Aircraft Accident/Incident Report

Vineyard Haven, Massachusetts 02568
Friday, July 16, 1999 21:41 EDT

NTSB Narrative Summary Released at Completion of Accident

The noninstrument-rated pilot obtained weather forecasts for a cross-country flight, which indicated visual flight rules (VFR) conditions with clear skies and visibilities that varied between 4 to 10 miles along his intended route. The pilot then departed on a dark night. According to a performance study of radar data, the airplane proceeded over land at 5,500 feet. About 34 miles west of Martha's Vineyard Airport, while crossing a 30-mile stretch of water to its destination, the airplane began a descent that varied between 400 to 800 feet per minute (fpm). About 7 miles from the approaching shore, the airplane began a right turn. The airplane stopped its descent at 2,200 feet, then climbed back to 2,600 feet and entered a left turn. While in the left turn, the airplane began another descent that reached about 900 fpm. While still in the descent, the airplane entered a right turn. During this turn, the airplane's rate of descent and airspeed increased. The airplane's rate of descent eventually exceeded 4,700 fpm, and the airplane struck the water in a nose-down attitude. Airports along the coast reported visibilities between 5 and 8 miles. Other pilots flying similar routes on the night of the accident reported no visual horizon while flying over the water because of haze. The pilot's estimated total flight experience was about 310 hours, of which 55 hours were at night. The pilot's estimated flight time in the accident airplane was about 36 hours, of which about 9.4 hours were at night. About 3 hours of that time was without a certified flight instructor (CFI) on board, and about 0.8 hour of that was flown at night and included a night landing. In the 15 months before the accident, the pilot had flown either to or from the destination area about 35 times. The pilot flew at least 17 of these flight legs without a CFI on board, of which 5 were at night. Within 100 days before the accident, the pilot had completed about 50 percent of a formal instrument training course. A Federal Aviation Administration Advisory Circular (AC) 61-27C, "Instrument Flying: Coping with Illusions in Flight," states that illusions or false impressions occur when information provided by sensory organs is misinterpreted or inadequate and that many illusions in flight could be caused by complex motions and certain visual scenes encountered under adverse weather conditions and at night. The AC also states that some illusions might 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 further 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 accidents. 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. Examination of the airframe, systems, avionics, and engine did not reveal any evidence of a preimpact mechanical malfunction.

NTSB Probable Cause Narrative

The pilot's failure to maintain control of the airplane during a descent over water at night, which was a result of spatial disorientation. Factors in the accident were haze, and the dark night.

Event Information

Type of Event Accident
Event Date 7/16/1999
Event Day of the Week Friday
Time of Event 2141
Event Time Zone Eastern Daylight Time
Event City VINEYARD HAVEN
Event State MASSACHUSETTS
Event Country --
Zipcode of the event site 02568
Event Date Year 1999
Event Date Month 7
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Partial - limited by pilot
Investigator's weather source Weather Observation Facility
Time of the weather observation 2153 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 95
Weather Observation Facility ID MVY
Elevation of weather observation facility 68
Distance of event from weather observation facility (units?) 15
Time Zone of the weather observation EDT
Lighting Conditions Night/Dark
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 75
Dew Point at event time (in degress fahrenheit) 64
Wind Direction (degrees magnetic) 240
Variable Wind Indicator Unknown
Wind Speed (knots) 10
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 15
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 1349
NTSB Notification Source --
NTSB Notification Date Jul 17 1999 12:00AM
NTSB Notification Time 445
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Jul 25 2001 4:45AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N9253N
NTSB Number NYC99MA178
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Piper
Aircraft Model PA-32R-301
Aircraft Series Identifier PA-32R-301
Aircraft Serial Number 32-13100
Certified Max Gross Weight 3600
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jun 25 1999 12:00AM
Airframe hours since last inspection 41
Airframe Hours 664
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name JOHN F. KENNEDY JR.
Aircraft Owner Street Address 1633 BROADWAY
Aircraft Owner City NEW YORK
Aircraft Owner State NY
Aircraft Owner Country
Aircraft Owner Zipcode 10019
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code CDW
Departure City CALDWELL
Departure State NJ
Departure Country
Departure Time 2039
Departure Time Zone EDT
Destination Same as Local Flt crash at destination city
Destination Airport Code MVY
Destination City
Destination State MA
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jul 25 2001 4:05AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --