ASN Wikibase Occurrence # 43840
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information.
If you feel this information is incomplete or incorrect, you can submit corrected information.
| Date: | Saturday 24 March 2007 |
| Time: | 09:19 |
| Type: |  Piper PA-32R-301 |
| Owner/operator: | Private |
| Registration: | N324ST |
| MSN: | 3246237 |
| Year of manufacture: | 2006 |
| Fatalities: | Fatalities: 3 / Occupants: 3 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Jacksonville, MD -
 United States of America
|
| Phase: | Manoeuvring (airshow, firefighting, ag.ops.) |
| Nature: | Private |
| Departure airport: | Churchville, MD (OW6) |
| Abingdon, VA (VJI) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The instrument-rated private pilot obtained a weather briefing and filed an instrument flight plan for a personal flight that would occur the following morning to attend a stock car race. On the morning of the accident, the pilot contacted air traffic control (ATC) to obtain an instrument clearance. The pilot was given a clearance and was told that it would be void in 10 minutes. Two minutes prior to the expiration of the ATC void time, the pilot departed.
Recorded non-volatile memory (NVM) data from the electronic cockpit flight display system were downloaded and analyzed by investigators, and these data greatly aided in the investigation. Analysis of the data indicated that, while climbing in instrument conditions, and most likely using the autopilot, the pilot attempted to increase the airplane’s climb rate by using the vertical speed bug on the electronic (glass) Primary Flight Display (PFD) in the cockpit. However, the NVM data revealed that the PFD had failed to “align”, and was not fully functional. As a result of the PFD not being aligned, the bug settings (altitude and vertical speed) were suppressed, and not transmitted to the autopilot computer. Therefore, when the pilot attempted to increase the airplane’s vertical speed using the PFDs vertical speed bug, the changes were not transmitted to the autopilot computer and the autopilot did not command an increase to the rate of climb. Subsequently, the rate of climb momentarily increased twice, most likely due to pilot control inputs via the control wheel. (A review of the PFD Pilot's Guide revealed that it does not provide information to the pilot regarding the suppression of the bug settings when the PFD is not aligned.).
Soon after the last vertical speed bug change, the airplane’s vertical speed began to fluctuate (and oscillate between climbing and descending) significantly. These fluctuations continued for the remainder of the flight (about 9 minutes). During this period, the airplane completed three left-hand orbits at varying altitudes. The pilot then reported an “autopilot problem” to ATC, and he requested a clearance to divert to a nearby airport. The airplane’s course deviated again to the left, after which the pilot again reported a problem with the autopilot. The airplane continued to fly for another 4 minutes as the vertical speed continued to oscillate. The airplane’s ground track remained erratic and was not consistent with a course toward the diversion airport. The airplane entered an uncontrolled descent, impacted terrain, and was destroyed.
Examination of the wreckage revealed that the pitch trim jackscrew was in the full nose-down position. No preimpact malfunctions of the autopilot or flight control systems were discovered. The nose-down trim condition likely resulted from the pilot pulling on the control wheel with the autopilot engaged which would have resulted in the trim running nose down. Exams of the airplane’s other systems, structure and engine did not reveal any evidence of preimpact malfunctions or failures.
Risk factors for spatial disorientation were present at the time of the accident, including IMC and maneuvering flight. Analysis of the airplane’s flight path during the accident flight, and the pilot’s communications with ATC, indicates that the pilot became spatially disoriented while attempting to maneuver with reference to a degraded PFD. The pilot was instrument current and qualified and he had accumulated about 291 hours operating the electronic flight display system. He had received formal training in two models of airplanes equipped with the same flight display system, and also experienced a failure of the display system on a previous airplane. Thus, the pilot was likely familiarized with the functionality of the PFD.
Analysis of the NVM data from the PFD revealed that the PFD had not aligned during its “power cycle” of the accident flight, nor had it aligned on the previous power cycle that occurred on the day of the accident. The recorded data do not explicitly indicate the reason for the failu
Probable Cause: The pilot's failure to maintain control of the airplane which was a result of spatial disorientation after takeoff into instrument conditions with an operationally degraded electronic primary flight display. Contributing to the accident were the pilot’s failure to properly utilize the airplane’s standby flight instruments, the electronic primary flight display system’s unaligned state prior to takeoff for undetermined reasons, and the pilot’s lack of knowledge of degraded autopilot functions with an unaligned primary display system.
Accident investigation:
 |
|
Sources:
NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20070406X00376&key=1
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 28-Oct-2008 00:45 | ASN archive | Added |
| 21-Dec-2016 19:24 | ASN Update Bot | Updated [Time, Damage, Category, Investigating agency] |
| 04-Dec-2017 18:32 | ASN Update Bot | Updated [Cn, Operator, Other fatalities, Departure airport, Source, Narrative] |
Corrections or additions? ... Edit this accident description
The Aviation Safety Network is an exclusive service provided by:
Quick Links:
| ASN Home | Send Correction / Feedback |
| FSF Home | Disclaimer | Copyright |
| Contact Us | Privacy Policy |
| Press / Media |
CONNECT WITH US:
©2024 Flight Safety Foundation