAA
reported that the PRP had crashed into trees.
The airplane impacted trees in a heavily wooded area during the hours of daylight about
43 degrees 32 minutes North latitude, and 71 degrees, 12 minutes West longitude.
PILOT INFORMATION
The pilot held a Private Pilot Certificate with ratings for airplane single engine
land, and instrument airplane. The pilot had recorded a total flight experience of
approximately 352 hours, upon the completion of his instrument flight test on January 13,
1991. From January 13, 1991, until the last log book entry dated January 4, 1996, the
pilot only logged events such as adverse weather, actual instrument time, and the tach
time at each refueling. On his application for a third class medical that was issued on
August 1, 1995, he reported over 700 hours of total flight experience.
The pilot rated passenger held a private pilot certificate with a single engine land
rating. According to her application for a third class medical certificate dated December
28, 1993, she reported 165 hours of total flight experience.
METEOROLOGICAL CONDITIONS
At 1251, Concord Municipal Airport, Concord, New Hampshire, located about 26 miles
south of the accident site, reported the following observation:
Sky condition, ceiling 7000 broken; visibility, 10 miles; temperature, 9 degrees
Fahrenheit (F); dew point, -14 degrees F; winds from 290 at 14 knots with wind gusts up to
33 knots; and altimeter, 29.74 inches Hg.
WRECKAGE AND IMPACT INFORMATION
The airplane wreckage was examined at the accident site on January 18 and 19, 1997.
Examination of the accident site revealed impact scars at the tops of trees. The airplane
wreckage was distributed over an area approximately 150 feet long by 25 feet wide,
oriented on a magnetic heading of 060 degrees. All major components of the airplane were
accounted for at the scene.
The main wreckage, which consisted of the empennage, top of the fuselage and remainder
of the right wing were found about 130 feet beyond the initial impact point (IIP). The
engine was separated from the fuselage and located about 150 feet beyond the IIP.
The lower forward section of the fuselage was destroyed. The cockpit section along with
the right front seat, cabin door, and a section of the right side fuselage skin were
located adjacent to the main wreckage against a tree. This area contained the rear fresh
air vents, which were in the closed position. The front fresh air vents were separated,
and found near the main wreckage. One vent was closed while the other vent was partially
opened.
The overhead vent knob and the overhead vent were in the open position. The panel
mounted fan switch was in the high position. The heater control box remained attached to
the fuselage and was in the open position. The two forward floor heat vents were also in
the open position.
The stabilizers and rudder remained attached to the main wreckage. The vertical
stabilizer was crushed aft at the top. The rudder was crushed down and aft from the top to
the top hinge. The rudder was compressed below the hinge from the leading edge to the
trailing edge. The left side and right side horizontal stabilizer were damaged and were
not functional. The elevator trim measured 3 threads. According to the Piper
representative, this corresponded to 1.8 degrees tab up.
The propeller hub and propeller separated from the engine. One blade was bent aft while
the other blade was straight. The blades displayed some chordwise scratches and gouges at
the tips.
The engine was removed from the wooded area and examined in a hangar at the Lakes
Region Airport, Wolfeboro, New Hampshire, on January 19, 1997, under the supervision of
the National Transportation Safety Board (NTSB).
When the muffler shroud was removed, it revealed a large hole in the muffler that, was
shared by the #5 and #6 cylinder exhaust stacks. The hole was near the left end (#6side),
and measured approximately 4.5 inches long and 1 inch wide. The muffler was removed and
sent to the NTSB laboratory for further examination.
TESTS AND RESEARCH
The muffler was examined at the NTSB laboratory. According to the Metallurgists factual
report, the inlet end of the muffler case on the left side was crushed and contained a
large crack that extended approximately two thirds of the muffler circumference. Most
portions of the crack were darkly-discolored, as if they had been exposed to exhaust gases
for a period of time. Other areas were shiny, as if they were recently created. The left
inlet port of the muffler contained a welded in repair patch; however, the examination
revealed that the crack was not associated with the repair welds.
In the area located about 5 inches from the inlet end of the muffler, a piece of the
muffler case had separated creating an irregular hole. The fracture faces surrounding the
hole had brittle appearance, and were covered with a layer of dark deposits. A section was
cut from the muffler for Xray energy dispersive spectroscopy (EDS) and metallographic
examination.
The EDS analysis of the fracture surface showed the presence of large quantities of
lead and bromine, elements associated with the combustion of aviation fuel. The EDS
analysis of the cut surface generated a spectrum typical of a stainless steel, with
chromium and nickel as the primary alloying elements.
Metallographic examination revealed heavy pitting corrosion and high temperature
oxidation on the interior surface of the muffler case.
MEDICAL AND PATHOLOGICAL INFORMATION
Autopsies and toxicological testing of the pilot and passenger were conducted by Dr.
James A. Kaplan, Acting Chief Medical Examiner of the State of New Hampshire, on January
18, 1997.
The toxicological testing report from the FAA Toxicology Accident Research Laboratory,
Oklahoma City, Oklahoma, showed the pilot's lung fluid had a Carboxyhemoglobin (Carbon
Monoxide) saturation of 43%, while the passenger's blood had 69%.
ADDITIONAL DATA/INFORMTION
According to the Piper Maintenance Manual, it states in part:
"The entire exhaust system, including heat exchange shroud, muffler, muffler
baffles, stacks, and all exhaust connections must be rigidly inspected at each annual or
100 hour inspection. The possibility of exhaust system failure increases with use. The
system must also be checked carefully before winter operation when the cabin heater will
be in use. Remove or loosen all exhaust shields, carburetor, and cabin heat muffs,
shrouds, heat blankets, etc., as required to permit inspection of the system. Clean and
inspect all external surfaces for dents, cracks, and missing parts.
Pay particular attention to welds, clamps, supports, and support attachment lugs, slip
joints, stack flanges, and gaskets. Inspect internal baffle or diffusers. Any cracks,
warpage, or severe oxidation are cause for replacement.
If any component is inaccessible for a visual inspection, conduct one of the following:
1. Conduct a submerged pressure check of muffler and exhaust stack at 2 psi air
pressure. 2. Conduct a ground test using a carbon monoxide indicator. Head airplane into
the wind. Warm engine on the ground. Advance throttle to full static RPM with cabin heat
valves open, and take readings of heated airstream inside cabin at each outlet (including
rear seat heat outlet, if installed) Appropriate sampling procedures applicable to the
particular indicator must be followed. If carbon monoxide concentration exceeds 0.005
percent or if a dangerous reading is obtained on an indicator not calibrated in
percentages, the muffler must be replaced."
According to the airplane's engine log book, the last annual inspection was completed
on January 17, 1996, by Shakalis Aviation Services Inc., and the airplane had accumulated
over 88 hours since the inspection. The inspection included replacing the #1 cylinder
exhaust gasket. The pilot had contacted the above maintenance facility, and scheduled an
annual inspection for January 27, 1997. There was no entry in the airplane or engine logs
that the muffler had been checked or replaced.
According to the Army Aeromedical Training Handbook for Flight Personnel, it states in
part:
"...The effects of carbon monoxide (CO) are subtle and deadly. CO is perhaps the
most common gaseous poison in the aviation environment...It is a colorless, odorless gas
slightly lighter than air...A relatively low concentration of CO in the air can, in time,
produce high blood concentrations of CO. If an individual inhales a 0.5 percent
concentration of CO for 30 minutes while at rest, a 45 percent concentration of CO will
result. This is enough to produce total collapse... ."
The aircraft wreckage was released on January 23, 1997, to Allen A. Ryan, a
representative of the owner's insurance company.
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