# NTSB CEN19LA051: Piper PA 23, N2146P, Beaver Island, MI, December 31, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: December 30, 2018, 19:48 local (Dec 31, 2018, 00:48 UTC) - Place: Beaver Island, MI - Coordinates: 45.684722, -85.574447 - Nearby events: https://openairdocs.org/map.md?lat=45.6847&lon=-85.5744&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Piper Aircraft Co., FAA Flight Standards, Lycoming Engines - NTSB case key (mKey): 98810 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA051 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98810/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98810 - Page: https://openairdocs.org/ntsb/CEN19LA051 ## Probable cause The pilot's failure to maintain a positive rate of climb after takeoff which resulted in an impact with trees and terrain. Contributing to the accident was the pilot's inability to see a visible horizon due to the dark night lighting conditions and limited ground lights in the vicinity of the airport. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=7102302), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=7102302), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7102302), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Piper PA-23, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=7102302), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Initial climb: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-events/000/sequence.md?model=7102302), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Initial climb: Altitude deviation](https://openairdocs.org/ntsb-events/282); cases with it: [Piper PA-23, 1 case](https://openairdocs.org/ntsb-events/282/sequence.md?model=7102302), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-23, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102302), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The instrument, multi-engine rated private pilot was departing into dark night visual meteorological conditions at the time of the accident. The airport was located in an area with minimal ground lighting with no discernable horizon visible after takeoff. Witnesses heard the airplane take off toward the west and subsequently turn to the north. They described the sound of the engines as "very loud." One witness added that the engines seemed to be operating normally. Another witness noted that the sound changed to a lower pitch similar to when a pilot transitions to climb power after takeoff. The sound ended abruptly when the airplane impacted a wooded area about 1/3 mile from the airport on a north-northeasterly heading. Examination of the airframe and engines did not reveal any anomalies consistent with a preimpact failure or malfunction. It is possible that the pilot experienced some level spatial disorientation which led to a loss of control and impact with the trees and terrain. However, it is also possible that the pilot became distracted configuring the airplane for climb during the initial turn after takeoff which led to the airplane entering an inadvertent descent and controlled flight into terrain. This scenario is consistent with the witness statement noting a transition to climb power immediately after takeoff. In addition, the earwitness reports did not describe a typical loss-of-control event. The lack of a visible horizon due to the dark night lighting conditions and lack of ground lights in the vicinity of the airport would have contributed to either scenario. ## Factual narrative Controllable-Pitch Propeller The Federal Aviation Administration (FAA) Airplane Flying Handbook noted that for airplanes equipped with constant speed propellers, the power output of the engine(s) is reduced when climbing out after takeoff by decreasing the manifold pressure (throttle control) and reducing the engine speed by increasing the propeller blade angle (prop control). Spatial Disorientation The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude. The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation." At the time of the most recent annual inspection on September 27, 2018, the airframe had accumulated 8,809 hours total time. The left and right engines had accumulated 4,223 hours and 2,333 hours total time, respectively. Both engines had accumulated 105 hours since overhaul. The airplane was equipped and had current inspections for flight under instrument flight rules. Beaver Island is located in Lake Michigan about 16 miles west from the mainland and about 13 miles south of the upper peninsula shoreline. Two smaller unpopulated islands are located west of Beaver Island in Lake Michigan. No ground lighting was available west of the Beaver Island shoreline. The airport was located in a sparsely populated area near the western shoreline of the island. It was served by a 4,299-ft long asphalt runway oriented on a 275° heading, and equipped with medium intensity runway edge lights. The departure end of the runway 27 was about 0.72 mile from the Lake Michigan shoreline. Minimal ground lighting was available in the area surrounding the airport. On December 30, 2018, about 1948 eastern standard time, a Piper PA-23 airplane, N2146P, impacted trees and terrain shortly after takeoff from Beaver Island Airport (SJX), Beaver Island, Michigan. The pilot sustained fatal injuries. The airplane was destroyed. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part91 personal flight. Dark night visual meteorological conditions (VMC) prevailed. The flight was originating at the time of the accident and was destined for the Fitch H. Beach Airport (FPK), Charlotte, Michigan. Due to the government furlough, neither the National Transportation Safety Board, nor the Federal Aviation Administration responded to the accident site. The on-scene documentation for this accident was conducted by the Charlevoix County Sheriff's Department. A witness reported hearing the airplane for about 10 minutes before the sound of the engines increased dramatically. He added, "it was very loud." After taking off, the airplane seemed to turn to the right (north). Shortly afterward, the sound changed to a lower pitch similar to when a pilot adjusts the pitch of the propellers; then it went silent; although, he did not recall hearing the impact. A second witness noted that the airplane was "real loud." She subsequently drove past the airport and observed the airplane which appeared to be taking off to the west. Nothing seemed unusual during the time she saw it. She did not witness the accident and only heard about it later that evening. A third witness reported hearing the "distinct sound" of a twin-engine airplane. He noted that it was "plenty loud" and that the engines didn't seem to be having any difficulties. Shortly afterward, the sound of the engines abruptly "went quiet," after which he heard the airplane impacting the trees. The airplane impacted a wooded area about 1/3 mile north-northeast of the departure end of the runway. The impact path was oriented toward the north-northeast and was about 115 feet long. An autopsy, performed on behalf of the Charlevoix County Medical Examiner, Boyne City, Michigan, attributed the pilot's death to multiple blunt injuries sustained in the accident. Toxicology testing performed by the FAA Forensic Sciences Laboratory identified atorvastatin in liver tissue. Atorvastatin is commonly prescribed to lower blood cholesterol/triglyceride levels and is not considered to be impairing. Both witnesses recalled that there was no precipitation at the time of the accident. One witness added that it was "very dark." Sunset occurred at 1707 on the day of the accident and civil twilight ended at 1741. The moon had set at 1328 and did not rise again until 0249 the following day. The pilot's logbook was not available. On his most recent application for a Federal Aviation Administration (FAA) medical certificate, the pilot reported a total flight time of 5,468 hours, with 52.2 hours within the preceding 6 months. He held an instrument rating; however, his recent instrument experience could not be determined. In addition, his recent night flight experience was unknown. The pilot's family stated that he was familiar with the route of flight, having completed the trip between SJX and FPK at least twice per month. The fuselage was fragmented consistent with impact forces. The wings were separated from thefuselage at the roots and both engines had separated from their respective wing pylons. The horizontal stabilizers remained attached to the aft fuselage section; however, the vertical stabilizer was separated at the root. The fragmented debris was located along the impact path from the vicinity of the initial tree strike to the main wreckage. A post-recovery examination did not reveal any anomalies consistent with a preimpact failure or malfunction. No evidence of an in-flight structural failure was observed. ## Aircraft - Registration: [N2146P](https://openairdocs.org/deregistered/N2146P-2020-07-23), registration cancelled 2020-07-23, S/N 23-748, built 1956 (OpenAirDocs) - Reported make and model: Piper PA 23 (Undesignat) - Registry model: [Piper PA-23](https://openairdocs.org/model/piper-pa-23) (registry code 7102302) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 23-748 - Year built: 1956 - Airframe hours: 8809 - Engines: Lycoming O-360-A1D 180 horsepower reciprocating; Lycoming O-360-A1D 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 27, 2018 - Departed: SJX, Beaver Island, MI - Destination: FPK, Charlotte, MI - Airport: SJX, Beaver Island, runway 27, 4,299 × 75 ft, asphalt - Equipment: Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 5,468 total ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 240° at 8 knots, gusting 15 - Visibility: 10 statute miles - Lowest ceiling: 2,500 ft broken - Temperature: 34 °F, dew point 27 °F - Altimeter: 29.92 inHg - Observed at: SJX, 1 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 20181230021789A](https://openairdocs.org/incident/20181230021789A), Dec 30, 2018: Piper PA-23, Beaver Island, MI, Destroyed, 1 fatal. On December 30, 2018 at approximately 7:48 pm eastern standard time, a PA-23-180 aircraft, N2146P, registered to and operated by a private pilot, was destroyed… ## Docket (6 files) The files NTSB released with the investigation on January 17, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98810. 6.6 MB in all. - Accident Site Diagram (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480053&FileExtension=.PDF&FileName=Accident%20Site%20Diagram-Master.PDF - Witness Statements (item 2, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480054&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Conversation Summary -- Pilot's Family (item 3, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480055&FileExtension=.PDF&FileName=Conversation%20Summary%20--%20Pilot%27s%20Family-Master.PDF - Report Photos (item 4, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480056&FileExtension=.PDF&FileName=Report%20Photos-Master.PDF - Airplane Examination Summary (item 5, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480057&FileExtension=.PDF&FileName=Airplane%20Examination%20Summary-Master.PDF - FAA Aviation Physiology -- Spatial Disorientation (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480070&FileExtension=.PDF&FileName=FAA%20Aviation%20Physiology%20--%20Spatial%20Disorientation-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.