# NTSB ERA18FA092: Quest Kodiac 100, N969TB, Georgetown, FL, February 28, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 27, 2018, 19:25 local (Feb 28, 2018, 00:25 UTC) - Place: Georgetown, FL - Coordinates: 29.430555, -81.676391 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.4306&lon=-81.6764&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Quest Aircraft Company, Pratt & Whitney Engine Services - NTSB case key (mKey): 96800 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18FA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96800/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96800 - Page: https://openairdocs.org/ntsb/ERA18FA092 ## Probable cause The pilots' spatial disorientation while maneuvering for landing in night conditions over unlighted terrain, which resulted in an uncontrolled descent and impact with water. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Quest KODIAK 100, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7320001), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Quest KODIAK 100, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7320001), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Quest KODIAK 100, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7320001), [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: [Quest KODIAK 100, 2 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7320001), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: use of automation](https://openairdocs.org/ntsb-findings/02063010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Quest KODIAK 100, 1 case](https://openairdocs.org/ntsb-findings/02063010/cases.md?model=7320001), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/02063010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Quest KODIAK 100, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7320001), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Quest KODIAK 100, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7320001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot and pilot-rated passenger were returning to the airport in night visual meteorological conditions with a cloud ceiling about 1,500 ft above ground level. Radar data indicated that the airplane overflew the airport and completed a 360° descending right turn and overflew the airport again before entering an approximate 180° left climbing turn toward and over an unlighted area within a densely-wooded national forest. The airplane continued the left turn and entered a descent to impact in a river about 1 mile from the airport. All major components of the airplane were recovered from the river except the outboard section of the left wing and the left aileron. An examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. Because each of the two pilots onboard would have been capable of safely landing the airplane, it is unlikely that an acute event from either occupant's heart disease contributed to the accident. The night conditions, which included overcast clouds that would have obscured the nearly full moon, and the pilots' maneuvering for landing over an area devoid of cultural lighting provided conditions conducive to the development of spatial disorientation. It is likely that the pilots experienced a "black hole" illusion while maneuvering to align with the runway for landing, which resulted in an uncontrolled descent and impact with water. ## Factual narrative Spatial Disorientation The FAA Pilot's Handbook of Aeronautical Knowledge, Chapter 16, "Aeromedical Factors," stated: Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which normal motions and forces create convincing illusions that are difficult to overcome…Unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible. A pilot can reduce susceptibility to disorienting illusions through training and awareness, and learning to rely totally on flight instruments. According to the FAA Airplane Flying Handbook (FAA-H-8083-3A), Chapter 10 - Night Operations, "In addition to night vision limitations, pilots should be aware that night illusions could cause confusion and concerns during night flying." The handbook also stated: A black-hole approach occurs when the landing is made from over water or non-lighted terrain where the runway lights are the only source of light. Without peripheral visual cues to help, pilots will have trouble orienting themselves relative to Earth. ... If navigation aids (NAVAIDs) are unavailable, careful attention should be given to using the flight instruments to assist in maintaining orientation and a normal approach. If at any time the pilot is unsure of his or her position or attitude, a go-around should be executed. According to FAA airworthiness records, the airplane was manufactured in 2016 and issued an airworthiness certificate in April 2016. It was equipped with a Pratt and Whitney Canada PT6A-34, 750-horsepower engine that powered a 4-bladed Hartzell constant speed propeller. A Hobbs meter located in the wreckage indicated about 68 hours. 3FL0 was a non-tower-controlled private airport located about 3 miles south of Welaka, Florida. The airport elevation was 41 ft msl. Runway 8/25 was 3,000 ft long and 50 ft wide and was equipped with medium-intensity edge lights. There were no published instrument procedures to or from the airport. The airport was bordered to the west by the Ocala National Forest, which comprised 673 square miles of densely-wooded and unlighted terrain. On February 27, 2018, about 1925 eastern standard time, a Quest Aircraft Company Kodiak 100 airplane, N969TB, was substantially damaged when it impacted a river near Georgetown, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was privately owned and was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed, and there was no flight plan filed for the flight, which was destined for Mount Royal Airport (3FL0), Welaka, Florida. A witness statedthat the airplane departed 3FL0 about 1530 on the day of the accident. According to air traffic control data provided by the Federal Aviation Administration (FAA), a radar target identified as the accident airplane overflew 3FL0 about 975 ft mean sea level (msl) about 1911 and proceeded to make a right turn over the Ocala National Forest. It descended over the forest to 775 ft msl, continued the right turn back to the airport, which it overflew a second time about 1920, then entered a climbing left turn to an altitude of 1,200 ft msl. The airplane continued the left turn and began a descent that continued to impact with a river about 1 mile west of the airport. A witness who saw the airplane shortly before the accident noted that it was flying "really low," and was in a 45° bank left turn; the airplane "wobbled" once and continued the turn. She stated that the lights on the airplane had "halos" around them because it was foggy, and that the engine sounded "fine." Local law enforcement and recovery personnel reported that there were no downed tree branches or powerlines along the river shoreline in the vicinity of the accident site. The Office of the Medical Examiner of Florida performed the autopsy of the pilot and the pilot-rated passenger in St. Augustine, Florida. The autopsy report indicated that they both occupants died as a result of multiple blunt force injuries. The autopsy of the pilot-rated passenger revealed that the coronary arteries were dilated with moderate to severe calcific atherosclerosis with 70-80% stenosis of the left anterior descending, as well as up to 60 -70% stenosis of the circumflex and right coronary arteries. The remainder of the cardiac exam was unremarkable. The FAA's Forensic Sciences Laboratory performed toxicological testing of the pilot and passenger. The pilot's fluid and tissue specimens were tested and identified 0.025 gm/dl of ethanol in muscle, but none in liver tissue, thus it was likely produced postmortem. An unspecified level of valsartan was identified in muscle and liver. Toxicology testing of the pilot-rated passenger identified unspecified levels of valsartan, rosuvastatin, and amlodipine in cavity blood. All of these, in addition to clopidogrel, were identified in urine. According to the FAA Forensic Toxicology Drug Information, amlodipine is a prescription medication used alone or in combination with other medications to treat high blood pressure. Clopidogrel is a prescription medication used to inhibit blood clots in coronary artery disease, peripheral vascular disease, cerebrovascular disease, and to prevent myocardial infarction (heart attack) and stroke. Rosuvastatin is a prescription medication used to reduce blood cholesterol and triglycerides levels. Valsartan is a prescription medication used alone or in combination with other medications to treat high blood pressure. None are considered to be impairing. The 1915 recorded weather observation at Palatka Municipal Airport – Lt. Kay LarkinField (28J), Palatka, Florida, about 13 miles north of the accident location, included wind from 050° at 8 knots, 10 miles visibility, an overcast cloud layer at 1,500 ft above ground level, temperature 17°C, dew point 15°C, and an altimeter setting of 30.25 inches of mercury. According to the Astronomical Applications Department at the United States Naval Observatory, the sunset was at 1824, the end of civil twilight was at 1848, and moonrise was at 1605. The phase of the moon on the day of the accident was waxing gibbous, with 93% of the moon's visible disk illuminated. According to FAA records, the pilot held a private pilot certificate with ratings for airplane single-engine land, single-engine sea, multiengine land, multiengine sea, and instrument airplane. The pilot was issued a third-class medical certificate on November 27, 2016. At that time, he reported 3,400 total hours of flight experience, of which 20 hours were within the previous 6 months. The pilot's logbook was not recovered; therefore, his total flight experience and recency of experience could not be determined. The pilot previously reported hypertension and gout to the FAA. In 2005, he reported having had triple vessel coronary artery bypass surgery. By 2007, he had received a special issuance medical certificate. No significant abnormalities were noted on the most recent physical exam and a review of the information from the pilot's cardiologist from January 2017 demonstrated a recent nuclear stress test that did not identify any reversible ischemia. According to FAA records, the pilot-rated passenger held an airline transport pilot certificate with ratings for airplane multiengine land and airplane multiengine sea. He held commercial privileges for airplane single-engine land and airplane single-engine sea. In addition, he held a flight instructor certificate with ratings for airplane multiengine and instrument airplane. His most recent second-class medical certificate was issued on October 4, 2013, and at that time, he reported 23,165 total hours of flight experience. The airplane impacted a river and came to rest inverted in about 10 ft of water. All major components of the airplane were recovered from the river, except the outboard section of the left wing and the left aileron. The forward section of the fuselage was crushed aft. The right wing was impact separated from the fuselage and an unquantified amount of Jet A fuel drained from the wing when the wing was moved for examination. The inboard section of the left wing was impact separated from the fuselage and the left flap was separated from the left wing. The flap jackscrew corresponded to full flap extension. The empennage remained attached to the fuselage and the horizontal stabilizers and elevators were cut to facilitate recovery. The cockpit was impact damaged, and the attitude indicator was located and disassembled. Rotational scoring was noted on the gyro housing. Flight control continuity was obtained fromall flight control surfaces to the cockpit through tensile overload breaks and cuts made to facilitate recovery. The propeller remained attached to the reduction gearbox but was impact separated from the engine. All four propeller blades remained attached to the hub; one of the blades was in a feathered position. Two of the blades exhibited S-bending, the other two blades were bent aft, and leading edge gouging was noted on three of the blades. The engine was separated from the airframe and recovered from the river. The left exhaust stack was impact crushed and the right exhaust stack received minor impact damage. The reduction gear box chip detector was examined, and no debris was noted. Continuity was confirmed between the compressor turbine and the accessory section of the engine by rotating the compressor turbine. Rotational scoring was noted on the compressor turbine. The power turbine was examined and exhibited rotational scoring on the fir tree disk, the blades, and the leading edge of the shroud tips. In addition, the power turbine shroud exhibited rotational scoring. ## Aircraft - Registration: [N969TB](https://openairdocs.org/deregistered/N969TB-2019-04-01), registration cancelled 2019-04-01, S/N 100-0173, built 2016 (OpenAirDocs) - Reported make and model: QUEST AIRCRAFT COMPANY LLC KODIAC 100 (NO SERIES) - Registry model: [Quest KODIAK 100](https://openairdocs.org/model/quest-kodiak-100) (registry code 7320001) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-34 series](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-34-series) (registry code 52250, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 100-0173 - Year built: 2016 - Airframe hours: 68 - Engines: Pratt & Whitney Canada PT6A-34 750 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Pegasus Of Montana LLC - Registered owner: Pegasus Of Montana LLC - Airworthiness certificate: Standard, Normal - Destination: 3FL0, Georgetown, FL - Airport: 3FL0, Mount Royal - Equipment: Electronic primary flight display, Electronic multifunction display, Auto-pilot, Stall warning system, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; private; airplane ratings: multi-engine sea, single-engine sea, multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; toxicology performed; flight hours: 3,400 total - Pilot-rated passenger; age 56; injuries: fatal; airline transport, flight instructor, commercial; airplane ratings: multi-engine sea, single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; restraint: lap only; toxicology performed; flight hours: 23,165 total ## Weather - Conditions: Visual (VMC), Night - Wind: 50° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 63 °F, dew point 59 °F - Altimeter: 30.25 inHg - Observed at: 28J, 13 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 20180227003179A](https://openairdocs.org/incident/20180227003179A), Feb 27, 2018: Quest QA-KODIAK, Georgetown, FL, Substantial damage, 2 fatal. The aircrafts route of flight, as identified by a radar target according to preliminary air traffic control data provided by the federal aviation… ## Docket (11 files) The files NTSB released with the investigation on March 17, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96800. 8.6 MB in all. - Witness Statements (item 1, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481258&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Radar Data Figures (item 2, .PDF, 480 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481259&FileExtension=.PDF&FileName=Radar%20Data%20Figures-Master.PDF - Radar Data - Tabular (item 3, .CSV, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481260&FileExtension=.csv&FileName=Radar%20Data%20-%20Tabular-Master.csv - Weather Reports and Records (item 4, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481261&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Sun and Moon Data (item 5, .PDF, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481262&FileExtension=.PDF&FileName=Sun%20and%20Moon%20Data-Master.PDF - Investigative Photographs (item 6, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481263&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Pilot Toxicological Report (item 7, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481264&FileExtension=.PDF&FileName=Pilot%20Toxicological%20Report-Master.PDF - Pilot-Rated Passenger Toxicological Report (item 8, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481265&FileExtension=.PDF&FileName=Pilot-Rated%20Passenger%20Toxicological%20Report-Master.PDF - NTSB Medical Factual Report (item 9, .PDF, 258 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481266&FileExtension=.PDF&FileName=NTSB%20Medical%20Factual%20Report-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 and Evidence Control Form (item 10, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481267&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20and%20Evidence%20Control%20Form-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 396 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481268&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. --- 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.