N324ST

HISTORY OF FLIGHT

On March 24, 2007, about 0920 eastern daylight time, a Piper PA-32R-301, N324ST, was destroyed when it impacted terrain following a loss of control while maneuvering near Jacksonville, Maryland. The certificated private pilot and two passengers were fatally injured. Instrument meteorological conditions (IMC) prevailed for the flight that departed Harford County Airport (0W3), Churchville, Maryland, about 0906, destined for Virginia Highlands Airport (VJI), Abingdon, Virginia. An instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 Code of Federal Regulations (CFR) Part 91.

According to transcripts provided by the Federal Aviation Administration (FAA), the accident pilot contacted the Williamsport Automated Flight Service Station via telephone on the day prior to the accident to obtain a weather briefing and to file an IFR flight plan. During the briefing, the pilot indicated that he was going to fly to VJI so that he could attend a NASCAR race in Bristol, Tennessee.

The next morning, the pilot contacted Potomac Terminal Radar Approach Control (TRACON) to obtain his IFR clearance. At 0858, the pilot was given a clearance and was told that the clearance would be void at 0908 (10 minutes). The pilot acknowledged. Eight minutes later the pilot departed and contacted Potomac TRACON shortly after departure.

The airplane’s Avidyne Entegra flight deck instrumentation was capable of recording some flight data and other parameters. Safety Board investigators downloaded these data, and compared them to air traffic control (ATC) recorded radar and voice data provided by the FAA. The flight deck instrumentation data revealed that the Primary Flight Display's (PFD) Attitude Heading Reference System (AHRS) had failed to align twice on the day of the accident; once on the electrical power cycle preceding the accident flight, and again when the PFD was started up for the accident flight.

According to Avidyne, if the PFD is not aligned, then heading data, Horizontal Situation Indicator (HSI) navigation data, and attitude data are removed from the display and replaced with Red “Xs". The PFD also cannot be used to control the autopilot computer, limiting the available functionality of the autopilot. The PFD would still however, display altitude, airspeed, and vertical speed.

According to the recorded data, prior to takeoff, the vertical speed “bug” on the PFD was set at 750 feet per minute (fpm). The airplane then took off, maneuvered to a westerly heading on track to the Westminster VOR, and at 09:06:37 established an indicated climb rate of about 450-500 fpm. At 09:07:11, the airplane was at an altitude of about 1,440 feet msl and ATC instructed the pilot to climb and maintain 8,000 feet. The PFD altitude bug changed from 5,000 to 8,000 feet. At 09:08:24, the airplane was at an altitude of about 2,000 feet msl and ATC asked “verify you are climbing”. The pilot responded with “say again please.” ATC replied, “climb and maintain eight thousand,” which the pilot acknowledged.

At 09:08:37, the data indicated that the PFD’s vertical speed bug setting changed from 750 fpm to 950 fpm. About 09:09:24, the setting increased to 1,050 fpm. At the same time, the pitch attitude reversed its downward trend to an upward trend. About 16 seconds later, a vertical speed was established at about 1,100-1,200 fpm, which lasted for approximately 43 seconds. During this 43-second period, the pitch attitude continually increased at a relatively constant rate, and airspeed decreased at relatively constant rate from about 115 knots to about 94 knots.

Also during this 43-second period, the vertical speed bug setting reduced twice; first to 850 fpm and once again to 750 fpm. However, the vertical speed remained at 1,100-1,200 fpm. After this period, the vertical speed began to fluctuate, at times reaching peaks of 5,000 fpm down, and 7,500 fpm up. The fluctuation continued until the end of the recording. Altitude, pitch attitude, airspeed, and vertical acceleration also continued to fluctuate until the end of the recording, with trends consistent with the vertical speed trend.

Twenty seconds after the vertical speed fluctuations began, at about 09:10:53, the airplane began the first of three 360-degree turns to the left. As the turn began, the trend of roll attitude was initially to the left followed by a reversal and brief trend to the right before reversing again and remaining left wing down (though oscillating in value) for the duration of the 3 “orbit” turns to the left. During these turns, the vertical speed, airspeed, and pitch and roll attitudes continued to fluctuate. About halfway through the set of turns, at 09:12:15, the pilot transmitted to ATC: “we seem to be having some type of difficulty here could uh you give us assistance please”.

At 09:13:01, after the airplane completed the three turns, the pilot transmitted: “we’re with ya we were off getting back on course here we had a little difficulty with the auto pilot.” At this time, the airplane’s track was approaching its original course line to the Westminster VOR. At 09:13:35 the pilot requested a heading to the Frederick airport, so they could “do a stop”, and he received a clearance to fly a heading of 280 degrees. Also over the next 30 seconds, the airplane’s track stabilized at about 274 degrees magnetic. Altitude and airspeed continued to fluctuate during this time; however the pitch attitude was relatively stable when compared to the previous and subsequent pitch oscillations.

At 09:14:08, the airplane again began a turn toward the left. At 09:14:46 the “next waypoint” parameter changed from EMI (the Westminster VOR) to KFDK (Frederick Municipal Airport). At 09:15:23, the pilot again reported to ATC that he was “having some problems with the autopilot”. After the left turn, the airplane did not return to a course toward Frederick, and did not maintain any course/heading for longer than about 12 seconds. Altitude and airspeed continued to fluctuate significantly, with the exception of one period of about 20 seconds where the altitude was relatively stable around 2,600 feet (pressure altitude) and the airspeed remained around 110 knots. Over the last 2 minutes of the flight, the fluctuations in altitude and airspeed appear to be somewhat periodic in nature.

The last recorded data points indicated a pressure altitude of 707 feet, indicated airspeed 148 knots, and a descent rate of 6,824 fpm.

AIRCRAFT INFORMATION

According to FAA and airplane maintenance records, the accident airplane was manufactured in 2006. The airplane’s most recent annual inspection was completed on March 1, 2007. At the time of the inspection, the airplane had accrued 74.9 total hours of operation.

The airplane was equipped with an Avidyne FlightMax Entegra Integrated Flight Deck, which included two 10.4-inch displays, one of which was the PFD and the other of which was the Multi Function Display (MFD).

A set of standby flight instruments were also installed which consisted of a magnetic “whiskey” compass (attached to the center post of the windscreen), a conventional attitude indicator, conventional airspeed indicator, and a conventional altimeter (all of which were located to the left of the PFD in a vertical line). All could be used by the pilot to fly the airplane in instrument meteorological conditions in the event that the PFD malfunctioned.

Additionally, the airplane was equipped with dual Garmin GNS 430 global positioning systems (GPS), and an S-TEC System 55X autopilot, with full-function heading, navigation, and altitude hold, with localizer/glideslope coupling, and altitude pre-select functions that were integrated into the PFD. Together with the audio control panel, these systems were located to the right of the PFD in a vertical line.

During the most recent annual airworthiness inspection, maintenance personnel determined that the accident airplane required modification of the PFD as required by Avidyne's PFD Mandatory Service Bulletin, SB 601-00006-067. This bulletin referenced earlier alerts and requested that the PFDs be returned to the factory for an update which would “reduce the likelihood” that the PFD could present erroneous indications. According to an FAA inspector and the maintenance provider’s Director of Service , the maintenance facility was advised by the pilot that due to the amount of time required to update the unit (10 business days), and since the pilot was trading in the airplane soon, the pilot elected to defer the maintenance action until a later date.

PERSONNEL INFORMATION

According to FAA records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. His most recent FAA third-class medical certificate was issued on December 12, 2006. The pilot records also indicate that the accident airplane was the second Avidyne-equipped airplane the pilot had owned; the first airplane that he owned was a Piper PA-32-301FT. The pilot also had taken formal training at Simcom when he purchased his first Avidyne equipped airplane, and again when he purchased the accident airplane. He had accrued 546.2 total hours of flight experience of which 291.5 hours were accrued in the two airplanes. At the time of the accident, records indicated that he was IFR current and qualified.

METEOROLOGICAL INFORMATION

The recorded weather at Martin State Airport (MTN), Baltimore, Maryland, approximately 26 nautical miles southeast of the accident site, at 0918, included: wind 020 degrees at 3 knots, visibility 3 miles in heavy drizzle, scattered clouds at 800 feet, broken clouds at 2,400 feet, overcast at 3,000 feet, temperature 8 degrees C, dew point 8 degrees C, and an altimeter setting of 30.36 inches of mercury. Cloud tops were reported to ATC by a Southwest Airlines flight as being at 8,500 to 9,000 feet above mean sea level (msl). Witnesses reported that t...