CEN18LA014

NTSB accident investigation · Diamond Aircraft Ind DA 40 · Gustavus, OH · October 17, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
October 16, 2017, 21:12 local (Oct 17, 2017, 01:12 UTC)
Place
Gustavus, OH
Injuries
1 serious, 1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N105MKDiamond Aircraft Ind DA 40
Defining event
Approach-VFR pattern final: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night/dark
Status
Completed · report January 25, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Cleveland FSDO
FAA report
20171016014839A
Case key
96203

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s geographic disorientation while maneuvering in the airport traffic pattern in dark night conditions, which resulted in the airplane descending below a normal approach path and a collision with trees. Contributing to the accident was the pilot's lack of recent night flight experience.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedDiamond Aircraft Ind DA 40: 2 casesAll aircraft: 809 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on personnelDiamond Aircraft Ind DA 40: 4 casesAll aircraft: 448 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Effect on operationDiamond Aircraft Ind DA 40: 1 caseAll aircraft: 933 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was maneuvering to land at the destination airport after a cross-country flight in dark night, visual meteorological conditions. The pilot reported that he became disoriented as he orbited the airport waiting for the airport manager to turn on the runway lights, which resulted in him believing that he was on final approach to runway 1 instead of runway 19. The pilot stated that, during final approach, he incorrectly identified a crossing road that he believed was about 3/4 mile south of the runway 1 approach threshold; however, the road he observed was about 1 mile north of the airport. The pilot stated that he and his passenger suddenly saw tree branches appear as the airplane descended on final approach. The pilot immediately increased engine power and airplane pitch in an attempt to avoid the trees, but the right wing impacted a tree, and the airplane subsequently impacted terrain about 1/2 mile north of runway 19. The pilot reported that there were no mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot had previously flown 7 hours during nighttime conditions; however, he had not flown at night within the 238 days preceding the accident. According to federal regulations, pilots are prohibited from acting as pilot-in-command with passengers at night unless they have completed three night takeoffs and three night landings within the previous 90 days. An ancillary benefit of pilots maintaining their regulatory night flight currency is that it demonstrates their having an adequate level of proficiency of night flight operations on a recurring basis. The pilot's lack of recent night flight experience likely contributed to his becoming disorientated while maneuvering in the airport traffic pattern, the airplane descending below a normal approach path, and the collision with trees.

Factual narrative

On October 16, 2017, about 2112 eastern daylight time, a Diamond Aircraft Industries DA40 single-engine airplane, N105MK, collided with trees and terrain while on final approach to Gustavus Airport (OH33), Gustavus, Ohio. The private pilot was seriously injured, his passenger was not injured, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. Night visual meteorological conditions prevailed for the cross-country flight that departed at 1730 central daylight time from Bult Field Airport (C56), Monee, Illinois.The pilot reported that he had originally planned to land at Northeast Ohio Regional Airport (HZY), Ashtabula, Ohio; however, as the flight approached HZY he was unable to activate the airport's runway lights using the designated common traffic advisory frequency. The pilot subsequently diverted to OH33 and telephoned the airport manager to have the runway lights turned on. The pilot reported that he became disoriented as he orbited the airport waiting for the runway lights to be turned on, which resulted in him believing that he was on final approach to runway 1 instead of runway 19. The pilot stated that during final approach he incorrectly identified a crossing road that he believed was about 3/4 mile south of runway 1 approach threshold; however, the road he observed was about 1 mile north of the airport. The pilot stated that he and his passenger suddenly saw tree branches appear as the airplane descended on final approach. The pilot immediately increased engine power and airplane pitch in attempt to avoid the trees, but the right wing impacted a tree and the airplane subsequently impacted terrain about 1/2 mile north of runway 19. The right wing, aft fuselage, and empennage sustained substantial damage during the impact sequence. The pilot reported that there were no mechanical failures or malfunctions with the airplane that would have precluded normal operation. At 2051, the Youngstown-Warren Regional Airport automated surface observing system located about 12 miles south of the accident site reported: calm wind, a clear sky, 10 miles surface visibility, temperature 5°C, dew point 0°C, and an altimeter setting of 30.28 inches of mercury. The United States Naval Observatory data indicated that the sunset and end of civil twilight at the accident site were at 1840 and 1908, respectively. Moon transit, the time at which the moon is highest in the sky, occurred at 1051 and the moonset was at 1726. Additionally, the accident site was located in a sparsely populated area with minimal illumination from ground light sources. As such, dark nighttime conditions likely existed at the time of the accident. The pilot reported that he had previously flown 7 hours during nighttime conditions; however, he had not flown at night within the 90 days preceding the accident. He reported that his most recent nightflight was completed on February 20, 2017, during which he made a night landing on runway 1 at OH33. According to federal regulation 14 CFR Part 61.57(b), pilots are prohibited from acting as pilot-in-command with passengers at night unless they have completed 3 night takeoffs and 3 night landings within the previous 90 days.

Aircraft

Registration
N105MK
Reported as
Diamond Aircraft Ind DA 40
Category
Airplane
Serial number
40.244
Built
2002
Airframe hours
768.4
Engine
Lycoming IO-360-M1A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 11, 2017
Departed
C56 · Monee, IL
Destination
OH33 · Gustavus, OH
Airport
OH33 · Gustavus Airport, runway 19, 3,300 × 90 ft, grass/turf
Equipment
Electronic multifunction display, Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
71
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
February 20, 2017
Seat
Left
Restraint
3-point
Flight hours
778 total · 402 in this make and model · 668 as pilot in command · 36 in the last 90 days · 18 in the last 30 days · 11 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 32 °F
Altimeter
30.28 inHg
Observed at
YNG, 12 nm away

Docket · 5

The files NTSB released with the investigation on November 6, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.