# NTSB ERA17FA108: Piper PA28R, N4504X, Cedar Key, FL, February 12, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 12, 2017, 11:06 local (16:06 UTC) - Place: Cedar Key, FL - Coordinates: 29.049165, -82.968055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.0492&lon=-82.9681&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report February 26, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming Engines, Piper Aircraft - NTSB case key (mKey): 94723 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17FA108 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94723/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94723 - Page: https://openairdocs.org/ntsb/ERA17FA108 ## Probable cause The non-instrument-rated pilot's improper decision to continue visual flight rules flight into instrument meteorological 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. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28R-200, 11 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102811), [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-28R-200, 3 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102811), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-200, 4 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7102811), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-200, 29 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102811), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Experience/qualifications: total instrument experience](https://openairdocs.org/ntsb-findings/02031030): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/02031030/cases.md?model=7102811), [All aircraft, 66 cases](https://openairdocs.org/ntsb-findings/02031030/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=7102811), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=7102811), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) - [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Piper PA-28R-200, 2 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=7102811), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28R-200, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102811), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The non-instrument rated private pilot departed in the airplane in visual meteorological conditions, which prevailed along most of the route of the over-water cross-country flight. However, about 20 miles from the destination airport, the airplane encountered an area of instrument meteorological conditions (IMC) that consisted of overcast clouds with bases about 400 ft above the water. According to GPS data, when the airplane reached this area, it began to descend from a cruising altitude of 2,400 ft. About 7 minutes later, at an altitude of about 1,000 ft, the airplane began a left, descending, 180° turn during which the altitude fluctuated until the data ended about 600 ft above the water near the accident site. The airplane continued to descend until it impacted the water. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The pilot had logged only 4.6 hours of simulated instrument experience and had no documented actual instrument experience. No evidence was found indicating that the pilot obtained an official weather briefing before the flight. If he had obtained such a briefing, he would have been told that visual flight rules (VFR) flight was not recommended due to IMC near the destination airport. Given the instrument conditions in the destination area and the pilot's limited instrument flying experience, it is likely that the pilot attempted to continue VFR flight into IMC, experienced spatial disorientation, and lost control of the airplane. ## Factual narrative According to FAA records, the airplane was manufactured in 1975. It was equipped with a fuel-injected, horizontally-opposed four-cylinder, direct-drive, air-cooled Lycoming IO-360-C1C engine. Damaged portions of the maintenance logbook were found inside the airplane. The most recent annual inspection was completed May 1, 2016, at 2,806 total airframe hours. The airplane had accrued 14 hours since that date. The engine total time and time since overhaul could not be determined from the logbook remnants. On February 12, 2017, about 1106 eastern standard time, a Piper PA-28R-200, N4504X, was destroyed when it impacted the Gulf of Mexico about 7 miles southeast of Cedar Key, Florida. The private pilot and two passengers were fatally injured. The airplane was registered to Flying Arrow, LLC and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed in the area of the accident site, and no flight plan was filed for the personal flight. The flight departed Brooksville-Tampa Bay Regional Airport (BKV), Brooksville, Florida, at 1037, destined for George T. Lewis Airport (CDK), Cedar Key, Florida. According to GPS data recovered from a handheld device onboard the airplane, the airplane flew a northwesterly track from BKV toward CDK at a cruising altitude of about 2,400 ft mean sea level (msl) over coastal islands and the Gulf of Mexico. Review of the GPS track and satellite imagery indicated that about 20 nautical miles southeast of CDK, the airplane began to gradually descend near a line of overcast cloud cover that ran from southwest to northeast. Weather data from the closest available reporting stations and from pilot reports indicated that the cloud bases decreased in height from south to north. About 3 minutes later, the airplane's descent rate increased to about 250 ft per minute (fpm) as the airplane continued its northwesterly track. About 4 minutes later, when the airplane was about 7 nautical miles from CDK at an altitude of about 1,000 ft msl, the airplane began a descending left 180° turn. During the turn, the vertical speed varied, and the airplane began a brief climb before descending again at a rate of about 2,900 fpm; the recorded data ended at an altitude of about 570 ft msl. The Office of the Medical Examiner, District 8, Gainesville, Florida, performed an autopsy on the pilot. The cause of death was listed as massive injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. Results were positive for pioglitazone and sitagliptin, which are used treat type 2 diabetes and to lower blood sugar levels, respectively. In general, neither of these medications are considered to be impairing. There was no record of the pilot obtaining an official weather briefing from flight service or via direct user access terminal. The Cross City Airport (CTY), Cross City, Florida, locatedabout 36 miles north of the accident site, was the nearest weather reporting station. At 1055, the reported weather at CTY included an overcast ceiling at 400 ft above ground level (agl) with a visibility of 10 miles. Atmospheric models and data from other nearby stations indicated that the conditions at the accident site included fog and low stratus cloud cover up to about 4,000 ft agl. The weather reported for the airplane's route of flight south of the accident location indicated visual meteorological conditions with clear skies below 12,000 ft agl and visibility greater than 5 miles. The National Weather Service issued an area forecast at 0648 for northern Florida that advised to expect scattered to broken clouds at 1,000 ft agl with visibility 3 miles in mist and scattered clouds at 1,500 ft were expected by 1100. The forecast for the eastern panhandle of Florida included overcast clouds at 1,000 ft agl with visibility 3 miles in mist. Advisories issued at the time of this forecast warned of instrument meteorological conditions at and near the accident site and the destination airport. According to Federal Aviation Administration (FAA) airmen records, the pilot held a private pilot certificate with a rating for airplane single-engine land. He did not possess an instrument rating. His most recent FAA third-class medical certificate was issued February 19, 2015, at which time he reported 579 total hours of flight experience. According to his logbook, as of January 28, 2017, he had accrued a total of 606 hours of flight experience that included 3 hours in the 90 days preceding the accident. He had logged a total of 4.6 hours of simulated instrument flight time of which the most recent was 0.3 hour during his last flight review performed on August 13, 2016, in the accident airplane. The airplane was recovered from the Gulf of Mexico and moved to a secure facility for examination. All major components of the airplane were accounted for except for a large section of the left wing that included the left main landing gear. Flight control continuity was established from the cockpit area through recovery cuts to the attach points on the rudder, stabilator, and stabilator trim jackscrew. Aileron control continuity was established from the cockpit area through overload fractures to the right aileron pushrod and to the root area of the left wing. The right main and nose landing gears were found in the retracted position. The flaps were not recovered; however, the left rod end of the flap torque tube was found in the forward position, consistent with a fully retracted position. The engine was separated from the airframe. The propeller remained attached to the engine crankshaft flange, and the spinner was crushed against the hub. Two of the propeller blades exhibited longitudinal twisting. The third blade was bent aft about 180° and exhibited leading edge gouging at a distance from the hub consistent with impact damage found on the No. 2 engine cylinder.The engine was rotated by hand at the propeller, and crankshaft continuity was observed to the rear accessory section. Valve action was observed at each cylinder, and thumb compression and suction were present on cylinders Nos. 1 and 3. Cylinder No. 2 was significantly damaged and exhibited an impact mark consistent with a strike from a propeller blade. A damaged spark plug precluded compression testing of cylinder No. 4. Neither magneto produced spark when rotated by hand. Internal examination of both magnetos revealed that sand, water, and corrosion were present. The vacuum pump remained attached to the engine; the drive coupling, carbon rotor, and carbon vanes were intact. ## Aircraft - Registration: [N4504X](https://openairdocs.org/deregistered/N4504X-2019-07-26), registration cancelled 2019-07-26, S/N 28R-7635065, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA28R (200) - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7635065 - Year built: 1975 - Airframe hours: 2806.2 - Engines: Lycoming IO-360-C1C 200 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Flying Arrow LLC - Registered owner: Flying Arrow LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2016, 14 hours before - Departed: BKV, BROOKSVILLE, FL - Destination: CDK, CEDAR KEY, FL - Equipment: Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 13, 2016; seat: left; toxicology performed; flight hours: 606 total, 300 in this make and model, 3 in the last 90 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 240° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 66 °F, dew point 64 °F - Altimeter: 30.25 inHg - Observed at: KCTY, 36 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 20170212000929A](https://openairdocs.org/incident/20170212000929A), Feb 12, 2017: Piper PA-28R-200, Cedar Key, FL, Destroyed, 3 fatal. On February 12, 2017, at approximately 11:06 et (16:06 z), a Piper PA-28R-200, N4504X, registered to "flying arrow LLC" (tampa, FL), impacted the gulf of… ## Other investigations on N4504X (1) 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. - [NTSB MIA77FKQ33](https://openairdocs.org/ntsb/MIA77FKQ33), Aug 21, 1977: Piper PA-28 (N4504X), Natchez, MS, substantial damage ## Docket (8 files) The files NTSB released with the investigation on December 6, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94723. 4.0 MB in all. - Pilot Logbook Excerpts (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469030&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Master.PDF - Maintenance Logbook Excerpts (item 2, .PDF, 621 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469031&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Excerpts-Master.PDF - Global Positioning System Device Factual Report (item 3, .PDF, 452 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469032&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Device%20Factual%20Report-Master.PDF - Attachment 1 GPS Factual Report (item 4, .CSV, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469033&FileExtension=.csv&FileName=Attachment%201%20GPS%20Factual%20Report-Master.csv - Weather Study (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469034&FileExtension=.PDF&FileName=Weather%20Study-Master.PDF - Toxicological Report (item 6, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469035&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469036&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 / Evidence Tracking Form (item 8, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469037&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20%2F%20Evidence%20Tracking%20Form-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.