It gets harder and harder to keep up with the cover-up.
Originally, this link would have taken you to the NTSB website at www.ntsb.gov/aviation/nyc/99a178.htm
As you will see if you go to the NTSB site, on January 8, 2001, the NTSB
removed their original posting, and greatly edited the contents of the
report. The unedited original NTSB report, downloaded from the NSTB
website in August of 2000, follows. : Return
On July 16, 1999, about 2141 eastern daylight time, a
Piper PA-32R-301, Saratoga II, N9253N, was destroyed when it crashed into
the Atlantic Ocean approximately 7 1/2 miles southwest of Gay Head, Martha's
Vineyard, Massachusetts. The certificated private pilot and two passengers
received fatal injuries. Night visual meteorological conditions (VMC) prevailed,
and no flight plan had been filed for the personal flight conducted under
the provisions of 14 Code of Federal Regulations (CFR) Part 91. The flight
originated from Essex County Airport (CDW), Caldwell, New Jersey, and was
destined for Barnstable Municipal-Boardman/Polando Field (HYA), Hyannis,
Massachusetts, with a scheduled stop at Martha's Vineyard Airport (MVY),
Vineyard Haven, Massachusetts.
During interviews, witnesses stated that the purpose
of the flight was to fly to Martha's Vineyard to drop off one passenger
and then continue to HYA. An employee of a fixed-base operator (FBO) at
CDW stated that he had called the pilot about 1300 on the day of the accident
to verify that the pilot intended to fly the airplane, N9253N, over the
weekend. The pilot informed the employee that he did plan to fly the airplane
and that he would arrive at the airport between 1730 and 1800. The employee
informed the pilot that he would have the airplane parked outside of the
Witnesses who were at CDW on the night of the accident
stated that they saw the pilot and a female near the accident airplane.
The witnesses also reported that they saw the pilot using crutches and
loading luggage into the airplane. One witness stated that he watched the
pilot perform an engine run-up and then take off about 2040. The witness
further stated that "takeoff and right downwind departure seem[ed] normal."
According to air traffic control (ATC) transcripts from
CDW's tower, about 2034, the pilot of N9253N contacted the ground controller
and stated, "...saratoga niner two five three november ready to taxi with
mike...right turnout northeast bound." The ground controller instructed
the pilot to taxi to runway 22, which the pilot acknowledged. At 2038:32,
the pilot of N9253N contacted the tower controller and advised that he
was ready to take off from runway 22. At 2038:39, the tower controller
cleared N9253N for takeoff; at 2038:43, the pilot acknowledged the clearance.
A few seconds later, the tower controller asked the pilot if he was heading
towards Teterboro, New Jersey. The pilot replied, "No sir, I'm uh actually
I'm heading a little uh north of it, uh eastbound." The tower controller
then instructed the pilot to "make it a right downwind departure then."
At 2038:56, the pilot acknowledged the instruction stating, "right downwind
departure two two." No records of any further communications between the
pilot and ATC exist.
According to radar data, at 2040:59, a target transmitting
a visual flight rules (VFR) code was observed about 1 mile southwest of
CDW at an altitude of 1,300 feet. The target proceeded to the northeast,
on a course of about 55 degrees, remaining below 2,000 feet. The target
was at 1,400 feet when it reached the Hudson River. When the target was
about 8 miles northwest of the Westchester County Airport (HPN), White
Plains, New York, it turned north over the river and began to climb. After
proceeding north about 6 miles, the target turned eastward to a course
of about 100 degrees. The target continued to climb and reached 5,500 feet
about 6 miles northeast of HPN. When the target's course was plotted on
a New York VFR navigational map, the extended course line crossed the island
of Martha's Vineyard.
The target continued eastward at 5,500 feet, passing
just north of Bridgeport, Connecticut, and crossed the shoreline between
Bridgeport and New Haven, Connecticut. The target ground track continued
on the 100-degree course, just south and parallel to the Connecticut and
Rhode Island coastlines. After passing Point Judith, Rhode Island, the
target continued over the Rhode Island Sound.
A performance study of the radar data revealed that the
target began a descent from 5,500 feet about 34 miles west of MVY. The
speed during the descent was calculated to be about 160 knots indicated
airspeed (KIAS), and the rate of descent was calculated to have varied
between 400 and 800 feet per minute (fpm). About 2138, the target began
a right turn in a southerly direction. About 30 seconds later, the target
stopped its descent at 2,200 feet and began a climb that lasted another
30 seconds. During this period of time, the target stopped the turn, and
the airspeed decreased to about 153 KIAS. About 2139, the target leveled
off at 2,500 feet and flew in a southeasterly direction. About 50 seconds
later, the target entered a left turn and climbed to 2,600 feet. As the
target continued in the left turn, it began a descent that reached a rate
of about 900 fpm. When the target reached an easterly direction, it stopped
turning; its rate of descent remained about 900 fpm. At 2140:15, while
still in the descent, the target entered a right turn. As the target's
turn rate increased, its descent rate and airspeed also increased. The
target's descent rate eventually exceeded 4,700 fpm. The target's last
radar position was recorded at 2140:34 at an altitude of 1,100 feet. (For
a more detailed description of the target's [accident airplane's] performance,
see Section, "Tests and Research," Subsection, "Aircraft Performance Study.")
On July 20, 1999, about 2240, the airplane's wreckage
was located in 120 feet of water, about 1/4 mile north of the target's
last recorded radar position.
The accident occurred during the hours of darkness. In
the area of and on the night of the accident, sunset occurred about 2014.
Civil twilight ended about 2047, and nautical twilight ended about 2128.
About 2140, the moon was about 11.5 degrees above the horizon at a bearing
of 270.5 degrees and provided about 19 percent illumination. The location
of the accident wreckage was about 41 degrees, 17 minutes, 37.2 seconds
north latitude; 70 degrees, 58 minutes, 39.2 seconds west longitude.
The pilot obtained his private pilot certificate for
"airplane single-engine land" in April 1998. He did not possess an instrument
rating. He received a "high performance airplane" sign-off in his Cessna
182 in June 1998 and a "complex airplane" sign-off in the accident airplane
in May 1999. His most recent Federal Aviation Administration (FAA) second-class
medical certificate was issued on December 27, 1997, with no limitations.
A copy of the pilot's logbook that covered from October
4, 1982, to November 11, 1998, was provided to the Safety Board. The pilot's
most recent logbook was not located. The Board used the copied logbook,
records from training facilities, copies of flight instructors' logbooks,
and statements from instructors and pilots to estimate the pilot's total
flight experience. The pilot's estimated total flight experience, excluding
simulator training, was about 310 hours, of which 55 hours were at night.
The pilot's estimated experience flying without a certified flight instructor
(CFI) on board was about 72 hours. The pilot's estimated flight time in
the accident airplane was about 36 hours, of which 9.4 hours were at night.
Approximately 3 hours of that flight time was without a CFI on board, and
about 0.8 hour of that time was flown at night, which included a night
landing. In the 15 months before the accident, the pilot had flown about
35 flight legs either to or from the Essex County/Teterboro, New Jersey,
area and the Martha's Vineyard/Hyannis, Massachusetts, area. The pilot
flew over 17 of these legs without a CFI on board, including at least 5
at night. The pilot's last known flight in the accident airplane without
a CFI on board was on May 28, 1999.
On October 4, 1982, the pilot started receiving flight
instruction. Over the next 6 years, he flew with six different CFIs. During
this period, the pilot logged 47 hours, consisting of 46 hours of dual
instruction and 1 hour without a CFI on board. The pilot made no entries
in his logbook from September 1988 to December 1997.
In December 1997, the pilot enrolled in a training program
at Flight Safety International (FSI), Vero Beach, Florida, to obtain his
private pilot certificate. Between December 1997 and April 1998, the pilot
flew about 53 hours, of which 43 were flown with a CFI on board. The CFI
who prepared the pilot for his private pilot checkride stated that the
pilot had "very good" flying skills for his level of experience.
On April 22, 1998, the pilot passed his private pilot
flight test. The designated pilot examiner who administered the checkride
stated that as part of the flight test, the pilot conducted two unusual
attitude recoveries. The pilot examiner stated that in both cases, the
pilot recovered the airplane while wearing a hood and referencing the airplane's
flight instruments. After receiving his private pilot certificate, the
pilot flew solo in his Cessna 182 and received instruction in it by CFIs
local to New Jersey. He also received instruction at Million Air, a flight
school in New Jersey, and flew their airplanes. During calendar year 1998,
the pilot flew approximately 179 hours, including about 65 hours without
a CFI on board. On March 12, 1999, the pilot completed the FAA's written
airplane instrument examination and received a score of 78 percent.
On April 5, 1999, the pilot returned to FSI to begin
an airplane instrument rating course. During the instrument training, the
pilot satisfactorily completed the first 12 of 25 lesson plans. The pilot's
primary CFI during the instrument training stated that the pilot's progression
was normal and that he grasped all of the basic skills needed to complete
the course; however, the CFI did recall the pilot having difficulty completing
lesson 11, which was designed to develop a student's knowledge of very
high frequency omnidirectional radio range (VOR) and nondirectional beacon
operations while working with ATC. It took the pilot four attempts to complete
lesson 11 satisfactorily. After two of the attempts, the pilot took a 1-week
break. After this break, the pilot repeated lesson 11 two more times. The
CFI stated that the pilot's basic instrument flying skills and simulator
work were excellent. However, the CFI stated that the pilot had trouble
managing multiple tasks while flying, which he felt was normal for the
pilot's level of experience.
The pilot attended this training primarily on weekends.
During this training, the pilot accumulated 13.3 hours of flight time with
a CFI on board. In addition, the pilot logged 16.9 hours of simulator time.
The pilot departed from FSI for the last time on April 24, 1999.
The pilot continued to receive flight instruction from
CFIs in New Jersey in his newly purchased Piper Saratoga, the accident
airplane. One CFI flew with the pilot on three occasions. One of the flights
was on June 25, 1999, from CDW to MVY. The CFI stated that the departure,
en route, and descent portions of the flight were executed in VMC, but
an instrument approach was required into MVY because of a 300-foot overcast
ceiling. The CFI requested an instrument flight rules (IFR) clearance and
demonstrated a coupled instrument landing system (ILS) approach to runway
24. The CFI stated that the pilot performed the landing, but he had to
assist with the rudders because of the pilot's injured ankle. (For additional
information about the pilot's ankle injury, see Section, "Medical and Pathological
Information.") The CFI stated that the pilot's aeronautical abilities and
his ability to handle multiple tasks while flying were average for his
level of experience.
A second CFI flew with the pilot between May 1998 and
July 1999. This CFI accumulated 39 hours of flight time with the pilot,
including 21 hours of night flight and 0.9 hour flown in instrument meteorological
conditions (IMC). The pilot used this CFI for instruction on cross-country
flights and as a safety pilot. On July 1, 1999, the CFI flew with the pilot
in the accident airplane to MVY. The flight was conducted at night, and
IMC prevailed at the airport. The CFI stated that, during the flight, the
pilot used and seemed competent with the autopilot. The instructor added
that during the flight the pilot was wearing a nonplaster cast on his leg,
which required the CFI to taxi the airplane and assist the pilot with the
The CFI stated that the pilot had the ability to fly
the airplane without a visible horizon but may have had difficulty performing
additional tasks under such conditions. He also stated that the pilot was
not ready for an instrument evaluation as of July 1, 1999, and needed additional
training. The CFI was not aware of the pilot conducting any flight in the
accident airplane without an instructor on board. He also stated that he
would not have felt comfortable with the accident pilot conducting night
flight operations on a route similar to the one flown on, and in weather
conditions similar to those that existed on, the night of the accident.
The CFI further stated that he had talked to the pilot on the day of the
accident and offered to fly with him on the accident flight. He stated
that the accident pilot replied that "he wanted to do it alone."
A third CFI flew with the pilot between May 1998 and
July 1999. This CFI accumulated 57 hours of flight time with the pilot,
including 17 hours of night flight and 8 hours flown in IMC. The pilot
also used this instructor for instruction on cross-country flights and
as a safety pilot. This CFI had conducted a "complex airplane" evaluation
on the pilot and signed him off in the accident airplane in May 1999. According
to the CFI, on one or two occasions, the airplane's autopilot turned to
a heading other than the one selected, which required the autopilot to
be disengaged and then reengaged. He stated that it seemed as if the autopilot
had independently changed from one navigation mode to another. He also
stated that he did not feel that the problem was significant because it
only happened once or twice.
The CFI had made six or seven flights to MVY with the
pilot in the accident airplane. The CFI stated that most of the flights
were conducted at night and that, during the flights, the pilot did not
have any trouble flying the airplane. The instructor stated that the pilot
was methodical about his flight planning and that he was very cautious
about his aviation decision-making. The CFI stated that the pilot had the
capability to conduct a night flight to MVY as long as a visible horizon
The accident airplane, N9253N, was a Piper PA-32R-301,
Saratoga II, single-engine, low-wing airplane with retractable landing
gear. The airplane was originally certificated by Piper Aircraft Corporation
on June 9, 1995. The airplane was sold to Skytech, Inc., Baltimore, Maryland,
on June 16, 1995, and then resold to Poinciana LLC, Wilmington, North Carolina,
on January 5, 1996.
A review of records from an engine overhaul facility
revealed that during a 100-hour and annual inspection of the airplane in
May 1998, corrosion was observed on the interior surfaces of the engine
cylinder walls. Additionally, pitting was observed on the surfaces of several
valve tappets. At that time, the engine had a total time since new of 387.1
hours. The documents also revealed that the engine was shipped to the overhaul
facility in June 1998, where the engine was disassembled, inspected, and
reassembled (parts were replaced as necessary) in June and July 1998. The
engine was also run in a test cell before it was shipped and was reinstalled
in the airplane in July 1998.
On August 25, 1998, the airplane was purchased by Raytheon
Aircraft Company, Wichita, Kansas, and then resold the same day to Air
Bound Aviation, Inc., Fairfield, New Jersey. The airplane was sold on August
27, 1998, to a pilot in New Jersey. On April 28, 1999, the airplane was
sold to Columbia Aircraft Sales, Inc., Groton, Connecticut. On the same
day, the airplane was sold back to Air Bound Aviation and then to the accident
pilot, operating as Random Ventures, Inc., New York, New York. According
to maintenance personnel at CDW, the pilot kept the airplane's maintenance
records inside of the airplane. The maintenance records were not recovered
during the wreckage recovery operation.
According to FAA records, work orders, and a statement
from an employee of a maintenance facility, a prepurchase inspection of
N9253N was conducted on April 16, 1999. According to the maintenance facility
employee, "the aircraft was found to be in very good condition, with only
a few minor discrepancies." According to the records and the maintenance
facility employee, an annual inspection was completed on June 18, 1999,
at a total airframe time of 622.8 hours, and the airplane was returned
to service on June 25, 1999. The records and maintenance facility employee
also revealed that the airplane's return to service was delayed because
of an error on the airplane's registration form about its exact make and
model. A new registration form with the correct information had to be sent
to the pilot for his signature.
A July 13, 1999, work order revealed that a "swing" of
the compass and the horizontal situation indicator (HSI) were completed.
No total airframe time was recorded on that work order. The tachometer
recovered in the wreckage indicated 663.5 hours.
A review of other pilots' logbooks revealed that they
had flown the airplane without the accident pilot on board. However, it
could not be accurately determined how many other pilots might have flown
the airplane without the pilot on board or how many flight hours they might
have added on to the airplane.
The following airport designators (and those previously
defined) are used in this section:
ACK - Nantucket Memorial Airport, Nantucket, Massachusetts.
BDR - Igor I. Sikorsky Memorial Airport, Bridgeport,
BID - Block Island State Airport, Block Island,
BLM - Allaire Airport, Belmar-Farmingdale, New
EWB - New Bedford Municipal Airport, New Bedford,
EWR - Newark International Airport, Newark, New
FMH - Otis ANGB, Falmouth, Massachusetts.
FOK - Francis S. Gabreski Airport, Westhampton
Beach, New York.
FRG - Republic Airport, Farmingdale, New York.
ISP - Long Island MacArthur Airport, Islip, New
JFK - John F. Kennedy International Airport, New
York, New York.
PVD - Theodore Francis Green State Airport, Providence,
TAN - Taunton Municipal, Taunton, Massachusetts.
TEB - Teterboro Airport, Teterboro, New Jersey.
ACK is located about 27 nautical miles (nm) east-southeast
of MVY. HYA is located about 22 nm northeast of MVY.
Pilot Preflight Weather Requests
According to Weather Service International (WSI) personnel,
a search of their briefing logs indicated that the pilot, or someone using
his user code, made two weather requests from WSI's PILOTbrief Web site
on July 16, 1999. The first request, made at 1832:59, was for a radar image.
The second request, made at 1834:18, was for a route briefing from TEB
to HYA with MVY as an alternate.
The information provided to the requester included en
route weather observations from BID, BLM, EWB, EWR, FMH, FOK, FRG, ISP,
JFK, PVD, and TAN. These observations indicated that visibilities varied
from 10 miles along the route to 4 miles in haze at CDW. The lowest cloud
ceiling was reported at 20,000 feet overcast at PVD. These observations
were made about 1800. Observations for ACK, CDW, HYA, and MVY were also
included. Excerpts from these observations include the following:
ACK 1753...Clear skies; visibility 5 miles in mist; winds
240 degrees at 16 knots.
CDW 1753...Clear skies; visibility 4 miles in haze; winds
230 degrees at 7 knots.
HYA 1756...Few clouds at 7,000 feet; visibility 6 miles
in haze; winds 230 degrees at 13 knots.
MVY 1753...Clear skies; visibility 6 miles in haze; winds
210 degrees at 11 knots.
Also included were the following terminal forecasts for
ACK and HYA:
ACK (July 16 at 1400 to July 17 at 1400)...July 16...1400
to 2000...Clear skies; visibility greater than 6 miles; winds 240 degrees
at 15 knots. Becoming 2000 to 2100, winds 260 degrees at 13 knots.
HYA (July 16 at 1400 to July 17 at 1400)...July 16...1400
to 2200...Clear skies; visibility greater than 6 miles; winds 230 degrees
at 10 knots.
According to WSI, the pilot, or someone using his user
code, did not access the National Weather Service (NWS) Area Forecast.
Aviation Forecasts and Surface Weather Observations
Area Forecasts (FA)
Excerpts from the Boston FA, issued July 16 about 2045
and valid until July 17 about 0200, included the following: Coastal Waters
(includes area of MVY); Scattered clouds at 2,000 feet. Occasional visibility
3 to 5 miles in haze. Haze tops 7,000 feet.
Excerpts from the Boston FA, issued July 16 about 2045
and valid until July 17 about 0900, included the following: Coastal Waters
(includes area of MVY); North of 40 degrees north latitude... Scattered
cirrus. Occasional visibility 4 to 5 miles in haze. Haze tops 8,000 feet.
Aviation Terminal Forecasts (TAF)
NWS does not prepare TAFs for MVY. Excerpts from TAFs
pertinent to the accident include the following:
The TAF for ACK, issued July 16 about 1330 and valid
from July 16 about 1400 to July 17 about 1400, was as follows: July 16
at 1400 to July 17 at 1100...Clear skies; visibility greater than 6 miles;
winds 240 degrees at 15 knots. Becoming July 16 at 2000 to July 16 at 2100,
winds 260 degrees at 13 knots.
The TAF for ACK, issued July 16 about 1930 and valid
from July 16 about 2000 to July 17 about 2000, was as follows: July 16
at 2000 to July 17 at 0200...Winds 240 degrees at 15 knots; visibility
4 miles, mist; scattered clouds at 25,000 feet. Temporary changes from
July 16 at 2100 to July 17 at 0100...clouds 500 feet scattered; visibility
2 miles, mist.
The TAF for HYA, issued July 16 about 1330 and valid
from July 16 about 1400 to July 17 about 1400, was as follows: July 16
at 1400 to July 17 at 1100...Clear skies; visibility greater than 6 miles;
winds 230 degrees at 10 knots. Winds becoming July 16 at 2200 to July 17
at 0000...250 degrees at 8 knots.
The TAF for HYA, issued July 16 about 1930 and valid
from July 16 about 2000 to July 17 about 2000, was as follows: July 16
at 2000 to July 17 at 0200...Winds 230 degrees at 10 knots; visibility
6 miles, haze; scattered clouds at 9,000 feet. Temporary changes from July
16 at 2000 to July 17 at 0000...Visibility 4 miles, haze.
In-flight Weather Advisories
No airmen's meteorological information, significant meteorological
information (SIGMET), or convective SIGMETs were issued by the NWS Aviation
Weather Center in Kansas City, Missouri, for the time and area of the accident.
No in-flight weather advisories were in effect along the route between
CDW and MVY from 2000 to 2200.
Surface Weather Observations
MVY had an Automated Surface Observing System (ASOS),
which was edited and augmented by ATC tower personnel if necessary. The
tower manager at MVY was on duty on the night of the accident for an 8-hour
shift, which ended when the tower closed, about 2200. During an interview,
the tower manager stated that no actions were taken to augment or edit
the ASOS during his shift. He also stated the following:
"The visibility, present weather, and sky condition at
the approximate time of the accident was probably a little better than
what was being reported. I say this because I remember aircraft on visual
approaches saying they had the airport in sight between 10 and 12 miles
out. I do recall being able to see those aircraft and I do remember seeing
the stars out that night...To the best of my knowledge, the ASOS was working
as advertised that day with no reported problems or systems log errors."
ASOS observations for the night of the accident include
2053...Clear at or below 12,000 feet; visibility 4 miles,
mist; winds 240 degrees at 11 knots; temperature 21 degrees [Celsius] C;
dewpoint 20 degrees C; altimeter setting 30.10 inches of [mercury] Hg.
2153...Clear at or below 12,000 feet; visibility 4 miles,
mist; winds 240 degrees at 12 knots; temperature 21 degrees C; dewpoint
20 degrees C; altimeter setting 30.11 inches of Hg.
2054...Clear at or below 12,000 feet; visibility 8 miles,
haze; winds 230 degrees at 4 knots; temperature 27 degrees C; dewpoint
21 degrees C; altimeter setting 30.08 inches of Hg.
1953...Clear at or below 12,000 feet; visibility 4 miles,
haze; winds 230 degrees at 4
knots; temperature 33 degrees C; dewpoint 18 degrees
C; altimeter setting 30.07 inches of Hg.
2053...Clear at or below 12,000 feet; visibility 5 miles,
haze; winds 220 degrees at 5
knots; temperature 31 degrees C; dewpoint 19 degrees
C; altimeter setting 30.08 inches of Hg.
2045...7,500 feet broken, 15,000 feet overcast, visibility
5 miles haze; winds 140 degrees at 4 knots; temperature 28 degrees C; dewpoint
22 degrees C; altimeter setting 30.08 inches of Hg.
2056...Few clouds at 7,000 feet; visibility 6 miles,
mist; winds 230 degrees at 7 knots;
temperature 23 degrees C; dewpoint 21 degrees C; altimeter
setting 30.07 inches of Hg.
2156...Few clouds at 7,500 feet; visibility 6 miles,
mist; winds 230 degrees at 8 knots;
temperature 23 degrees C; dewpoint 22 degrees C; altimeter
setting 30.08 inches of Hg.
2053...Clear at or below 12,000 feet; visibility 8 miles;
winds 250 degrees at 7 knots; temperature 23 degrees C; dewpoint 19 degrees
C; altimeter 30.09 inches of Hg.
2153...Clear at or below 12,000 feet; visibility 10 miles;
winds 240 degrees at 10 knots, gusts to 15 knots; temperature 24 degrees
C; dewpoint 18 degrees C; altimeter 30.10 inches of Hg.
U.S. Coast Guard Station (USCG) Weather Observations
Safety Board staff reviewed weather observations from
USCG stations. Excerpts pertinent to the accident include the following:
Point Judith, Rhode Island
1700...Cloudy, 3 miles visibility in haze, winds south-southwest
at 10 knots.
2000...Cloudy, 3 miles visibility in haze, winds south-southwest
at 10 knots.
2300...Cloudy, 2 miles visibility, winds southwest at
Brant Point, Massachusetts
1700...Clear, 8 miles visibility.
2000...Overcast, 6 miles visibility.
2300...Scattered clouds, 6 miles visibility.
The Brant Point report stated that two observations were
reported by ships. About 2000, a ship 1 nm north of buoy 17, which was
about 8 miles north of Martha's Vineyard, reported that the seas were 2
to 3 feet and that the visibility was 5 nm. About 2300, another ship reported
that the winds were west-southwest at 10 to 15 knots, the seas were 2 to
3 feet, and the visibility was 6 nm in light haze.
Pilot Weather Observations
Three pilots who had flown over the Long Island Sound
on the night of the accident were interviewed after the accident.
One pilot kept his twin turboprop airplane at TEB, and
on the evening of the accident, he flew from TEB to ACK. The pilot stated
that he drove to TEB from New York City and that the traffic was the second
heaviest he had seen in 15 years. The pilot stated that he had called the
TEB FBO and estimated that his arrival time would be about 1850; however,
he did not arrive until between about 1930 and 2000 because of traffic.
The pilot also stated that this delay changed the flight from one that
would have been conducted entirely during the day to one that would have
to be conducted partially at night. The pilot further stated, "Our car
took route 80 to Teterboro Airport. Caldwell Airport, where [the accident
pilot] flew from is another 14 minute drive west on route 80 past TEB."
Before departing the city, the pilot had obtained current
weather observations and forecasts for Nantucket and other points in Massachusetts,
Connecticut, New York, and New Jersey. He stated that the visibility was
well above VFR minimums. He also stated that he placed a telephone call
to a flight service station (FSS) before leaving the city, while driving
to TEB. Regarding the telephone call, he stated the following:
"I asked if there were any adverse conditions for the
route TEB to ACK. I was told emphatically: 'No adverse conditions. Have
a great weekend.' I queried the briefer about any expected fog and was
told none was expected and the conditions would remain VFR with good visibility.
Again, I was reassured that tonight was not a problem."
The pilot stated that he departed TEB "...in daylight
and good flight conditions and reasonable visibility. The horizon was not
obscured by haze. I could easily pick our land marks at least five [miles]
away." The pilot also stated that he did not request or receive flight
information after his departure from TEB. Once clear of the New York Class
B airspace, he stated that he climbed his airplane to 17,500 feet and proceeded
towards Nantucket. He reported that above 14,000 feet, the visibility was
unrestricted; however, he also reported that during his descent to Nantucket,
when his global positioning system (GPS) receiver indicated that he was
over Martha's Vineyard, he looked down and "...there was nothing to see.
There was no horizon and no light....I turned left toward Martha's Vineyard
to see if it was visible but could see no lights of any kind nor any evidence
of the island...I thought the island might [have] suffered a power failure."
He stated that he had his strobe lights on during the
descent and that at no time did they illuminate clouds or fog. He also
stated, "I had no visual reference of any kind yet was free of any clouds
or fog." The pilot stated that when he contacted the ACK tower for landing,
he was instructed to fly south of Nantucket about 5 miles to join the downwind
for runway 24; however, he maintained a distance of 3 to 4 miles because
he could not see the island at 5 miles. The pilot stated that, as he neared
the airport, he had to make a 310-degree turn for spacing. He stated that,
during the turn, "I found that I could not hold altitude by outside reference
and had to use my [vertical speed indicator] VSI and HSI to hold altitude
and properly coordinate the turn."
Another pilot had flown from Bar Harbor, Maine, to Long
Island, New York, and crossed the Long Island Sound on the same evening,
about 1930. This pilot stated that during his preflight weather briefing
from an FSS, the specialist indicated VMC for his flight. The pilot filed
an IFR flight plan and conducted the flight at 6,000 feet. He stated that
he encountered visibilities of 2 to 3 miles throughout the flight because
of haze. He also stated that the lowest visibility was over water, between
Cape Cod, Massachusetts, and eastern Long Island. He stated that he did
not encounter any clouds below 6,000 feet.
A third pilot departed TEB about 2030 destined for Groton,
Connecticut, after a stopover at MVY. He stated that, after departure,
he flew south of HPN and, remaining clear of the Class B airspace, he climbed
to 7,500 feet. He also stated that, while en route, he monitored several
ATC frequencies, but did not transmit on any of them until he neared MVY.
His route of flight took him over the north shore of Long Island to Montauk,
New York. He stated that he then crossed over Block Island, Rhode Island,
and proceeded directly to MVY.
He stated that the entire flight was conducted under
VFR, with a visibility of 3 to 5 miles in haze. He stated that, over land,
he could see lights on the ground when he looked directly down or slightly
forward; however, he stated that, over water, there was no horizon to reference.
He stated that he was not sure if he was on top of the haze layer at 7,500
feet and that, during the flight, he did not encounter any cloud layers
or ground fog during climb or descent. He further stated that, between
Block Island and MVY, there was still no horizon to reference. He recalled
that he began to observe lights on Martha's Vineyard when he was in the
vicinity of Gay Head. He stated that, before reaching MVY, he would have
begun his descent from 7,500 feet and would have been between 3,000 and
5,000 feet over Gay Head (the pilot could not recall his exact altitudes).
He did not recall seeing the Gay Head marine lighthouse. He was about 4
miles from MVY when he first observed the airport's rotating beacon. He
stated that he had an uneventful landing at MVY about 2145.
About 2200, the pilot departed MVY as the controller
announced that the tower was closing. After takeoff, he proceeded on a
heading of 290 degrees, climbed to 6,500 feet, and proceeded directly to
Groton. The pilot stated that, during the return flight, the visibility
was the same as that which he had encountered during the flight to MVY,
which was about 3 to 5 miles in haze.
Another pilot at CDW had stated to the news media that
he cancelled his planned flight from CDW to MVY on the evening of the accident
because of the "poor" weather. In a written statement he stated the following:
"From my own judgement visibility appeared to be approximately
4 miles-extremely hazy. Winds were fairly light. Based only on the current
weather conditions at CDW, the fact that I could not get my friends to
come with me, and the fact that I would not have to spend money on a hotel
room in Martha's Vineyard, I made the decision to fly my airplane to Martha's
Vineyard on Saturday."
No record exists of the pilot, or a pilot using the airplane's
registration number, receiving a weather briefing or filing a flight plan
with any FAA FSS for the accident flight. Further, no record exists of
the pilot, or a pilot using the airplane's registration number, contacting
any FSS or ATC tower or facility during the duration of the flight, except
for those at CDW.
The MVY ATC tower tape revealed that, during the period
of time from when the accident airplane departed CDW until the tower closed
and the recorder was turned off (about 2200), no contact was attempted
by the pilot, the call sign of N9253N, or any unknown station.
TRAFFIC ALERT AND COLLISION AVOIDANCE SYSTEM (TCAS) ALERT
According to the Aeronautical Informational Manual (AIM),
definitions for Class B and D airspace are as follows:
Class B Airspace: "Generally, that airspace from the
surface to 10,000 feet MSL [mean sea level], surrounding the nation's busiest
airports in terms of IFR operations or passenger enplanements...An ATC
clearance is required for all aircraft to operate in the area, and all
aircraft that are so cleared receive separation services within the airspace...Regardless
of weather conditions, an ATC clearance is required prior to operating
within Class B airspace..."
Class D Airspace: "Generally, that airspace from the
surface to 2,500 feet above the airport elevation (charted in MSL) surrounding
those airports that have an operational control tower...Two-way radio communication
must be established with the ATC facility providing ATC services prior
to entry and thereafter maintain those communications while in the Class
The following TCAS alert occurred during the approach
of a commercial airplane to HPN, which was located within published Class
D airspace and the New York Class B airspace. On July 16, 1999, about 2049,
American Airlines flight 1484, a Fokker 100, was inbound for landing at
HPN. According to the transcripts of communications between flight 1484
and the New York approach controller, at 2049:33, flight 1484 was level
at 6,000 feet. At 2049:48, the controller instructed flight 1484 to descend
and maintain 3,000 feet, which flight 1484 acknowledged. At 2050:32, the
controller issued an approach clearance to flight 1484, which flight 1484
also acknowledged. The following is an excerpt of the communications transcript
between flight 1484 and the controller regarding the TCAS:
2052:22, the controller, "American fourteen eighty four
traffic one o'clock and five miles eastbound two thousand four hundred,
unverified, appears to be climbing."
2052:29, flight 1484, "American fourteen eighty four
2052:56, the controller, "fourteen eighty four traffic
one o'clock and uh three miles twenty eight hundred now, unverified."
2053:02, flight 1484, "um yes we have uh (unintelligible)
I think we have him here american fourteen eighty four."
2053:10, flight 1484, "I understand he's not in contact
with you or anybody else."
2053:14, the controller, "uh nope doesn't not talking
2053:27, flight 1484, "seems to be climbing through uh
thirty one hundred now we just got a traffic advisory here."
2053:35, the controller, "uh that's what it looks like."
2053:59, flight 1484, "uh we just had a."
2054:12, the controller, "American fourteen eighty four
you can contact tower nineteen seven."
2054:15, flight 1484, "nineteen seven uh we had a resolution
advisory seemed to be a single
engine piper er commanche or something."
2054:21, the controller, "roger."
The event occurred outside of the New York Class B and
the HPN Class D airspace, and no corrective action was reported to have
been taken by the controller or flight 1484. A review of the radar data
correlated the unknown target with the track of N9253N.
MVY had a field elevation of 68 feet. The hours of operation
for the contract-operated tower were from 0600 to 2200. MVY had two runways.
Runway 06/24 was asphalt-surfaced, 5,500 feet long, and 100 feet wide.
Runway 15/33 was asphalt-surfaced, 3,297 feet long, and 75 feet wide. A
VOR-distance measuring equipment (DME) navigation aid was located on the
airport. The VOR was listed with a normal anticipated interference-free
service of 40 nm, up to 18,000 feet with DME. ILS, VOR, and GPS instrument
approaches were published for the airport.
MVY was located about 10 miles east of Gay Head. Gay
Head had a lighthouse for marine navigation at 41 degrees, 20.9 minutes
north latitude; 70 degrees, 50.1 minutes west longitude. According to USCG
personnel, the top of the lighthouse was 170 feet above mean low water
and operated 24 hours-a-day. The rotating beacon ran on a 15-second cycle,
7.3 seconds white and 7.3 seconds red. The expected range of the white
light was 24 miles, and the expected range of the red light was 20 miles.
The airplane was equipped with a Flightcom Digital Voice
Recorder Clock, DVR 300i. The unit contained a digital clock, was wired
into the radio communications circuits, and could record conversations
between the airplane and other radio sources, ground, or air. The unit
was voice activated, and the continuous loop could record and retain a
total of 5 minutes of data. The unit had a nonvolatile speech memory that
required a 9-volt backup battery to preserve the speech data. When the
unit was located in the wreckage, it was crushed, its backup battery was
missing, and it had retained no data.
On July 20, 1999, the airplane wreckage was located by
U.S. Navy divers from the recovery ship, USS Grasp, at a depth of about
120 feet below the surface of the Atlantic Ocean. According to the divers,
the recovered wreckage had been distributed in a debris field about 120
feet long and was oriented along a magnetic bearing of about 010/190 degrees.
The main cabin area was found in the middle of the debris field.
A Safety Board investigator was present on the USS Grasp
during the salvage operation. On July 21, 1999, the main cabin area was
raised and placed aboard the USS Grasp. On July 22, 1999, the divers made
five additional dives, and the wreckage retrieved from these dives was
also placed aboard the USS Grasp. On July 23, 1999, about 2100, the wreckage
was transferred from the USS Grasp to the Safety Board at a naval base
in Newport, Rhode Island. The wreckage was then transported to the USCG
Air Station at Otis Air Force Base, Cape Cod, Massachusetts, the evening
of July 23, 1999. The wreckage was examined by Board investigators in a
hangar at the USCG Air Station on July 24, 25, and 26, 1999. Follow-up
examinations were conducted on August 1 and 2, 1999.
According to the Airworthiness Group Chairman's Report,
the engine was found separated from the engine mount truss. The structural
tubing on the right side of the engine mount truss was missing. The engine
mount truss was deformed to the right and fractured in numerous locations.
The upper left engine mount ear and both lower mount ears were fractured.
The upper right engine mount ear was bent. The engine and propeller were
retained for additional examination.
About 75 percent of the fuselage structure was recovered.
A section of the aft cabin roof, about 5 feet long by 3 1/2 feet wide,
had separated from the fuselage; this section included the airframe-mounted
hinge of the left-side cargo door and a partial frame of the left-side
cabin door. The left side of this section exhibited accordion crush damage
in the aft direction and contained multiple folds about 5 inches deep.
No fuselage structure from the left or right side of the cabin area was
recovered, except for a piece of skin, about 2 feet by 2 feet, located
beneath the left-side passenger window frame. The belly skin and floor
structure of the fuselage were intact aft of the wing spar box carry-through
section. The recovered floor structure forward of this section was fragmented.
Portions of five of the six seats were found inside the fuselage. The sixth
seat was not recovered. Most of the fuselage structure aft of the cabin
area was recovered.
About 60 percent of the right wing structure was recovered,
including the entire span of the main spar. The right wing had separated
into multiple pieces and exhibited more damage than the left wing. The
right wing main spar had separated into three pieces. The wing spar had
fractured at its attachment to the main carry-through section. The upper
spar cap fracture exhibited tension on its forward edge and compression
on its aft edge. The spar web exhibited aft bending and tearing in this
The outboard portion of the wing leading edge exhibited
rearward accordion crush damage and was separated from the remainder of
the wing. No evidence of upward spar bending damage was found. No evidence
of metal fatigue was found in any of the fracture surfaces.
The entire span of the right flap was recovered; it had
separated into two sections (chordwise fracture), and both sections had
separated from the right wing. Neither flap section exhibited bowing, bulging,
or planar deformation. About 33 inches of the right aileron was recovered,
and the leading edge of this section exhibited rearward crush deformation.
About 80 percent of the left wing structure was recovered,
including the entire span of the main spar. The left wing main spar had
separated into several pieces and exhibited less deformation than the right
wing. The wing spar was fractured near the left edge of the main carry-through
section. The upper and lower spar cap fractures in this area exhibited
tension on the forward edges and compression on the aft edges. The spar
web also exhibited aft bending and tearing in this area. No evidence of
upward spar bending damage was found. No evidence of metal fatigue was
found in any of the fracture surfaces.
About 90 percent of the upper and lower wing skin between
the main and rear spars was recovered. The upper skin near the left wing
tip was flattened out. The leading edge skin near the inboard portion of
the left wing, near the stall warning port, exhibited damage consistent
with uniform hydrodynamic deformation in the aft direction.
A 27-inch inboard section of the wing flap section was
recovered, and the leading edge of this section exhibited aft accordion
crush damage. The flap section did not exhibit any bowing, bulging, or
planar deformation. The entire span of the left aileron was recovered;
it had separated into two pieces. The outboard section of the aileron was
The vertical stabilizer and rudder had separated from
the aft fuselage. The stabilator had separated from the aft fuselage attach
points and had fractured into five pieces. Two of the pieces consisted
of left and right outboard sections, about 22 inches long, and exhibited
symmetrical aft crush marks that were semicircular, with diameters of about
5 inches. The fracture surfaces of the left outboard section exhibited
tearing in the aft direction. The fracture surfaces of the right outboard
sections exhibited forward and upward tearing. The left inboard section
of the stabilator was more intact than the right inboard section. The leading
edge of the right stabilator section exhibited rearward uniform crush damage
along its entire leading edge.
The lower portion of the rudder had separated from the
vertical stabilizer fin structure and remained attached to the torque tube
bellcrank assembly and fin aft spar. The rudder was folded over toward
the right side of the airplane. The vertical stabilizer was also twisted,
bent, and curled around toward the right. The structure surrounding the
dorsal fin area was deformed symmetrically upward.
All three landing gear assemblies had separated from
the airframe and were recovered. The retraction/extension actuating cylinders
associated with the nose gear and the left main gear were found in the
fully retracted position. The retraction/extension actuating cylinder for
the right main gear was not recovered.
Examination of the aileron control cable circuit and
associated hardware did not reveal any evidence of a preexisting jam or
failure. Flight control cable continuity for the entire right aileron control
circuit, including the entire balance cable that links the right aileron
to the left aileron, was established. The control cable continuity for
the left aileron could not be established because of impact damage and
fragmentation. All of the ends of the separations of the aileron control
cable circuits exhibited evidence of tensile overload. The stops for the
ailerons were examined; no evidence of severe repetitive strike marks or
deformations was noted.
Examination of the stabilator control cable circuit and
associated hardware did not reveal any evidence of a preexisting jam or
failure. Flight control cable continuity for the stabilator was established
from the control surfaces to the cockpit controls. The stabilator balance
weight had separated from the stabilator, and the fractures associated
with the separation were consistent with tensile overload. The stops for
the stabilator were examined; no evidence of severe repetitive strike marks
or deformations was noted.
Examination of the stabilator trim control cable circuit
and associated hardware did not reveal any evidence of a preexisting jam
or failure. Control cable circuitry for the stabilator trim was established
from the control surfaces to the cockpit area. An examination of the stabilator
trim barrel jackscrew revealed that one full thread was protruding out
of the upper portion of the trim barrel assembly housing. The barrel assembly
was free to rotate and had the trim control cable wrapped around it. The
two cable ends were separated about 41 inches and 37 inches, respectively,
from the barrel assembly winding. Examination of the separations revealed
evidence consistent with tensile overload.
Examination of the rudder control cable circuit and associated
hardware did not reveal any evidence of a preexisting jam or failure. Flight
control cable continuity for the rudder was established from the control
surfaces to the cockpit controls. The stops for the rudder were examined;
no evidence of severe repetitive strike marks or deformations was noted.
The electrically driven wing flap jackscrew actuator
was not recovered. The flap switch in the cockpit was destroyed. The throttle
and propeller controls were found in the FULL-FORWARD position. The mixture
control was broken. The alternate air control was found in the CLOSED position.
The key in the magneto switch was found in the BOTH position.
The tachometer needle was found intact, fixed in place,
and pointed to 2,750 rpm. The red line on the tachometer began at 2,700
rpm. The hour register inside the tachometer read 0663.5 hours. The manifold
pressure gauge needle was found fixed in place and indicated 27 inches
Hg. The fuel flow gauge needle was found slightly loose and indicated 22
gallons per hour. The exhaust gas temperature gauge needle was found loose
and indicated 1,000 degrees Fahrenheit (F). The oil temperature gauge was
found fixed and indicated 150 degrees F. The oil pressure gauge was found
fixed and indicated about 17 pounds per square inch (psi). The cylinder
temperature gauge needle was not found. The fuel quantity gauges were destroyed.
The altimeter needle was found fixed and indicated 270 feet. The altimeter
setting was found fixed at 30.09 Hg. The top of the VOR indicator heading
card was found at the 097-degree bearing.
Examination of all recovered electrical wiring and components
did not reveal any evidence of arcing or fire. The circuit breaker panel
was deformed and impact damaged. All of the breakers were found in the
tripped position, except for the flap, transceiver, and DME. The circuit
breaker that provided protection for the transponder, which provided the
VFR code and altitude readout to radar facilities down to 1,100 feet, was
also found tripped.
The fuel selector valve was recovered, and the bottom
of the valve was missing. All three fuel line connections were broken off.
The valve had separated from the fuselage attach points. The selector valve
linkage was deformed, and the valve was found in the OFF position.
A liquid that had a similar color, odor, and texture
as 100 low-lead aviation gasoline was found in the fuel selector valve
sump. The electrically driven fuel boost pump was able to function when
electrical power was applied to it.
The airplane had been equipped with six seats. The seats
had been configured in a "club style" arrangement, with two forward-facing
seats in row 1 (including the pilot's seat), two aft-facing seats in row
2, and two front-facing seats in row 3. The five recovered seats had separated
from the floor structure. Examination of the aluminum backs of both aft-facing
seats revealed that they were deformed (bulged) in the forward direction.
The left and right front seats were equipped with lap
belts and shoulder harnesses. None of the belts for these seats could be
identified in the wreckage. The four seats in rows 2 and 3 were also equipped
with lap belts and shoulder harnesses. Both sections of the lap belt for
the left-side aft-facing seat were found and exhibited evidence of stretching.
The inboard section of the lap belt for the right-side aft-facing seat
in row 2 had been cleanly cut about 3 inches from the male-end of the latch,
and the outboard section of lap belt for this seat exhibited evidence of
stretching. All of the lap belt sections for the seats in row 3 were identified
and none exhibited evidence of stretching. The shoulder harnesses for the
rear seats could not be identified in the wreckage.
MEDICAL AND PATHOLOGICAL INFORMATION
On July 21, 1999, examinations were performed on the
pilot and passengers by Dr. James Weiner, Office of the Chief Medical Examiner,
Commonwealth of Massachusetts. The results indicated that the pilot and
passengers died from multiple injuries as a result of an airplane accident.
Toxicological testing was conducted by the FAA Toxicology
Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicological
tests were negative for alcohol and drugs of abuse.
According to medical records, on June 1, 1999, the pilot
fractured his left ankle in a "hang gliding" accident, and on June 2, 1999,
he underwent surgical "open reduction internal fixation of left ankle fracture."
On June 23, 1999, the pilot's leg was removed from a cast and placed in
a "Cam-Walker." On July 15, 1999, the pilot's Cam-Walker was removed, and
on July 16, 1999, he was given a "straight cane and instructed in cane
usage." The medical records noted that the pilot was "full-weight bearing
with mild antalgic gait."
During interviews, the pilot's physical therapist stated
that the pilot did not have full dorsiflexion (bending upward of the foot)
and that he could not determine whether the pilot's gait was caused by
his slight limitation of motion or by mild pain. The pilot's orthopedic
surgeon stated that he felt that, at the time of the accident, the pilot
would have been able to apply the type of pressure with the left foot that
would normally be required by emergency brake application with the right
foot in an automobile.
According to 14 CFR Section 61.53, "Prohibition On Operations
During Medical Deficiency," in operations that required a medical certificate,
a person shall not act as a pilot-in-command while that person, "(1) Knows
or has reason to know of any medical condition that would make the person
unable to meet the requirements for the medical certificate necessary for
the pilot operation."
According to an FAA medical doctor, a pilot with the
type of ankle injury that the accident pilot had at the time of the accident
would not normally be expected to visit and receive approval from an FAA
Medical Examiner before resuming flying activities.
TESTS AND RESEARCH
Engine and Propeller Examinations
On July 26, 1999, the engine was examined at the Textron-Lycoming
Facility, Williamsport, Pennsylvania, under the supervision of a Safety
Board powerplants investigator. On July 28, 1999, the propeller hub and
blades were examined at the Hartzell Propeller Facility, Piqua, Ohio, under
the supervision of a Safety Board powerplants investigator. Parties to
the investigation were present during both examinations.
According to the Powerplants Group Chairman's Factual
Report, the examinations of the engine and propeller did not reveal evidence
of any preexisting failures or conditions that would have prevented engine
operation. The report further stated that "the investigation team found
impact marks on one of the propeller blades and the top of the engine,
witness marks inside the propeller, and the engine controls and instruments
in the cockpit that indicated high engine power output."
The airplane was equipped with a Bendix/King 150 Series
Automatic Flight Control System (AFCS), which was approved for use in Piper
PA-32R-301 model airplanes by the FAA on November 1, 1982. The AFCS provided
two-axis control for pitch and roll. It also had an electric pitch trim
system, which provided autotrim during autopilot operation and manual electric
trim for the pilot during manual operation.
The AFCS installed on the accident airplane had an altitude
hold mode that, when selected, allowed the airplane to maintain the altitude
that it had when the altitude hold was selected. The AFCS did not have
the option of allowing the pilot to preselect an altitude so that the autopilot
could fly to and maintain the preselected altitude as it climbed or descended
from another altitude. The AFCS had a vertical trim rocker switch installed
so that the pilot could change the airplane's pitch up or down without
disconnecting the autopilot. The rocker switch allowed the pilot to make
small corrections in the selected altitude while in the altitude hold mode
or allowed the pitch attitude to be adjusted at a rate of about 0.9 degree
per second when not in altitude hold mode.
The AFCS incorporated a flight director, which had to
be activated before the autopilot would engage. Once activated, the flight
director could provide commands to the flight command indicator to maintain
wings level and the pitch attitude. To satisfy the command, the pilot could
manually fly the airplane by referencing the guidance received in the flight
command indicator, or the pilot could engage the autopilot and let it satisfy
the commands by maneuvering the aircraft in a similar manner via the autopilot
The AFCS incorporated a navigation mode that could provide
guidance to the pilot, or the autopilot, about intercepting and tracking
VOR and GPS courses. While engaged in this mode, the AFCS could receive
input signals from either the selected VOR frequency and course or from
GPS course data selected for presentation on the pictorial navigation indicator.
The flight command indicator could then command the bank required to maintain
the selected VOR or GPS course with automatic crosswind compensation, and
the autopilot, if engaged, would satisfy those commands.
The AFCS incorporated a heading select mode that allowed
the pilot to select a heading by moving a "bug" on the outer ring of the
pictorial navigation indicator. Once the bug was moved to the desired heading
with the heading select button engaged, the autopilot could command the
airplane to that heading at a bank angle of about 22 degrees.
The AFCS had a control wheel steering (CWS) button mounted
on the control yoke that allowed the pilot to maneuver the aircraft in
pitch and roll without disengaging the autopilot. According to AlliedSignal,
when the CWS button was released, the autopilot would resume control of
the aircraft at the heading and altitude that had been selected at the
time the CWS button was released.
According to the FAA and Bendix/King, the trim system
was designed to withstand any single in-flight malfunction. Trim faults
were visually and aurally annunciated in the cockpit. Through the use of
monitor circuits, aircraft control would automatically be returned to the
pilot when a fault was detected.
After the AFCS had been preflight tested, it could be
engaged and disengaged either manually or automatically. The following
conditions would cause the autopilot to automatically disengage: power
failure, internal flight control system failure, loss of a valid compass
signal, roll rates greater than 14 degrees per second, and pitch rates
greater than 8 degrees per second.
On July 29 and 30, 1999, the avionics were examined at
the AlliedSignal/King Radios Facility, Olathe, Kansas, under the supervision
of a Safety Board investigator. On October 13 and 14, 1999, a follow-up
examination of the navigation and communications transceivers and all three
autopilot servos was also performed at the AlliedSignal/King Radios Facility
under the supervision of a Safety Board investigator. parties to the investigation
were present during both examinations.
The accident airplane's AFCS was examined. Examination
and functional testing of the AFCS pitch, pitch trim, and roll servos did
not reveal any evidence of a preimpact malfunction or jam.
The accident airplane was equipped with a GPS receiver,
Bendix/King model KLN-90B. The GPS was capable of presenting moving map
displays; bearings and distances to programmable destinations, such as
airports and waypoints; airport information; ground speed; and other information.
The GPS was also capable of interfacing with the AFCS and the pictorial
Examination of the GPS unit revealed that it was crushed
vertically. The display in the front face of the unit was destroyed. The
ON/OFF switch was found in the ON position. The navigation database indicated
that it was effective on October 8, 1998, and that it expired on November
4, 1998. A wire that connected the circuitry of a 3.6-volt lithium battery
was separated. According to AlliedSignal, the lithium battery provided
electrical power to retain the nonvolatile memory of the GPS receiver and
required a minimum of 2.5 volts to retain memory. The battery voltage was
measured to be 0.2 volt, and it was determined that the memory had not
Examination of the Bendix/King model KR-87, automatic
direction finder, revealed that the receiver's primary frequency was set
at 400 kilohertz (kHz) and the secondary frequency was set at 200 kHz.
Both of the airplane's communication/navigation transceivers
received severe impact damage and could not be powered up. The nonvolatile
memory circuit chips were extracted from the transceivers, placed in a
test unit, and powered up. The following information was noted about each
of the transceivers:
Transceiver No. 1, KX-165
The in-use communication frequency was set at 132.02,
which was the same frequency as the TEB automatic terminal information
The standby communication frequency was set at 135.25;
the CDW ATIS had a frequency of 135.5.
The in-use navigation frequency was set at 109.80, which
was the same frequency as the New Haven, Connecticut, VOR.
The standby navigation frequency was set at 113.10, which
was the same frequency as the LaGuardia Airport, New York, VOR.
Transceiver No. 2, KX-165
The in-use communication frequency was set at 121.40,
which was the same frequency as the MVY tower.
The standby communication frequency was set at 127.25;
the MVY ATIS had a frequency of 126.25.
The in-use navigation frequency was set at 108.80, which
was the same frequency as the BDR VOR.
The standby navigation frequency was set at 110.00, which
was the same frequency as the Norwich, Connecticut, VOR.
Safety Board Materials Laboratory Examinations
An examination of the accident airplane's components
was conducted in the Safety Board Materials Laboratory in Washington, D.C.
The flight command indicator (Bendix/King model KI-256)
was deformed, and its glass faceplate was missing. The center portion of
the pictorial display was partially embedded in the side of the housing
in a position that indicated a right turn with a bank angle of about 125
degrees and a nose-down pitch attitude of about 30 degrees. The air-driven
gyro housing inside of the flight command indicator was corroded but not
deformed. Disassembly and inspection of the gyro did not reveal any scoring
marks on the spinning mass gyro and mating housing. The turn coordinator
was deformed, and its glass was missing. The display was captured in a
position indicating a steep right turn. The electrically driven gyro assembly
inside of the instrument was removed and found free to rotate with no binding
or case interference. No scoring marks were found on either the spinning
mass gyro or mating housing.
The pictorial navigation indicator (Bendix/King model
KI-525A) was deformed, and its glass faceplate was missing. The heading
indicator was pointing to 339 degrees. The center navigational display
needle was oriented along the 300/120-degree bearing. The heading flag
was displayed. The heading bug was located at the 095-degree mark. The
slaved gyro assembly was partially separated from its mounting, and its
case exhibited minor deformation. The gyro housing and internal rotor were
disassembled. The interior surface of the case and the exterior surface
of the spinning mass rotor did not exhibit any deformation, impact marks,
or rotational scoring.
The engine-driven vacuum pump drive shear shaft was intact.
The drive end was removed to expose the internal rotor and vanes. The rotor
showed several cracks between the bottom of the vane slots and the center
of the rotor. All six vanes were removed intact. The rotor was removed
in several pieces, and the housing was examined. Examination revealed no
evidence of scoring or rotational damage. A metal straight-edge was placed
along the long ends of each vane, and no warping or wear was noted.
The electrically driven vacuum pump drive shear shaft
was intact. The pump was opened from the motor drive end to expose the
rotor and internal vanes. Several cracks were noted in the rotor between
the vane slots and the center shaft area. Five of the six vanes were removed
and found intact with no fractures or edge chipping. The sixth vane was
found wedged and stuck in the rotor, which was stuck inside the housing.
Approximately half of the rotor was removed, and examination of its housing
revealed no evidence of scoring or rotational damage. A metal straight-edge
was placed along the long ends of the removed vanes, and no warping or
wear was noted. Disassembly and examination of the vacuum system filter
did not reveal any evidence of contaminants or blockages.
The airspeed indicator was damaged, and its glass faceplate
was missing. The needle position was found off-scale near the right edge
of the density altitude adjustment window; it could be moved, however,
when released, it spring-loaded to its as-found position. Magnified examination
of marks on the instrument face revealed an outline similar to the size
and shape of the needle. This mark was located about two needle widths
above the 210-knot marking, which was the maximum marking on the indicator.
The location of the needle mark on the airspeed indicator was consistent
with the maximum mechanical needle travel position for the airspeed indicator
The VSI needle was missing. Magnified examination of
marks on the instrument face revealed an outline similar to the size and
shape of a needle. This needle mark was pointed at the down-limit position
of 2,000 fpm descent.
Microscopic examination of the AFCS light bulbs on the
front face of the unit was performed. None of the light bulbs exhibited
evidence of filament stretch, including the autopilot engage, flight director,
or trim failure light bulbs. An examination of all recovered light bulbs
from the airplane's main and landing gear annunciator panels revealed no
evidence of filament stretch.
Aircraft Performance Study
An aircraft performance study was performed by a Safety
Board specialist using the Board's computer simulation program. According
to the specialist's report, airplane performance data for the final portion
of the flight were calculated using radar, aircraft, and weather data.
Performance parameters were then computed for the final 7 minutes of the
The calculated parameters showed the airplane initially
descending from 5,500 feet at descent rates varying between 400 and 800
fpm, at 2133:40. At 2137:20, the airplane attained a steady descent rate
of close to 600 fpm as the airplane passed through 3,000 feet. During the
entire descent from 5,500 feet, the calculated airspeed remained near 160
KIAS, and the flightpath angle remained close to -2 degrees. About 2138,
the airplane started to bank in a right-wing-down (RWD) direction toward
a southerly direction. Calculated parameters indicated an almost constant
roll angle of 13 degrees RWD and a vertical acceleration of 1.09 Gs while
executing the turn. About 30 seconds after the turn was initiated, at an
altitude of 2,200 feet, the airplane stopped descending. The airplane then
climbed for the next 30 seconds, attaining a maximum climb rate of 600
fpm. During the ascent, the airplane finished the turn to a southeasterly
direction, reduced speed slightly to 153 KIAS, and returned to a wings-level
attitude by 2138:50. By 2139, the airplane leveled at 2,500 feet and then
flew in a southeasterly direction with wings level while increasing airspeed
back to 160 KIAS.
At 2139:50, the airplane entered a left turn, while slightly
increasing altitude to 2,600 feet. The airplane reached a maximum bank
angle of 28 degrees left-wing-down (LWD) and a maximum vertical acceleration
of 1.2 Gs in this turn. When the maximum LWD bank angle was obtained, the
altitude started to decrease at a descent rate close to 900 fpm. The LWD
attitude was maintained for approximately 15 seconds until the airplane
was heading towards the east. At 2140:07, the airplane bank angle returned
to wings level. At 2140:15, with the airplane continuing towards the east,
it reestablished a descent close to 900 fpm and then started to increase
its bank angle in a RWD direction at nearly a constant rate. As the airplane
bank angle increased, the rate of descent increased, and the airspeed started
to increase. By 2140:25, the bank angle exceeded 45 degrees, the vertical
acceleration was 1.2 Gs, the airspeed increased through 180 knots, and
the flightpath angle was close to 5 degrees airplane nose down. After 2140:25,
the airplane's airspeed, vertical acceleration, bank, and dive angle continued
to increase, and the right turn tightened until water impact, about 2141.
The cell phone records for the three occupants of the
airplane reflected one out-going call, about 2025. No calls were listed
as being made from, or received by, the cell phones from the time of the
takeoff through the estimated time of the accident.
The AIM, published by the FAA, is the official guide
to basic flight information and ATC procedures. Under the Section, "Preflight
Briefing," it states that FSSs are the primary source for obtaining preflight
briefings and in-flight weather information. The AIM states that a standard
briefing should be requested any time a pilot is planning a flight and
has not received a previous briefing or has not received preliminary information
through mass dissemination media. The standard briefing should include
the following information:
Adverse Conditions: Significant meteorological and aeronautical
information that might influence the pilot to alter the proposed flight.
VFR Flight Not Recommended: When VFR flight is proposed
and sky conditions or visibilities are present or forecast, surface or
aloft, that in the briefer's judgment would make flight under VFR doubtful,
the briefer will describe the conditions, affected locations, and use the
phrase "VFR flight not recommended."
Current Conditions: Reported weather conditions applicable
to the flight will be summarized from all available sources.
En Route Forecast: Forecast en route conditions for the
proposed route are summarized in logical order (for example, departure/climbout,
en route, and descent).
Destination Forecast: The destination forecast for the
planned estimated time of arrival. Any significant changes within 1 hour
before and after the planned arrival are included.
Winds Aloft: Forecast winds aloft will be provided using
degrees of the compass. The briefer will interpolate wind directions and
speeds between levels and stations as necessary to provide expected conditions
at planned altitudes.
The AIM also states that a standard briefing should include
synopsis, notices to airmen, and ATC delays.
A review of 14 CFR Part 61, "Certification: Pilots, Flight
Instructors, and Ground Instructors," revealed that no specific training
requirements exist regarding spatial disorientation. According to the FAA
Practical Test Standards, an applicant for a private pilot rating must
exhibit knowledge of spatial disorientation. In addition, the publication
states that "the examiner shall also emphasize stall/spin awareness, spatial
A review of training records from FSI revealed that while
the pilot was preparing for his private pilot certificate, he received
instruction on the symptoms, causes, and effects of spatial disorientation
and the correct action to take if it occurred. In addition, the pilot received
unusual attitude training while attending the private pilot and instrument
training courses at FSI.
According to an FAA Instrument Flying Handbook, Advisory
Circular 61-27C (AC) (Section II, "Instrument Flying: Coping with Illusions
in Flight"), one purpose for instrument training and maintaining instrument
proficiency is to prevent a pilot from being misled by several types of
hazardous illusions that are peculiar to flight. The AC states that an
illusion or false impression occurs when information provided by sensory
organs is misinterpreted or inadequate and that many illusions in flight
could be created by complex motions and certain visual scenes encountered
under adverse weather conditions and at night. It also states that some
illusions may lead to spatial disorientation or the inability to determine
accurately the attitude or motion of the aircraft in relation to the earth's
surface. The AC also states that spatial disorientation as a result of
continued VFR flight into adverse weather conditions is regularly near
the top of the cause/factor list in annual statistics on fatal aircraft
The AC further states that the most hazardous illusions
that lead to spatial disorientation are created by information received
from motion sensing systems, which are located in each inner ear. The AC
also states that the sensory organs in these systems detect angular acceleration
in the pitch, yaw, and roll axes, and a sensory organ detects gravity and
linear acceleration and that, in flight, the motion sensing system may
be stimulated by motion of the aircraft alone or in combination with head
and body movement. The AC lists some of the major illusions leading to
spatial disorientation as follows:
"The leans - A banked attitude, to the left for example,
may be entered too slowly to set in motion the fluid in the 'roll' semicircular
tubes. An abrupt correction of this attitude can now set the fluid in motion
and so create the illusion of a banked attitude to the right. The disoriented
pilot may make the error of rolling the aircraft back into the original
left-banked attitude or, if level flight is maintained, will feel compelled
to lean to the left until this illusion subsides.
Coriolis illusion - An abrupt head movement made during
a prolonged constant-rate turn may set the fluid in more than one semicircular
tube in motion, creating the strong illusion of turning or accelerating,
in an entirely different axis. The disoriented pilot may maneuver the aircraft
into a dangerous attitude in an attempt to correct this illusory movement....
Graveyard spiral - In a prolonged coordinated, constant-rate
turn, the fluid in the semicircular tubes in the axis of the turn will
cease its movement...An observed loss altitude in the aircraft instruments
and the absence of any sensation of turning may create the illusion of
being in a descent with the wings level. The disoriented pilot may pull
back on the controls, tightening the spiral and increasing the loss of
Inversion illusion - An abrupt change from climb to straight-and-level
flight can excessively stimulate the sensory organs for gravity and linear
acceleration, creating the illusion of tumbling backwards. The disoriented
pilot may push the aircraft abruptly into a nose-low attitude, possibly
intensifying this illusion.
Elevator illusion - An abrupt upward vertical acceleration,
as can occur in a helicopter or an updraft, can shift vision downwards
(visual scene moves upwards) through excessive stimulation of the sensory
organs for gravity and linear acceleration, creating the illusion of being
in a climb. The disoriented pilot may push the aircraft into a nose low
attitude. An abrupt downward vertical acceleration, usually in a downdraft,
has the opposite effect, with the disoriented pilot pulling the aircraft
into a nose-up attitude....
Autokinesis - In the dark, a stationary light will appear
to move about when stared at for many seconds. The disoriented pilot could
lose control of the aircraft in attempting to align it with the false movements
of this light."
The AC also states that these undesirable sensations
cannot be completely prevented but that they can be ignored or sufficiently
suppressed by pilots' developing an "absolute" reliance upon what the flight
instruments are reporting about the attitude of their aircraft. The AC
further states that practice and experience in instrument flying are necessary
to aid pilots in discounting or overcoming false sensations.
Further, the FAA Airplane Flying Handbook, FAA-H-8083-3,
chapter 10, states the following about night flying and its affect on spatial
"Night flying requires that pilots be aware of, and operate
within, their abilities and limitations. Although careful planning of any
flight is essential, night flying demands more attention to the details
of preflight preparation and planning. Preparation for a night flight should
include a thorough review of the available weather reports and forecasts
with particular attention given to temperature/dewpoint spread. A narrow
temperature/dewpoint spread may indicate the possibility of ground fog.
Emphasis should also be placed on wind direction and speed, since its effect
on the airplane cannot be as easily detected at night as during the day...Night
flying is very different from day flying and demands more attention of
the pilot. The most noticeable difference is the limited availability of
outside visual references. Therefore, flight instruments should be used
to a greater degree in controlling the airplane...Under no circumstances
should a VFR night-flight be made during poor or marginal weather conditions
unless both the pilot and aircraft are certificated and equipped for flight
under...IFR...Crossing large bodies of water at night in single-engine
airplanes could be potentially hazardous, not only from the standpoint
of landing (ditching) in the water, but also because with little or no
lighting the horizon blends with the water, in which case, depth perception
and orientation become difficult. During poor visibility conditions over
water, the horizon will become obscure, and may result in a loss of orientation.
Even on clear nights, the stars may be reflected on the water surface,
which could appear as a continuous array of lights, thus making the horizon
difficult to identify."
According to AC 60-4A, "Pilot's Spatial Disorientation,"
tests conducted with qualified instrument pilots indicated that it can
take as long as 35 seconds to establish full control by instruments after
a loss of visual reference of the earth's surface. AC 60-4A further states
that surface references and the natural horizon may become obscured even
though visibility may be above VFR minimums and that an inability to perceive
the natural horizon or surface references is common during flights over
water, at night, in sparsely populated areas, and in low-visibility conditions.
A book titled, Night Flying, by Richard Haines and Courtney
Flatau, provides some additional information concerning vertigo and disorientation.
It states the following:
"Vestibular disorientation refers to the general feeling
that one's flight path isn't correct in some way. By calling this effect
vestibular, it emphasizes the role played by the middle ear's balance organ.
Flying an uncoordinated turn produces this effect as does excessive head
turning during a turn in flight. Vestibular disorientation is often subtle
in its onset, yet it is the most disabling and dangerous of all disorientation."
Pilot's Operating Handbook (POH)
According to the POH and a photo of the accident airplane's
cockpit, the fuel selector control was located below the center of the
instrument panel, on the sloping face of the control tunnel, on the cockpit
floor. In the "Normal Procedures" section of the POH, under "Cruising,"
it states, "In order to keep the airplane in best lateral trim during cruise
flight, the fuel should be used alternately from each tank at one hour
intervals." Also, in the "Normal Procedures" section, under the "Approach
and Landing" checklist, the first item listed is "Fuel selector - proper
On August 5, 1999, the main airplane wreckage was released
to a representative of the accident pilot's insurance company. On November
17, 1999, the remainder of the retained parts were released and shipped
to the insurance company's storage facility.
Additional Persons Participating in the Investigation:
Richard I. Bunker - Massachusetts Aeronautics Commission,
Tom McCreary - Hartzell Propeller Inc., Piqua, Ohio
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