# NTSB CEN18LA014: Diamond Aircraft Ind DA 40, N105MK, Gustavus, OH, October 17, 2017 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 16, 2017, 21:12 local (Oct 17, 2017, 01:12 UTC) - Place: Gustavus, OH - Coordinates: 41.453609, -80.692779 - Nearby events: https://openairdocs.org/map.md?lat=41.4536&lon=-80.6928&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report January 25, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Cleveland FSDO - NTSB case key (mKey): 96203 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96203/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96203 - Page: https://openairdocs.org/ntsb/CEN18LA014 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 2 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2990002), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Perception/orientation/illusion: geographic disorient (lost)](https://openairdocs.org/ntsb-findings/02022030): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 1 case](https://openairdocs.org/ntsb-findings/02022030/cases.md?model=2990002), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/02022030/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 20 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2990002), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 4 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2990002), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Experience/qualifications: recent experience](https://openairdocs.org/ntsb-findings/02031035): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Diamond Aircraft Ind DA 40, 1 case](https://openairdocs.org/ntsb-findings/02031035/cases.md?model=2990002), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/02031035/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on operation; cases with it: [Diamond Aircraft Ind DA 40, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2990002), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Diamond Aircraft Ind DA 40, 7 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2990002), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## 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](https://openairdocs.org/deregistered/N105MK-2018-09-13), registration cancelled 2018-09-13, S/N 40.244, built 2002 (OpenAirDocs) - Reported make and model: DIAMOND AIRCRAFT IND INC DA 40 - Registry model: [Diamond Aircraft Ind DA 40](https://openairdocs.org/model/diamond-aircraft-ind-da-40) (registry code 2990002) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 40.244 - Year built: 2002 - Airframe hours: 768.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: serious; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20171016014839A](https://openairdocs.org/incident/20171016014839A), Oct 16, 2017: Diamond Aircraft Ind Inc DA 40, Gustavus, OH, Destroyed. Aircraft was approaching airport from the west and entered what appeared to be a left downwind to the south runway at 2110 local. The downwind and base turn… ## Docket (5 files) The files NTSB released with the investigation on November 6, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96203. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 900 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457731&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandums of Conversation (Robert J Gale) (item 2, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457732&FileExtension=.PDF&FileName=Memorandums%20of%20Conversation%20(Robert%20J%20Gale)-Master.PDF - Law Enforcement Statements (Witness, Pilot and Passenger) (item 3, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457733&FileExtension=.PDF&FileName=Law%20Enforcement%20Statements%20(Witness,%20Pilot%20and%20Passenger)-Master.PDF - Weather Reports (item 4, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457734&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF - United States Naval Observatory Data (Sun and Moon) (item 5, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457735&FileExtension=.PDF&FileName=United%20States%20Naval%20Observatory%20Data%20(Sun%20and%20Moon)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.