# NTSB ERA16LA106: Piper PA28, N2209W, Destin, FL, February 13, 2016

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Limited investigation · Final report
- Date: February 12, 2016, 18:50 local (Feb 13, 2016, 00:50 UTC)
- Place: Destin, FL
- Coordinates: 30.399999, -86.471389 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=30.4000&lon=-86.4714&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Loss of visual reference](https://openairdocs.org/ntsb-events/402)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report March 23, 2017
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Piper Aircraft Inc, FAA/FSDO, Lycoming Engines
- NTSB case key (mKey): 92710
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA106
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92710/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92710
- Page: https://openairdocs.org/ntsb/ERA16LA106

## Probable cause

The noninstrument-rated pilot's decision to turn the airplane away from the lighted airport at low altitude, over water, with no visible horizon, in dark night conditions, which resulted in spatial disorientation and a loss of airplane control.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=7102807), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md)
- [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Response/compensation; cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7102807), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-181, 21 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102807), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102807), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Loss of visual reference](https://openairdocs.org/ntsb-events/402) (defining event); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-events/402/sequence.md?model=7102807), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md)
- [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-28-181, 18 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102807), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)

## Analysis

The private pilot was flying along a shoreline of the Gulf of Mexico in dark night conditions, with a tailwind, on an extended left base leg for landing at the airport. Witnesses reported the pilot announced a go-around on the airport's common traffic advisory frequency (CTAF). Radar track data depicted the airplane crossing the approach end of the runway and then turning upwind on the far side of the runway. The airplane continued in a left circuit around the airport, and its altitude varied between 500 and 700 ft above ground level. Radar then depicted a left turn in a location consistent with a left base turn for a second attempt at landing; however, the airplane stopped its turn early and flew through the final approach course a second time as it tracked parallel to the coast. Instead of completing another left circuit around the airport, the airplane turned right, away from the lighted airport and out over open, dark water with no visible horizon. The last radar targets showed the airplane over the water in a descending right turn toward the airport, with the last target at 175 ft above the water, and 128 knots groundspeed. A witness, who was monitoring the CTAF as he approached the airport in his own airplane, reported that he heard the accident pilot announce his positions as he circumnavigated the airport. The pilot's last radio call announced he would be "circling somewhere." There were no further communications from the accident airplane.A postaccident examination of the airframe and engine revealed no preimpact mechanical anomalies that would have prevented normal operation of the airplane. The tailwind encountered on the base leg of the traffic pattern likely contributed to the pilot flying the airplane through the final approach course on two consecutive approaches. The rapid turn and descent at low altitude away from the lighted airport at night, over dark water, with no visible horizon, was consistent with the noninstrument-rated pilot experiencing spatial disorientation and a loss of airplane control.

## Factual narrative

On February 12, 2016, about 1850 central standard time, a Piper PA-28-181, N2209W, was destroyed during collision with water while maneuvering to land at Destin Executive Airport (DTS), Destin, Florida. The private pilot and a passenger were fatally injured. The flight departed Pearland Regional Airport (LVJ), Pearland, Texas, about 1715. Night visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.According to radar data from the Federal Aviation Administration (FAA), the airplane approached DTS from the west, and transitioned along the shore on the south side of the airport for landing on runway 32. The radar track depicted the airplane crossing the approach end of runway 32, then turning upwind on the east side of the runway. The airplane continued in a left circuit around the airport, and its altitude varied between 500 and 700 feet mean sea level (msl). The radar depicted a left turn in a location consistent with a left base turn for landing on runway 32. Instead of continuing to an approximate ground track of 050 degrees for the base leg of the traffic pattern, the airplane rolled out on an approximate ground track of 090 degrees, and flew through the final approach course, west to east, as it tracked parallel to the coast. The airplane then turned 90 degrees to the south and tracked out over the water. The last radar target showed the airplane at 175 feet msl at 128 knots groundspeed. A witness, who was monitoring the CTAF as he approached the airport in his own airplane, reported he heard the accident pilot announce his go-around and his positions as he circumnavigated the airport. The pilot's last radio call announced he would be "circling somewhere." There were no further communications from the accident airplane. The witness reported windy conditions as he approached DTS, and that conditions were "extremely bumpy" below 300 feet. A witness who was jogging in an easterly direction along the beach reported to an FAA inspector that his attention was drawn to the airplane as it crossed the beach and headed south over the water. He stated that the engine was running, but the front of the airplane was illuminated as if the engine was "on fire." The witness stated he thought the airplane was in a wings-level attitude, not turning, but descending rapidly. He said that when the airplane struck the water, he heard an explosion and the light at the front of the airplane "went out." The weather reported at DTS at the time of the accident included clear skies and wind from 240 degrees at 7 knots gusting to 15 knots. Official sunset was at 1731, and the end of civil twilight was at 1755. The moon was illuminated 13 percent in the western sky. According to FAA records, the pilot held a private pilot certificate with a rating for airplane single engine land. His most recent FAA third-class medical certificate was issuedon March 3, 2014. The pilot reported 306 total hours of flight experience on that date. The pilot did not possess an instrument rating. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. Results were negative for all tested-for drugs. The Office of the Medical Examiner, District I, Florida, performed an autopsy on the pilot. The cause of death was listed as multiple blunt force injuries. The four-seat, single-engine, low-wing airplane was manufactured in 1979, and was equipped with a Lycoming O-360 series reciprocating engine. The maintenance logbooks for the airplane were not recovered, but copies of logbook entries revealed the airplane's most recent annual inspection was completed May 8, 2015, at 2,239 total aircraft hours. On February 9, 2016, the engine oil was changed at 2,272 total aircraft hours. The airplane was recovered from the Gulf of Mexico and moved to a secure facility for a detailed examination. According to the FAA inspector on site during the recovery, the airplane was destroyed by impact forces. Except for a large section of the right wing, all major components of the airplane were accounted for. The engine, with the propeller attached, was completely entangled with the instrument panel, control cables, and wiring. All damage appeared consistent with impact and overload-type separation. There was no evidence of pre- or post-impact fire. The engine was removed from the airframe, and could not be rotated by hand at the propeller. Examination of the cylinders with a lighted borescope revealed that each contained sediment and corrosion from salt water immersion. The engine accessories and all four cylinders were removed, and the crankshaft rotated freely by hand. The propeller spinner was fragmented. The propeller remained attached to the engine crankshaft flange. One propeller blade exhibited scratches on the front and rear surfaces but was otherwise intact. The other blade was curved aft about 90 degrees and exhibited twisting, leading edge gouges and trailing edge "S" bending. Impact damage and saltwater immersion precluded testing of engine accessories. The vacuum pump was disassembled and the carbon rotor, carbon vanes, and the composite drive coupling were intact. The examination of the airframe and engine revealed no preimpact mechanical anomalies that would have prevented normal operation of the airplane. ADDITIONAL INFORMATION Spatial Disorientation According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums, and that an inability to perceive the natural horizon or surface references is commonduring flights over water, at night, in sparsely-populated areas, and in low-visibility conditions. According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured. "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."

## Aircraft

- Registration: [N2209W](https://openairdocs.org/deregistered/N2209W-2018-06-08), registration cancelled 2018-06-08, S/N 28-7990349, built 1979 (OpenAirDocs)
- Reported make and model: PIPER PA28 (181)
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7990349
- Year built: 1979
- Airframe hours: 2272
- Engines: LYCOMING O-360-A4M reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 8, 2015, 43 hours before
- Departed: LVJ, Pearland, TX
- Destination: DTS, Destin, FL
- Flight plan: Unknown
- Airport: DTS, Destin Executive, runway 32, 5,001 × 100 ft, asphalt
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 67; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 306 total, 100 in this make and model

## Weather

- Conditions: Visual (VMC), Night/dark
- Wind: 240° at 7 knots, gusting 15
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 63 °F, dew point 57 °F
- Altimeter: 30.18 inHg
- Observed at: DTS, 1 nm away

## Docket (10 files)

The files NTSB released with the investigation on February 23, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92710. 3.9 MB in all.

- Witness Statement (item 1, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449482&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF
- Witness (item 2, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449483&FileExtension=.PDF&FileName=Witness-Master.PDF
- Police Report Excerpt (item 3, .PDF, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449484&FileExtension=.PDF&FileName=Police%20Report%20Excerpt-Master.PDF
- FAA Inspector's Statement (item 4, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449485&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF
- Meteorology Review (NTSB) (item 5, .PDF, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449486&FileExtension=.PDF&FileName=Meteorology%20Review%20(NTSB)-Master.PDF
- Radar Track Plot (item 6, .PDF, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449487&FileExtension=.PDF&FileName=Radar%20Track%20Plot-Master.PDF
- Radar Data (Tabular) (item 7, .CSV, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449488&FileExtension=.csv&FileName=Radar%20Data%20(Tabular)-Master.csv
- Toxicological Report (item 8, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449489&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF
- Photos (Courtesy of Lycoming) (item 9, .PDF, 4 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449490&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20Lycoming)-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 400 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449491&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.

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