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NTSB Report

August 13, 1999 · Piper PA-28-181 · N281PF

Paw Paw, MI

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
August 13, 1999
Injury Outcomes
4 injuries (4 fatalities)
Location
Paw Paw, MI
Aircraft
Piper PA-28-181
Tail Number
N281PF
Operator
National Flyers Association
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
CHI99FA290

The non-instrument rated pilot contacted the Green Bay AFSS at 0117 EST on August 13 and again at 0614 for a weather brief. Both weather briefers reported there was an Airmet for IFR conditions and the VFR flight was not recommended. At 0835 the pilot filed a VFR flight plan. The weather briefer reported that VFR flight was not recommended. Witnesses reported hearing an airplane in the clouds with its engine 'screaming,' and the 'throttle full open.' They reported the wing was separated from the airplane when the airplane came out of the clouds. The right wing, stabilator, and rudder were located within 0.5 miles of the main wreckage site. The inspection of the airplane revealed no pre-existent anomalies to the engine or airframe and all spar fracture surfaces were observed to be granular. The pilot had a total of about 248 flight hours; 81 hours in make and model. The pilot had flown 2.5 hours in the last six months. The pilot had logged no actual instrument flight time, and had a total of one hour of simulated instrument flight. The cloud bases were approximately 1,300 feet agl. A PIPEP reported that cloud tops near Kalamazoo (AZO), located 16 nm to the east, were at 7,000 feet msl about 12 minutes prior to the accident. NTAP data indicated the airplane's altitude was approximately 4,800 feet msl before it was lost to radar.

NTSB Probable Cause

the pilot flew into known adverse weather, the pilot's lack of total instrument flight experience, and the pilot exceeded the design limits of the airplane. Factors included the pilot's total lack of experience in the type of operation and the pilot's overconfidence in his personal abilities.

Full Narrative

History of Flight On August 13, 1999, at 1046 eastern daylight time (All time edt), a Piper PA-28-181, N 281PF, operated by National Flyers Association, was destroyed when it experienced an in-flight breakup prior to impacting the ground about 3 miles south of Paw Paw, Michigan. The outboard section of the right wing and empennage were located approximately 0.5 miles north of the main wreckage. The 14 CFR Part 91 flight had departed Fond Du Lac County Airport, Fond Du Lac, Wisconsin, at approximately 0930 en route to the Ohio State University Airport, Columbus, Ohio, on a business flight. Visual meteorological conditions prevailed and a VFR flight plan was filed. The private pilot and three passengers received fatal injuries. The service lineman at the Fond Du Lac Airport reported N281PF had landed at Fond Du Lac on Thursday at 1600. He reported the pilot requested the airplane be topped off with fuel and oil. The lineman reported he topped off the fuel tanks with 35.9 gallons of fuel and added two quarts of oil. The pilot phoned the Federal Aviation Administration's Green Bay Automated Flight Service Station (FAA GRB AFSS) at 0117 on August 13, 1999. The pilot spoke with the weather briefer for approximately 13 minutes concerning the weather conditions for the pilot's intended route of flight from Fond Du Lac, Wisconsin, to Columbus, Ohio. At 0118:18, the GRB AFSS told the pilot, "Well, at the present time, there's an Airmet for Wisconsin forecasting occasional IFR conditions over the, ah, northwestern three quarters of Wisconsin." At 0118:50, the GRB AFSS told the pilot, "... so VFR flight is not recommended. A low pressure system is over La Crosse right now. A warm front stretches to the southeast through about the Dayton Ohio, area. A trailing cold front to the southwest through, ah, about Omaha, Nebraska, and there's severe thunderstorm watches and convective Sigmets out for numerous thunderstorms. Right now thunderstorms extend...." At 0119:34, the GRB AFSS told the pilot, "Ah, it looks like probably in about four hours, ah, most of the thunderstorm activity that's over central Illinois through, ah, the northern half of Indiana will probably be pushing over northern Ohio. Ah, so there's a very good probability of thunderstorms along your route of flight, especially across the Ohio area." The pilot contacted the GRB AFSS weather briefer again between 0614 and 0628 for a weather update. At 0616:19, the GRB AFSS told the pilot, "Well, there's an Airmet for IFR conditions for much of Wisconsin and, uh, pretty much all of Lake Michigan and lower Michigan through twenty hundred zulu. And it does, uh, well, they don't forecast any right now in Ohio. There's, uh, lines of thunderstorms that run from eastern Lake Superior to southwestern lower Michigan. Uh, other precipitation down through, uh, well, from western Lake Erie on down to southern Indiana moving east there's a line of thunderstorms, uh moving from about Marquette. It, uh, that extends back to about Wausau right now. But it looks like that line is gonna continue developing further southwest." At 0616:58, the GRB AFSS told the pilot, "Um, there's no Sigmet on that area yet, but there are Sigmets for Michigan and, uh, Indiana. Naturally, with the Airmet for IFR, VFR flight would not be recommended." At 0623:48, the GRB AFSS told the pilot, "Sir, uh, VFR flight is not recommended anywhere departing Fond Du Lac, east, west, south, north." At 0835 the pilot contacted the GRB AFSS and filed a VFR flight plan from Fond Du Lac, Wisconsin, to Columbus, Ohio. At 0838:03, the GRB AFSS told the pilot, "Okay, that flight plan is filed at this time. VFR is not recommended due to an Airmet and occasional IFR conditions due to fog en route and some lowered ceilings. Looks like they, ah, stay pretty much, yeah, right now pretty much marginal as far as, ah, ceilings go through much of the route." At 0840:16, the GRB AFSS told the pilot, "Oh well, yeah, just the Airmet does call for the IFR, so just VFR is not recommended. But, ah, if you do go, um, yeah, you will run into some lowered ceilings and visibilities." At approximately 0930, the pilot departed Fond Du Lac. The airport manager reported that the airplane sounded normal during takeoff, but that it had a long ground run before it lifted off. The airport manager reported the weather at Fond Du Lac was VFR, but the cloud bases were at 1,000 to 2,000 feet above ground level (agl) and that there were not many holes in the clouds. At 0947, the pilot contacted the GRB AFSS via radio and activated his VFR flight plan. At 0951:58, the GRB AFSS responded to N281PF, "(unintelligible) roger. And, uh, you have the Airmet for IFR conditions across, uh, Wisconsin, and uh, Lake Michigan and lower Michigan? Over." At 0952:10, N281PF responded, "That's affirmative." N281PF's approximate ground track from 1034:34 to 1946:56 was plotted using the FAA's National Track Analysis Program (NTAP) data. At 1034:34, the NTAP data indicated N281PF's approximate location was three miles west of South Haven, Michigan, at 4,500 feet mean sea level (msl) and on a heading of approximately 120 degrees magnetic. Between 1034:34 and 1437:46, the NTAP data indicated N281PF descended to 2,100 msl. Then the NTAP data indicated N281PF started a climb and reached 5,000 feet msl at 1045:45. The NTAP data indicated the last radar data point associated with a transponder code was at 1046:05. It indicated N281PF had turned left to a northeasterly heading and was at approximately 4,800 feet msl. The NTAP data indicated five other data points (primary hits) not associated with a transponder code were recorded. A witness reported hearing an airplane in the clouds. She reported the engine was "... as loud as could be," and the, "... engine was 'razzed' up like crazy," and the, "engine was screaming." She reported the wing had separated from the airplane and the airplane was whirling around, "... like a helicopter." She reported the airplane was, "... just screaming," and the, "... airplane [was] going full tilt coming down." Another witness reported he had heard the airplane in the clouds for about 30 seconds prior to seeing it come out of the clouds. He reported the wing was already off when the airplane came out of the clouds. He reported the engine was "wide open," and the "throttle full open." He reported the airplane was spinning down with one wing on the airplane in about a 75 degree nose down position. Personnel Information The pilot was a private pilot with a single engine land rating. He held a Third Class medical certificate. He had a total of about 248 hours of flight time; 81 flight hours were in the same make and model airplane as the accident airplane. The pilot's flight logbook indicated that prior to the accident flight, the pilot had flown 2.5 hours in the last six months. The pilot had not logged any actual instrument flight time, and had a total of one hour of simulated instrument flight. Aircraft Information The airplane was a single engine Piper PA-28-181, serial number 28-8190156. The airplane seated four and had a maximum gross weight of 2,550 pounds. The engine was a 180 horsepower Lycoming O-380-A4M engine. The last annual inspection was conducted on August 5, 1999. The airplane had flown 10 hours since the last inspection and had a total time of 2,613 hours. Meteorological Conditions A National Transportation Safety Board meteorologist prepared a Meteorological Factual Report. The report stated the following: "The Surface Analysis chart prepared by the National Weather Service (NWS) National Center for Environmental Prediction (NCEP) for 1100 August 13 showed a center of low pressure located over northern Michigan. A cold front extended south southwestward from the low through Lake Michigan, central Illinois, southern Missouri, and southern Oklahoma. In addition, the chart displayed a trough of low pressure in advance of the cold front from northwestern Ohio through central Indiana, western Kentucky, and western Tennessee. Station plots over lower Michigan indicated overcast clouds, dew points in the 70's (F), and southwest winds at 10-15 knots." At 1053, the surface weather observation at Kalamazoo/Battle Creek International Airport (KAZO), Michigan, reported the following weather: Wind-250 degrees at 9 knots; visibility-10 miles; present weather-none; sky condition-overcast 1,300 feet; temperature-23 degrees C; dewpoint-22 degrees C; altimeter setting-29.69 inches hg. At 1028, a pilot report (PIREP) indicated the following information: "Location-Kalamazoo; time-1028; altitude-7000 feet; type aircraft-Piper PA31; sky condition-top 6,000 feet/sky clear; temperature-15 degrees F; turbulence-negative; remarks-smooth." The In-flight Advisories (AIRMET SIERRA) for the North Central Area were valid for portions of N281PF's route of flight. (See Meteorological Factual Report) Wreckage Information The airplane wreckage was located in an area of small farm fields and wooded terrain approximately three miles south of Paw Paw, Michigan. The location of the main wreckage was in woods at coordinates N 42 degrees 08.981 minutes, W 85 degrees, 54.054 minutes. The right outboard wing section was located approximately 0.5 mile north of the main wreckage. The remaining pieces that had separated from the airplane and recovered during the on-site investigation were located between the right outboard wing section and the main wreckage. The coordinates of the airplane pieces that had separated from the fuselage during the in-flight break-up were: Right wing outboard section N 42 09.292, W 85 54.069 Left horizontal stabilator N 42 09.085, W 85 54.032 Vertical stabilizer N 42 09.068, W 85 54.081 Stabilator piece N 42 09.051, W 85 54.032 Bottom stringer N 42 09.047, W 85 54.073 Top stringer N 42 09.014, W 85 54.045 The rudder was located in the same vicinity as the above pieces but a coordinate position was not obtained. Pieces of the center section of the right wing were not located during the on-site investigation since they had landed in dense woods and cornfields. The pieces were later found, but their exact coordinates were not identified. The pieces included the right wing fuel tank, the fore and aft wing spar and wing section located directly behind the fuel tank, a piece of right flap, a piece of right aileron, a piece of corrugated skin, and a miscellaneous skin piece. The main wreckage impacted the ground in an approximately 60 degree nose down attitude. The engine and nose of the airplane was embedded in the ground. The fuselage and tailcone remained attached to the engine compartment. The left wing had separated from the fuselage at the wing root, but was located to the left and forward of the fuselage. The left wing impacted a tree 21 inches inboard from the wingtip and a semi-circular indentation was made in the wing. The right wing root was embedded in the ground under the right side of the fuselage. The examination of the left wing revealed the forward spar was separated from the fuselage structure. The nut and bolt remained attached. The main spar separated from the main spar box. The aft spar attachment was separated from the fuselage structure. The nut and bolt remained attached. The inboard leading edge was bent outboard at about 30 degrees. The fuel tank remained attached to the wing. There was impact damage along the leading edge 10 inches outboard of the inboard corner. An unknown amount of blue fuel was noted in the fuel tank. The aileron was attached at all three hinges. The aileron connecting rod was separated at the bellcrank. Both control cables had separated and were frayed. The flap remained attached at all three hinges. The main landing gear remained attached to the wing and received no visible damage. The fractures to the main spar were clean and granular. The examination of the main spar box revealed it had separated from the belly of the fuselage. The lower spar box cap separated from the box web. The lower spar box cap was "S" shaped. The fracture surfaces of the spars were granular. The right wing root fore and aft spars were fractured where the wing had separated from the airplane. The right wing bottom spar cap fractured diagonally across the spar cap through two rivet holes. The spar cap was bent upward and aft. The fracture surface was granular. A lip was located along the topside of the fracture surface. The right wing top spar cap fractured diagonally across the spar cap through two rivet holes. The spar cap was bent upward and aft. The fracture surface was granular, except at the aft edge where the fracture had rounded edges. A lip was located along the topside of the fracture surface. The examination of the approximately 3.5 foot right wing "center" section where the right wing fuel tank was attached revealed that the main spar was bent upward and twisted aft. The spar web between the upper and lower spar caps was buckled and broken. The bottom inboard spar cap was fractured diagonally across the spar cap and through two rivet holes. The fracture surface was granular. A shear lip was located along the topside of the fracture surface. The top inboard spar cap was fractured perpendicular across the spar cap and through a screw hole for the fuel tank. The fracture surface was granular. A shear lip was located along the topside of the fracture surface. The right wing fuel tank had separated from the right wing, and it appeared like it had been "peeled" open and turned inside out. The aft wall of the fuel tank remained attached to one side panel of the fuel tank. The right wing outboard section was approximately 8 feet long at the trailing edge and 10.5 feet at the leading edge. The wing had a diagonal crease starting from the leading edge and outboard to the trailing edge. The main crease was about 6.5 inches outboard of the fuel tank to the aileron middle hinge. The leading edge of the wing was torn open about 22 inches outboard of the fuel tank. The wing separated at the splice and the upper spar cap was bent upward. One section of the aileron remained attached at the middle and outboard hinges. The fracture surfaces of the spars were granular. The examination of the empennage revealed that the vertical stabilizer had separated from the tailcone. The vertical stabilizer leading edge was deformed left and right starting at the base and upwards for three feet. The lower one-third of the right side of the stabilizer had numerous tears in the skin and several black smear marks. Chaffing marks were evident 13 inches forward of the trailing edge and 12 inches up from its base. The upper rudder attachment broke in half in an upward direction. The rudder and torque tube remained attached to an 11 inch portion of the tailcone. The rudder spar was bent aft 35 degrees. The lower 6 inches of the rudder separated from the rest of the control surface. The rudder was crushed to the left at the trailing edge about 23 inches from the bottom. The lower 16 inches of trailing edge was bent to the right 90 degrees. The balance weight was recovered but it had separated from the rest of the rudder. The stabilator separated from the tailcone in four pieces. The right side of the stabilator separated from the spar going aft. The leading edge was deformed in three areas. There was a tear in the leading edge skin 13 inches outboard of the root. There was a dent 23 inches outboard of the root and a "V" shape starting 13 inches outboard of the root and extending 26 inches outboard of the root. The "V" shape extended aft to the spar. The upper and lower skin between the forward spar and aft spar was torn in two. The anti-servo trim tab remained attached to the rear aft spar. The left side of the stabilator leading edge crushed downward 6 inches outboard of the root. The leading edge was also crushed and torn 16 inches inboard of the tip. There was a 12 inch tear "V" shape starting 2 inches aft of the spar and 11 inches inboard of the tip. The tear curled up and aft to the aft spar where it measured 4.5 inches across. There was also a 9 inch scar 17 inches inboard of the tip in the same area. The entire upper and lower skin was torn in half. The anti-servo trim tab separated 30 inches from the outboard edge. The balance weight separated from the stabilator spar. The right side of the balance weight that attached to the spar was bent aft approximately 60 degrees, and left side was bent aft approximately 45 degrees. The jackscrew separated from the rear bulkhead and measured 7 threads. Paint transfer marks were evident on the left and right stabilators. The engine examination revealed there was continuity and compression to all four cylinders. The left magneto was intact and provided spark on all four towers. The right magneto was broken at the flange. The carburetor was broken at the mounting flange and separated from the airbox. The fuel pump pumped fluid when checked. The examination of the propeller revealed one blade did not have any nicks or dents along the leading edge, no chordwise scratches, and no blade twist. The other blade did not have any nicks or dents along the leading edge, no chordwise scratches, and no blade twist. The chamber side of the blade had a diagonal scratch about 21 inches from the blade tip. The blade was bent forward about 30 degrees, 12 inches inboard from the blade tip. There was no elongation of the propeller mounting holes. Medical and Pathological Information An autopsy was performed on the pilot at Memorial Hospital, Grand Rapids, Michigan. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report concerning the pilot indicated the following results: No carbon monoxide detected in blood. No cyanide detected in blood. No ethanol detected in urine. Phenylpropanolamine present in blood. Phenylpropanolamine present in urine. Phenylpropanolamine is commonly found in over-the-counter decongestants and diet pills. Additional Information Parties to the investigation included the Federal Aviation Administration and the New Piper Aircraft, Inc. The airplane wreckage was released to A. J. Fiedler and Associates. The airplane logbooks were released to National Flyers Association, Inc.

Flight

Event TypeAccident
Event Time10:46 EDT
Nearest Airport0nm
Runway0
Flight Plan FiledVFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA-28-181
Tail NumberN281PF
Aircraft CategoryAir
DamageDestroyed
OperatorNational Flyers Association
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-360-A4M · Reciprocating · 180
Seats4

People & Injuries

Injury Summary4 injuries (4 fatalities)
Fatal4
Serious0
Minor0
Uninjured0
Total4
Crew 1Age 48 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind250° @ 9 kt
Visibility9 sm
CeilingOvercast 1300 ft
Temperature / Dew Point70 F
Altimeter29.00 inHg
Observation Time14:53
Weather SourceWFAC

Appendix: Source Data