ERA18LA164

NTSB accident investigation · Piper PA 44 · Daytona Beach, FL · June 9, 2018

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
June 9, 2018, 15:00 local (19:00 UTC)
Place
Daytona Beach, FL
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N21161Piper PA 44
Defining event
Approach-IFR final approach: Loss of control in flight
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20180609007449A
Case key
97432

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 pilots’ improper in-flight weather evaluation and decision to continue the approach, which resulted in an encounter with a thunderstorm, a loss of airplane control, and collision with terrain. Contributing to the accident was the flight instructor’s inadequate preflight weather evaluation.

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.

Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Instructor/check pilotPiper PA-44-180: 3 casesAll aircraft: 3,098 casesProbable cause
Convective weather: thunderstormEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-44-180: 1 caseAll aircraft: 100 casesProbable cause
Planning/preparation: weather planningPersonnel issues › Task performance · Instructor/check pilotPiper PA-44-180: 1 caseAll aircraft: 156 casesProbable cause
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-44-180: 1 caseAll aircraft: 809 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotPiper PA-44-180: 12 casesAll aircraft: 9,295 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 flight instructor stated that he and the private pilot-receiving instruction, who had the controls, informally checked the weather before departing for the cross-country instructional flight but that they did not obtain an official weather briefing. The flight was operating on an instrument approach in instrument meteorological conditions, which included thunderstorms, frequent lightning, and low-level wind shear advisories in effect at the destination airport. A tower controller at the destination airport issued the flight a local instrument clearance and provided wind and supplemental weather information, which included wind from 310° at 14 knots, gusting to 20 knots; a low-level windshear advisory, which included wind from 320° at 15 knots and a 15-knot gain 1 mile from the end of the runway. The controller also advised the pilot that the visibility was probably 1 mile in “that precipitation" and that there was “frequent lightning cloud to ground.” During the approach, the airplane began encountering rain, which increased in intensity as the airplane neared the final approach fix (FAF). Shortly after passing the FAF, when the airplane was about 800 ft mean sea level, the controller issued a low-altitude alert. The flight instructor took the controls, added full power, and attempted to climb the airplane; however, it continued descending while about 90 knots throughout the descent and upon impact. The airplane impacted houses and then came to rest inverted in a retention pond. The flight instructor noted that there were thunderstorms east of the destination airport when the flight began; however, he did not anticipate their potential impact on the flight. While in-flight, both pilots failed to identify the frequent lightning and low-level windshear advisory as a severe weather hazard and continued the approach into an area of thunderstorm activity instead of diverting to an alternate airport.

Factual narrative

On June 9, 2018, about 1500 eastern daylight time, a Piper PA-44-180 airplane, N21161, was substantially damaged when it was involved in an accident near Daytona Beach International Airport (DAB), Daytona Beach, Florida. The flight instructor and pilot-receiving-instruction sustained minor injuries. The flight was operated as a Title 14 Code of Federal Regulations Part 91 local instructional flight. The flight instructor stated he and the pilot-receiving-instruction, who had the controls, departed DAB about 1400 in visual flight rules conditions. They practiced maneuvers and then landed at Flagler Executive Airport (FIN), Palm Coast, Florida. After departing FIN, a DAB tower controller issued the flight a local instrument clearance and provided wind and supplemental weather information, which included wind from 310° at 14 knots, gusting to 20 knots. The controller also issued a low-level windshear advisory, which included wind from 320° at 15 knots and a 15-knot gain 1 mile from the end of the runway. The controller also advised the pilot that the visibility was probably 1 mile in “that precipitation" and that there was “frequent lightning cloud to ground.” During the approach, the airplane encountered rain, which increased in intensity as the airplane neared the final approach fix (FAF). Shortly after passing the FAF and while the airplane was about 800 ft mean sea level, a DAB tower controller issued a low-altitude alert. The instructor took the flight controls, added full power, and attempted to climb the airplane. It continued descending while about 90 knots throughout the descent and upon impact with houses about 4 miles north of DAB. The airplane then came to rest inverted in a retention pond. Both wings outboard of the engines were separated. The flight instructor stated they informally checked the weather before departing but did not obtain an official weather briefing before the flight. He further stated that thunderstorms were an everyday occurrence in the afternoon. When they departed FIN the storms were east of DAB, but they moved quicker than they anticipated. A convective SIGMET advisory was valid at the time of the accident, and it warned of a line of severe thunderstorms about 20 miles wide with cloud tops above 45,000 ft above ground level (agl), hail to 1 inch, and possible wind gusts to 50 knots. A Center Weather Service Unit Center Weather Advisory was valid at the time of the accident, and it warned of an area of scattered developing thunderstorms with cloud tops to 40,000 ft agl and moderate-to-heavy precipitation. Base reflectivity scans from around the time of the accident indicated very heavy rainfall and possible hail. Two hundred fifty-five lightning flashes occurred around the accident site between 1445 and 1505; the closest lightning occurred within 1,000 ft of the accident flight. See figure 1 for the base reflectivity scan from 1501. Figure 1. Reflectivity scan at 1501 with the air traffic control flight track datapoints in pink and the lightning flashes as black dots. The National Weather Service issued an amended terminal aerodrome forecast (TAF) at 1416, which was valid at the time of the accident and included temporary conditions between 1500 and 1700 ft agl of variable winds at 15 knots, gusting to 25 knots; 2 miles visibility; thunderstorm and heavy rain; and a broken ceiling of cumulonimbus clouds at 2,000 ft agl. At 1444, the weather conditions reported at DAB, which was 4 miles from the accident site, included wind variable at 6 knots; visibility 9 statute miles; thunderstorms; cumulonimbus clouds at 2,500 ft agl; broken clouds at 4,100, 7,500, and 25,000 ft agl; temperature 28°C; dew point 23°C; and an altimeter setting of 30.09 inches of mercury (inHg). At 1453, the weather conditions reported at DAB included wind from 300° at 14 knots, gusting to 19 knots; visibility 9 statute miles; thunderstorms; scattered cumulonimbus clouds at 2,500 ft agl; broken ceiling at 4,100 ft agl; broken clouds at 7,500 and 25,000 ft agl; temperature 27°C; dew point 22°C; and an altimeter setting of 30.09 inHg. Two METARs issued by DAB just before and after the accident included lightning in the area farther than 10 miles and but less than 30 miles from the center of the airport and frequent in-cloud and cloud-to-ground lightning. The FAA Advisory Circular AC 00-24C, "Thunderstorms," issued February 19, 2013, provides guidance to pilots on thunderstorm hazards and avoidance. The AC states that all thunderstorms “have conditions that are a hazard to aviation. The following guidance is included for avoiding thunderstorms: Chapter 10, “DOS AND DON'TS OF THUNDERSTORM AVOIDANCE.,” section A, “Thunderstorm Avoidance,” states, in part, the following: Never regard any thunderstorm lightly, even when radar observers report the echoes are of light intensity. Avoiding thunderstorms is the best policy. Following are some dos and don'ts of thunderstorm avoidance: (1) Don't land or takeoff in the face of an approaching thunderstorm. A sudden gust front of low-level turbulence could cause loss of control. (17) Do regard as extremely hazardous any thunderstorm with top 35,000 ft or higher whether the top is visually sighted or determined by radar…. (19) Do divert and wait out the thunderstorms on the ground if unable to navigate around an area of thunderstorms.

Aircraft

Registration
N21161
Reported as
Piper PA 44 (180)
Category
Airplane
Serial number
44-7995041
Built
1978
Airframe hours
11,424
Engines
Lycoming LO-360-E1A6D, 180 horsepower, reciprocatingLycoming O-360-E1A6D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
ATP USA, Inc.
Registered owner
Airline Transport Professionals Corp Of
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 24, 2018
Departed
FIN · Palm Coast, FL
Destination
DAB · Daytona Beach, FL
Airport
DAB · Daytona Beach Intl
Equipment
Electronic flight bag or handheld device, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Injuries
Minor
Certificates
Flight instructor, Commercial, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 9, 2017
Seat
Right
Restraint
3-point
Flight hours
700 total · 114.5 in this make and model · 611.5 as pilot in command · 261.7 in the last 90 days · 92.4 in the last 30 days · 5.5 in the last 24 hours
Role
Student pilot
Age
30
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 17, 2018
Seat
Left
Restraint
3-point
Flight hours
211.1 total · 32.2 in this make and model · 115.9 as pilot in command · 101.5 in the last 90 days · 29.2 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
300° at 14 knots, gusting 19
Visibility
9 statute miles
Lowest ceiling
4,100 ft broken
Temperature
81 °F, dew point 72 °F
Altimeter
30.09 inHg
Observed at
KDAB, 4 nm away

Docket · 7

The files NTSB released with the investigation on July 7, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.7 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.