ERA13LA019

NTSB accident investigation · Piper PA-23-250 · Charlotte Amalie · October 13, 2012

Accident · FatalLimited investigationFinal report
Date
October 13, 2012, 04:58 local (08:58 UTC)
Place
Charlotte Amalie
Injuries
3 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5553YPiper PA-23-250
Defining event
Enroute-descent: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 12, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20121013023219A
Case key
85321

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 attempted visual flight rules (VFR) flight into marginal VFR conditions on a dark night over water and his failure to maintain sufficient altitude, which resulted in the airplane’s controlled flight into water. Contributing to the accident was the pilot's inadequate preflight weather planning.

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.

Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomePiper PA-23-250: 1 caseAll aircraft: 97 cases
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-23-250: 1 caseAll aircraft: 448 cases
Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-23-250: 1 caseAll aircraft: 108 cases
Planning/preparation: weather planningPersonnel issues › Task performance · PilotPiper PA-23-250: 3 casesAll aircraft: 156 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-23-250: 2 casesAll aircraft: 1,310 casesProbable cause

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 accident airplane departed over water on a dark night and flew toward its destination airport at an altitude of about 1,700 feet above the water. Radar data showed that the airplane began a gradual descent on about the same heading before it leveled off at 200 feet above the water. The airplane continued at 200 feet above the water for another 18 seconds before its radar target disappeared about 5 miles from the destination airport. The surviving passenger stated that she had flown with the pilot on this flight many times before. She stated that during the en route portion of the accident flight, the pilot flew progressively lower to "get under the weather." The passenger stated that she could see lights on the shore near the destination airport, and could see that it was raining. She recalled light turbulence and observed the pilot make his "usual" radio call. She next remembered the airplane "hitting a wall," and the airplane filled with water. She said that the pilot broke the window on his side of the airplane, and that she and the pilot egressed through it. She did not see any of the other occupants of the airplane after that. When asked if she noticed anything unusual with the flight or if the pilot provided any warning before striking the water, the passenger said no, and indicated that everything was normal. Examination of the wreckage revealed damage consistent with a high-speed, shallow-angle impact with water, and no evidence of preimpact mechanical anomalies. Weather data and imagery were consistent with the passenger’s account of flying beneath outer rain bands associated with a developing tropical storm southeast of the accident site. There was little to no illumination from the moon. Based on a search of flight service and commercial vendor records, the pilot did not obtain a weather briefing or file a flight plan before the accident flight. The destination airport was tower-controlled, but the tower was closed at the time of the accident. The runway was located along the shore, with the approach end surrounded by water on three sides. Multiple instrument approach procedures were available for the airport; however, those instrument approaches were not authorized while the tower was closed. A caution printed in the plan view of the approach charts stated, "CAUTION: Pilots may encounter false illusory indications during night approaches to Runway 10 when using outside visual cues for vertical guidance." It is likely that the pilot descended the airplane to remain clear of the lowering clouds and descended into the water due to the lack of visual cues.

Factual narrative

HISTORY OF FLIGHT On October 13, 2012, about 0458 Atlantic Standard Time (AST), a Piper PA-23-250, N5553Y, was substantially damaged during a collision with water in cruise flight near Charlotte Amalie, United States Virgin Islands (U.S.V.I.). The airline transport pilot was not found after the accident and is presumed fatally injured. Two passengers were fatally injured. One passenger survived the accident, and was found at sea with serious injuries. Night visual meteorological conditions prevailed, and no flight plan was filed for the business flight carrying newspapers which was operated by Rainbow International Airlines under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Henry E. Rohlsen Airport (TISX), Christiansted, U.S.V.I. about 0445 and was destined for Cyril E. King Airport (TIST), Charlotte Amalie, U.S.V.I. Review of radar data provided by the Federal Aviation Administration (FAA) revealed that a target identified as the accident airplane climbed to 1,700 feet after departure from TISX, where it leveled in cruise flight on a 330 degree heading for about 2 minutes. The airplane then entered a steady descent on the same approximate heading for the next 10 minutes until it leveled at 200 feet. The airplane cruised at 200 feet for the final 18 seconds of the flight until the radar contact was lost, approximately 5 miles from the destination airport. The surviving passenger was interviewed by the United States Coast Guard (USCG) and the Federal Aviation Administration (FAA). She stated that she was acquainted with the pilot and had flown with him on the newspaper carrying flights "many" times before. During the en route portion, the airplane flew progressively lower to "get under the weather." The passenger stated that she could see lights on the shore near the destination airport, and could see that it was raining. She recalled light turbulence, and observed the pilot as he made his "usual" radio call. She next remembered the airplane "hitting a wall" and "seeing a flash" before the airplane filled with water. She said the pilot broke the window on his side of the airplane, and that she and the pilot egressed through it. She did not see any of the occupants of the airplane after that. When asked if she noticed anything unusual with the flight, or if the pilot provided any warning before striking the water, she said no, and indicated that everything was "normal." PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with multiple type ratings. His most recent FAA first class medical certificate was issued June 1, 2012. He reported 17,000 total hours of flight experience on that date. The pilot's most recent FAR Part 135 flight review was completed 12/30/2011. AIRCRAFT INFORMATION The airplane was manufactured in 1963 and was registered to Cardair, Inc. It's most recent 100-hour inspection was completed on September 12, 2012, at 6,576 total aircraft hours. The accident airplane was notlisted in the operations specifications of the Rainbow International Airlines 14 CFR Part 135 operating certificate. METEOROLOGICAL INFORMATION An NTSB Senior Meteorologist provided a study of the weather surrounding the route of flight and the accident site at the time of the accident. A tropical storm advisory (Rafael) was in effect. At 0453, the weather reported at TIST included few clouds at 3,300 feet, a broken ceiling at 4,600 feet, with 10 miles of visibility in light rain. The winds were from 070 degrees at 9 knots gusting to 15 knots. The terminal area forecast for TISX in effect at the time of the accident expected northeast wind at 4 knots, visibility better than 6 statute miles with thunderstorms in the vicinity and a broken ceiling at 3,000 feet agl in cumulonimbus type clouds. The terminal area forecast for TIST in effect at the time of the accident expected wind from the east at 8 knots with visibility better than 6 miles, showers in the vicinity of the airport, scattered clouds at 4,000 feet, and a broken ceiling at 10,000 feet. The Geostationary Operational Environmental Satellite number 14 (GOES-14) infrared image at 0445 depicted an area of enhanced clouds associated with the developing Tropical Storm Rafael to the southeast of the accident site. In the vicinity of the accident site several towering cumulus type clouds were evident, and were associated with rain showers immediately east of the accident site, and over the route between TISX and TIST. According to the U.S. Naval Observatory, the moon was in the eastern sky, 9 degrees above the horizon, with 5 percent of the moon's visible disc illuminated. The weather data and imagery were consistent with the passenger’s account of flying beneath outer rain bands associated with the developing tropical storm southeast of the accident site. According to a search of Lockheed-Martin flight service and commercial vendor records, the pilot did not obtain a weather briefing nor file a flight plan prior to the accident flight. AERODROME INFORMATION Cyril E. King Airport (TIST) was located about 2 miles west of Charlotte Amalie, USVI, at an elevation of 23 feet. The airport was tower-controlled, but the tower was closed at the time of the accident. Runway 10/28 was 7,000 feet long and 150 feet wide, and was located along the shore, with the approach end of runway 10 surrounded by water on three sides. Instrument landing system and area navigation approaches were published for Runway 10, and a very high frequency omni-directional range approach was also published for the airport. The instrument approach procedures were not authorized while the tower was closed. A caution printed in the plan view of the approach charts stated, "CAUTION: Pilots may encounter false illusory indications during night approaches to Runway 10 when using outside visual cues for vertical guidance." WRECKAGE AND IMPACT INFORMATION Examination of photographs taken by divers revealed the airplane came to restinverted on the ocean floor. The right wing was partially separated but remained attached to the airframe. Both engines were in their respective nacelles, and the landing gear appeared extended and locked, or in transit. The photographs revealed that no landing gear doors remained attached to the airplane. Hydraulic deformation and tearing of the left wing and the belly skin of the airplane was consistent with a high-speed, shallow-angle impact. The airplane was recovered on October 20, 2012, and examined by a representative of the Piper Aircraft Company as well as FAA aviation safety inspectors. The examination revealed control continuity from the cockpit to all flight control surfaces, and no evidence of any pre-impact mechanical anomalies. MEDICAL AND PATHOLOGICAL INFORMATION The pilot was not recovered, and therefore no medical or pathological testing was conducted.

Aircraft

Registration
N5553Y
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-2295
Airframe hours
6,576
Engines
Lycoming 0-540 SERIES, 250 horsepower, reciprocatingLycoming O-540 SERIES, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Rainbow International Airlines
Registered owner
Cardair, Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 12, 2012
Departed
TISX · Christiansted
Destination
TIST · Charlotte Amali
Airport
TIST · Charlotte Amalie, runway 10, 7,000 × 150 ft, asphalt

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
57
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
December 30, 2011
Seat
Left
Flight hours
17,000 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
70° at 9 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
4,600 ft broken
Temperature
82 °F, dew point 75 °F
Altimeter
29.76 inHg
Observed at
TIST, 5 nm away

Docket · 12

The files NTSB released with the investigation on July 9, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 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.