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BuiltByNOF

IT SHOULD NOT HAPPEN TO YOU

 

COMANCHE ACCIDENTS, 8.2003, AND A CASE

by Omri Talmon

 

 

COMANCHE ACCIDENTS, 8.2003

 

This is the first time, since I began writing this column several years ago, there are no reported Comanche accidents/incidents for an entire month.

 

Fellow Comanche pilots - keep up the good work.  Fly safely

 

A CASE

I normally try to bring and discuss an accident which is quite related to the specifics of the Comanche.  The following one, although involving a Comanche, is not quite in that category but contains valuable lessons nevertheless.  It was a very tragic accident with four fatalities, and among those which weigh heavily on the safety record of our fleet.  Should it?

 

NTSB REPORT

Accident occurred Saturday, November 20, 1999 at NEW ORLEANS, LA
Aircraft: Piper PA-24-260. Injuries: 4 Fatal.

The airplane was number two in line behind traffic on a right base for runway 36R. The local controller asked the pilot if the visibility was hazy. The pilot replied, 'no it's not hazy uh it's just uh twilight (unintelligible) time.' When it appeared that the accident aircraft was lining up with runway 27, the local controller asked the pilot what his intentions were. The pilot advised local control that he would be turning downwind for runway 36R, but the local controller instructed him to turn right and enter a right base for runway 36R. The local controller asked the pilot if he had the runway in sight. The pilot replied 'roger.' A witness observed the aircraft flying slow at about 200 feet agl, with the wings level. The aircraft began a bank to the left and then a bank to the right. Then the aircraft's nose dropped, and it entered a left turn and descended from view. The airplane impacted the ground in a nose down attitude, and a fire erupted, which consumed the cockpit/cabin area. No structural or mechanical anomalies were observed during the post accident examination of the airplane.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows.

the pilot's failure to maintain aircraft control which resulted in a stall/spin. A contributing factor was the dusk light condition

 

FULL NARATIVE

History Of Flight

On November 20, 1999, at 1718 central standard time, a Piper PA-24-260 airplane, N8825P, was destroyed upon terrain impact during an approach to the Lakefront Airport near New Orleans, Louisiana. The airplane was owned and operated by the pilot. The private pilot and three passengers were fatally injured. Dusk visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight originated from the Peter Prince Field Airport near Milton, Florida, approximately 1610, and was destined for the Lakefront Airport.

At 1712, the pilot contacted the Lakefront Air Traffic Control Tower (local control), and reported seven miles east, inbound to land. The local controller instructed the pilot to report a right base for runway 36R. The pilot acknowledged the instructions.

At 1715, the local controller advised the pilot that he was number two following a Cessna on a right base for runway 36R. The pilot replied that he was "just out here waiting for final." The local controller asked the pilot if he had the traffic in sight that he was to follow on a right base. The pilot advised that he didn't have the traffic in sight but was still looking.

At 1716, the local controller asked the pilot if the visibility was hazy. The pilot replied, "no it's not hazy uh it's just uh twilight (unintelligible) time." The pilot was cleared to land on runway 36R and was issued a traffic advisory for traffic on final for runway 36L. The local controller asked the pilot to say his intentions and advised him it appeared he was heading toward runway 27.

At 1717, the pilot advised local control that he would be turning downwind for runway 36R. The local controller instructed the pilot to turn right and enter a right base for runway 36R, and again cleared him to land on runway 36R. The pilot was asked to say his altitude. The pilot advised that he was at 300 feet. The local controller then asked the pilot if he had the runway in sight. The pilot replied "roger."

A witness observed the aircraft flying slow at about 200 feet agl, with the wings level. The aircraft began a bank to the left and then a bank to the right. Then the aircraft's nose dropped, and it entered a left turn and descended out of view.

Personnel Information

According to FAA records, the pilot was issued a private pilot certificate on March 6, 1984, with an airplane single-engine land rating. The pilot's flight logbook was not located, therefore, the date of his last biennial flight review, and time in make and model of the accident airplane could not be determined. FAA records indicate the pilot reported having accrued 1,600 total flight hours on his application for a class three medical certificate, dated June 15, 1999. The medical certificate stipulated a limitation to wear corrective lenses when operating an aircraft. During the investigation, it could not be determined if the pilot was wearing corrective lenses at the time of the accident.

Aircraft Information

The 1965-model Piper PA-24-260, was a low wing, single-engine, four-place airplane, which had retractable tricycle landing gear. It was powered by a Lycoming IO-540-D4A5 engine rated at 260-horsepower, and a Hartzell, two-bladed, constant speed-controllable pitch propeller. An estimate of the weight of the airplane at the time of the accident placed it within weight and balance limits.

The maintenance records were in the airplane at the time of the accident and were destroyed by fire; however, a few burnt pages which were legible, were recovered. The aircraft underwent its last annual inspection on April 15, 1999, at a tachometer time of 1,788 hours and a total aircraft time of 6,154 hours. Tachometer time at the time of the accident was 1,887.1 hours.

Meteorological Information

At 1729, the Lakefront Airport weather observation was wind from 330 degrees at 6 knots, visibility 9 statute miles, few clouds at 3,400 feet, scattered clouds at 4,500 feet, ceiling overcast at 9,000 feet, temperature 70 degrees Fahrenheit, dew point temperature 64 degrees Fahrenheit, and altimeter 29.97 inches of mercury.

According to astronomical data, sunset was at 1702, and the end of civil twilight was at 1728.

Aerodrome Information

The Lakefront Airport (NEW) is located on the south shore of Lake Pontchartrain, at an elevation of 9 feet. The airport has three runways, 09/27, 18L/36R, and 18R/36L. There is a rotating beacon on top of the terminal building located south of runway 09/27, and all three runways have medium intensity runway edge lights, which operate dusk to dawn. The beacon and runway edge lights were on at the time of the accident.

Wreckage Information

The airplane impacted the ground within an industrial park between two warehouse buildings about 4,400 feet south of the approach end of runway 36R at latitude 30 degrees 01.690 minutes north and longitude 090 degrees 01.701 minutes west. Examination of the accident site revealed that the airplane impacted the ground on a measured magnetic heading of 054 degrees. The airplane came to rest upright 25 feet from the initial ground scar on a measured magnetic heading of 306 degrees. The airplane's cockpit/cabin area was consumed by fire. Both the left and right wing leading edges were crushed aft, and the left wing from the auxiliary fuel tank inboard was destroyed by the fire. The empennage was separated and adjacent to the fuselage, but was facing 344 degrees. Flight control continuity was confirmed from all flight control surfaces through the fuselage to under the instrument panel. The landing gear was found in the down position. The flap actuator was found to be in a position consistent with a 30 degree extension of flaps.

The engine remained attached to the airframe. The engine sustained impact damage, and the aft portion of the engine sustained heat and fire damage. The crankshaft was rotated by turning the vacuum pump drive. There was continuity to the accessory gears and valve action on all cylinders. There was thumb compression on all cylinders except #2; however, the #2 rocker box cover was crushed. Both magnetos were destroyed by the fire.

The propeller was separated from the crankshaft with the crankshaft propeller flange still attached to the propeller hub. One blade was loose in the hub, and it was twisted and curled with chordwise scratching. The other blade had a slight twist, leading edge damage, and chordwise scratching. The propeller was found at the initial ground scar.

Medical And Pathological Information

The Parish of Orleans Coroner's Office in New Orleans, Louisiana, conducted an autopsy of the pilot. Toxicological testing was performed by the FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research Center at Oklahoma City, Oklahoma. The toxicological tests were negative for alcohol and drugs.

Tests And Research

A radar study was completed by the National Transportation Safety Board's Vehicle Performance Division. Based on the available radar data, the aircraft descended to 600 feet at about 17:15:50. At about 17:16:17, it turned right heading north, and ascended to 700 feet. At about 17:16:45, the aircraft turned left heading west, and descended to 500 feet. At about 17:17:13, the aircraft turned right heading north again, and descended to 300 feet while turning left heading west again. At about 17:17:59, the aircraft descended until it dropped from radar coverage at an altitude of 200 feet. The aircraft continued to descend until ground impact, approximately 0.2 miles west-southwest of the last recorded radar target position.

 

FURTHER INVESTIGATION

 

Our resident Comanche 400 pilot, Charlie Horton, explains that flying over the lake in hazy conditions will cause spatial disorientation.  It's so bad, a warning is printed on the VFR charts.  However, the accident airplane was not over the lake, it was over land, paralleling the lake (coming from Florida).  The first runway he may have seen was 27 since he was coming from the east.

 

Runway 36R is not easily spotted; it looks like a taxiway and it is short.  Most arrivals usually get 36L, the longer runway.

 

KNEW Airpot, Looking South

 

This picture of the airport in the lake is a look at runway 18R and 18L.   Notice the parallel taxiway to the left of runway 18R.  The next strip of concrete to the left of the taxiway is runway 18L/36R, quite difficult to spot as a runway.  The aircraft crashed in the buildings in the background (4,400 feet south of runway 18L).  Runway 27 is just south of 18L, not easy to spot on this picture but better seen on the aerial photo below.

 

Aerial Photo of KNEW

DISCUSSION 
Further remarks of Charlie Horton contributed to the discussion.
 

The NTSB has determined that the probable cause of this accident was the pilot's failure to maintain aircraft control which resulted in a stall/spin.   A contributing factor was the dusk light condition

 

Apparently, the pilot was lined up for 27 in the landing configuration, at a reported altitude of 200 feet AGL which means he was very close to landing on 27.  Why would he misinterpret 27 for 36?  He was heading westbound and didn't make any turns to line up on runway 36.  It sounds as if he was confused, low and slow, and perhaps looking in his flight guide to determine the runway configuration.  Also, near the threshold of 27 (assuming he was there since he was at 200 feet AGL) one has to make a very steep left turn to enter a right downwind for 36R.  Now for the real confusion!!! 

 

Realizing his mistake, he told the tower he would enter a "downwind for 36".  He was probably in the downwind heading southbound when the tower told him to make a right turn to enter base for 36R.  Otherwise, how else could he crash off the airport 4,400 feet south of runway 36R?  If one looks at the airport diagram, an approach to runway 27 is also a right base for 36R!   Also, due to the location of the tower and the line of sight hangar interference, the controller probably couldn't see the airplane that low and so close to the runway 27 threshold.  It is then very possible that the Comanche had already turned south for the downwind when the controller gave him a "right turn for the base to 36R".

 

The contributing factor mentioned by the NTSB may explain some of the confusion and the disorientation.  The pilot was flying west, into the twilight illuminated sky, probably in haze.  It may have looked like an ivory wall with reduced forward visibility.  The downward visibility was probably not very clear and details were not easy to distinguish as darkness is slowly taking over.  In fairness, it seems many of us may have been in such circumstances (I was) and know the situation from personal experience.

 

A general aviation pilot on a routine flight should do nothing at 200 feet except fly wings level when committed to landing, or just after takeoff and climbing.  In particular, 200 feet is definitely not an altitude for any pattern work.  Taking the risk of being called a Monday quarterback, I daresay what the recommended conduct in such a case would have been:  Abort the landing and climb straight ahead to pattern altitude, advise the tower and ask for 36L; fly a left hand pattern to the west of the airport with the twilight skies behind during base and on the side during final.  At any rate, turning into downwind or base at 200 feet is to be avoided.

 

The following lessons do not necessarily have a direct relation to the accident but come to mind when reading and discussing it.

 

LESSONS

A pilot should familiarize and brief himself/herself with the airport he/she is flying to, and have the diagram and approach plates, as appropriate, handy.

Going around and/or telling "unable" to the controller are nothing to be afraid of.  The contrary is true.

Flying low and slow is an invitation to troubles.

PROVERB

Altitude is life.

Omri Talmon, born in 1936, lives in Tel Aviv, Israel. He holds degrees in engineering, business administration and accounting. Presently a consultant, he worked for many years as an executive for several hi-tech companies.  Omri is a private pilot with both Israeli and U.S. certificates.  His ratings include SEL, MEL, Instrument, Glider, and CFI (glider).  Since 1974 he owns and flies a 1966 PA-30-B, registration 4X-CAO.

  

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