# NTSB ERA18LA164: Piper PA 44, N21161, Daytona Beach, FL, June 9, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: June 9, 2018, 15:00 local (19:00 UTC) - Place: Daytona Beach, FL - Coordinates: 29.239166, -81.078887 - Nearby events: https://openairdocs.org/map.md?lat=29.2392&lon=-81.0789&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 97432 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA164 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97432/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97432 - Page: https://openairdocs.org/ntsb/ERA18LA164 ## 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 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-44-180, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7104402), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7104402), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Convective weather: thunderstorm](https://openairdocs.org/ntsb-findings/03033010): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-findings/03033010/cases.md?model=7104402), [All aircraft, 100 cases](https://openairdocs.org/ntsb-findings/03033010/cases.md) - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=7104402), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7104402), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-44-180, 12 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7104402), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=7104402), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Approach-IFR final approach: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390); cases with it: [Piper PA-44-180, 1 case](https://openairdocs.org/ntsb-events/390/sequence.md?model=7104402), [All aircraft, 224 cases](https://openairdocs.org/ntsb-events/390/sequence.md) - [Approach-IFR final approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-44-180, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7104402), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-IFR final approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-44-180, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104402), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N21161-2022-11-05), registration cancelled 2022-11-05, S/N 44-7995041, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA 44 (180) - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (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: 44-7995041 - Year built: 1978 - Airframe hours: 11424 - Engines: Lycoming LO-360-E1A6D 180 horsepower reciprocating; Lycoming 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: minor; 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 - Student pilot; age 30; injuries: minor; 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 ## 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 20180609007449A](https://openairdocs.org/incident/20180609007449A), Jun 9, 2018: Piper PA-44-180, Daytona Beach, FL, Destroyed. While on an RNAV instrument approch IMC to runway 16 Daytona Beach (dab) with the student at the controls, after passing the final approach fix (femba 4.7… ## Docket (7 files) The files NTSB released with the investigation on July 7, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97432. 17.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12402001&FileExtension=pdf&FileName=NTSB%206120%20N21161_Redacted-Rel.pdf - Pilot statements (item 2, PDF, 3 pages, 658 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9184237&FileExtension=pdf&FileName=Pilot%20Statements_Redacted-Rel.pdf - Weather study report (item 3, PDF, 39 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7115385&FileExtension=pdf&FileName=ERA18LA164_weatherstudySuffernfinal-Rel.pdf - Weather attachment 1 (item 4, GIF, 6.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7114108&FileExtension=gif&FileName=attachment1_animationwxradar1838to1920utc_basereflectivity_0_5degree-Rel.gif - Air traffic control (item 5, PDF, 1 page, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9194073&FileExtension=pdf&FileName=Memorandum%20for%20Record%20-%20ATC%20audio-Rel.pdf - Photo array (item 6, PDF, 3 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7855300&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7851651&FileExtension=pdf&FileName=NTSB%20Retention-Release%20of%20Wreckage%20Form-N21161_Redacted-Rel.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.