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NTSB investigation record

CEN11FA557

Completed

Piper Pa-23· N2286P

Date
August 8, 2011
Location
Millersburg, OH
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s failure to maintain clearance with terrain during the landing approach in night conditions and fog. Contributing to the accident was the pilot’s inadequate preflight planning.

Investigator assessment

Analysis narrative

The pilot received a weather briefing on the day before the visual flight rules flight during which he was informed that the weather conditions near his destination would be deteriorating. The pilot departed in night visual conditions. Toward the end of his planned flight, he flew over the destination airport but was unable to see it due to weather conditions that he described to an air traffic controller as “too thick.” The pilot informed the controller that he wanted to fly back toward Columbus, Ohio. About 1 minute later, the pilot informed the controller that he wanted to change his destination to a second airport, which is located about 24 miles northwest of his original destination. While en route to the second airport, the pilot was informed of a notice to airmen indicating that the runway lights at that airport were out of service. Fourteen minutes later, the air traffic controller in communication with the pilot asked if he wanted another airport or to proceed to his second destination. The pilot stated that, once again, he wanted to head back to Columbus. Shortly thereafter, the pilot informed the controller that he wanted to land at a third airport. On the approach to the third airport, the pilot was initially unable to see it because fog was in the area and the airport beacon was out of service; further, he was using the wrong frequency to activate the pilot-controlled runway lights. An air traffic controller informed the pilot of the correct frequency and shortly thereafter the pilot reported that he had the runway in sight. Several witnesses reported seeing and hearing the airplane as it flew over the area. One witness, who was a pilot living adjacent to the airport, stated that he heard the airplane make three passes over the airport from different directions beginning about 25 minutes before the accident. The airplane subsequently impacted trees and terrain in an upsloping wooded area that bordered the south side of the airport. A postaccident examination of the airplane and engines did not reveal any preimpact mechanical failures or malfunctions that would have precluded normal operation. It is likely that the pilot was unable to see the airport and continued to fly in the vicinity searching for the runway, and subsequently lost situational awareness and struck trees.

Source record

Factual narrative

HISTORY OF FLIGHT On August 8, 2011, about 0455 eastern daylight time, a Piper PA-23 airplane, N2286P, collided with trees and terrain while maneuvering to land at the Holmes County Airport (10G), Millersburg, Ohio. The commercial pilot and two passengers received fatal injuries. The airplane was registered to and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from the Sullivan County Airport (SIV), Sullivan, Indiana, about 0135. The original route of flight was intended to be from SIV to the Jefferson County Airpark (2G2), Steubenville, Ohio. The purpose of the flight was to fly one of the passengers to Steubenville, so that she could be with a family member who was having a medical procedure performed. The pilot contacted the Indianapolis air route traffic control center (ARTCC) at 0138 requesting visual flight rules (VFR) flight following, stating that he had just departed SIV and was en route to 2G2. At 0145, the pilot reported to air traffic control that they were in a layer of clouds and that he was going to climb to 7,500 feet. The airplane subsequently descended to 5,500 feet and continued on toward 2G2. At 0325, the airplane was instructed to contact Cleveland ARTCC. The pilot checked in with Cleveland and was given a squawk code. At 0341, the pilot was advised to contact Pittsburgh approach control. The pilot contacted Pittsburgh approach and was cleared through the Class B airspace and instructed to maintain VFR. The pilot advised the controller that he was going to descend to 3,500 feet and that he intended to land at 2G2. The controller instructed the pilot to report having the airport in sight. At 0351, the controller asked the pilot how he was doing and the pilot responded that he was looking for the airport and couldn’t find it. The controller informed the pilot that the airport was to his north. The controller then told the pilot that he could descend to 3,000 feet and the controller issued a vector to the airport. At 0353, the controller informed the pilot that he was over the airport. The pilot was unable to see the airport stating it was a little “too thick.” The controller asked the pilot what his intention was and the pilot responded that he wanted to fly back toward Columbus. The controller asked the pilot if he had enough fuel and the pilot responded that yes he did. The controller instructed the pilot to maintain VFR and suggested an altitude of 4,500. At 0354, the pilot reported that they wanted to proceed to the Carrollton County Airport, Carrollton, Ohio (TSO). TSO is located approximately 24 miles northwest of 2G2. The controller instructed the pilot to contact the Cleveland ARTCC and to let them know what his intentions were. The pilot acknowledged the instruction and subsequently checked in with the Cleveland ARTCC. At 0404, the controller advised the pilot that there was a Notice to Airmen (NOTAM) that the runway lights for runway 7/25 were out of service. At 0417, the controller asked the pilot if he wanted to try another airport or if he still wanted to go to TSO. The pilot responded that they were going to head back to Columbus at 6,500 feet. The pilot was instructed to contact the Indianapolis ARTCC and the pilot complied with that instruction. The pilot informed the controller, at 0438, that he was changing his destination from Columbus to 10G. The controller acknowledged the change. Approximately 0437, the controller informed the pilot that he was over the airport and asked if he could see the ground. The pilot stated that he could see the ground and he was looking for the airport. A short time later the controller informed the pilot that he was now east of the airport and asked the pilot if he could see the airport. The pilot replied that they could not see the airport. About a minute later the controller asked the pilot if he clicked the lights on. The pilot responded yes, but that apparently they weren’t working. The controller stated that there were no NOTAMS regarding the lights. The pilot responded “ok … just must be obscured to us then.” The controller then informed the pilot that the frequency for the lights was 123.4. When the pilot did not respond, the controller again stated that the frequency for the lights was 123.4 and asked the pilot if that was the frequency that he used. The pilot responded “123.4?” At 0453, the controller twice informed the pilot that radar contact was lost and asked if he could hear her. The pilot then responded that he had the runway in sight. The controller verified with the pilot that he had the runway in sight. The controller instructed the pilot to squawk VFR and that radar service was terminated. The pilot responded, “thank you, good day.” Several witnesses reported seeing and hearing the airplane between 0430 and 0445 as it flew over the Millersburg area. One witness, who was a pilot living adjacent to the airport, stated he heard the airplane make three passes over the airport from different directions beginning around 0430. He stated that around 0500 he went to the airport, turned on the runway lights, and made a call over the universal communications (UNICOM) frequency inquiring if the airplane circling the airport needed assistance. He did not receive a reply. He assumed the airplane diverted to another airport “…where the fog was not as thick… .” This witness stated the airplane sounded normal and as if both engines were running. He stated there was fog in the area at the time he heard the airplane and that he could see vertically through the fog. Another witness who was outside his residence located about 2 ¼ miles northeast of the airport reported hearing the airplane at 0445. This witness stated the airplane was low and headed south when it flew almost directly over his house. He stated he was able to see a “flash” from the light (rotating beacon) on the tail of the airplane and wondered why an airplane was flying in the fog. The witness reported that the airplane’s engines sounded normal. The wreckage was located by a State Highway Patrol helicopter on August 9, 2011, at approximately 1130. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with airplane single-engine land, airplane multi-engine land, and instrument ratings issued March 26, 2011. The pilot was issued a third-class airman medical certificate, with no restrictions, on August 10, 2009. The pilot’s logbook contained flights dated from June 12, 1994, when the pilot began flying, through August 3, 2011. The logbook indicated the pilot had approximately 412 hours of total flight time. The logbook showed the pilot had a total of 74 hours of multi-engine flight time, of which 73 hours were in the accident airplane. The pilot had a total of 11.1 hours of actual instrument flight time of which 8.5 hours were in the accident airplane. In addition, the logbook showed the pilot had a total of 71.7 hours of simulated instrument flight time, of which 7.0 hours were in the accident airplane and 16.7 hours were in a flight simulator. Federal Aviation Administration airman records indicate the pilot’s certification history as follows: October 7, 1986 - Private pilot certificate issued with airplane single-engine land rating. May 20, 2010 - Failed practical test for instrument rating. Areas to be re-examined were "Air Traffic Control Clearances and Procedures" and "Instrument Approach Procedures." May 23, 2010 - Passed instrument flight test. May 26, 2011 - Failed practical test for multi-engine rating. Areas to be re-examined were "Takeoffs, Landings, and Go-Arounds." May 26, 2011 - Re-tested on same day and passed multi-engine flight test. AIRCRAFT INFORMATION The accident airplane was a Piper PA-23, serial number 23-897. It was a four

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