# NTSB ERA19FA112: Piper PA25, N145AB, Fort Lauderdale, FL, March 1, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: March 1, 2019, 11:41 local (16:41 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.16611, -80.101112 - Nearby events: https://openairdocs.org/map.md?lat=26.1661&lon=-80.1011&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Aerial Banners North, Inc., Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 99044 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA112 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99044/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99044 - Page: https://openairdocs.org/ntsb/ERA19FA112 ## Probable cause The pilot’s failure to maintain proper altitude and clearance while maneuvering during a banner tow flight, which resulted in an in-flight collision with a 19-story building in a heavily congested area. Contributing to the accident were the easterly wind conditions, the pilot's total lack of experience in banner tow operations, and his inadvertent flight over a densely populated area with numerous tall buildings nearby. ## 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-25-235, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102504), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Experience/qualifications: total experience in position](https://openairdocs.org/ntsb-findings/02031020): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Piper PA-25-235, 2 cases](https://openairdocs.org/ntsb-findings/02031020/cases.md?model=7102504), [All aircraft, 19 cases](https://openairdocs.org/ntsb-findings/02031020/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-25-235, 10 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102504), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Wind](https://openairdocs.org/ntsb-findings/03034000): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/03034000/cases.md?model=7102504), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/03034000/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: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-25-235, 2 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7102504), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-25-235, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102504), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The newly-hired banner tow pilot departed on his first banner-tow flight away from the training airport. After completing several circuits the pilot was flying on a southerly heading with an 8 knot easterly wind about 1/4 mile offshore, which was about half the distance he was trained to be offshore. The pilot initiated a right turn descended to 250 ft mean sea level and flew over a heavily congested area with tall buildings nearby. The airplane was seen flying about 250 ft above ground level over a heavily-congested area before it impacted the 16th and 17th floors of a 19-story building while in a right turn. Although witnesses provided varying accounts of how the engine was operating near the end of the flight, a sound spectrum study conducted with video taken of the airplane just before the impact indicated that the engine was operating near its maximum available power at the time of impact. Postaccident examination of the airplane and engine revealed no evidence of preimpact failure or malfunction. The abnormal engine sounds reported by several witnesses were likely attributed to be from the lack of a muffler of the exhaust system. Given the lack of any mechanical malfunctions with the airplane, it was likely that the pilot did not adequately compensate for the wind conditions, which would have pushed the airplane inland during a right turn to reverse course. The operator reported that banner-tow flights were performed between 500 and 700 ft above mean sea level while offshore. At no time, except during takeoff or landing or unless authorized by air traffic control, were pilots expected to fly at altitudes less than 500 ft. According to training records, the pilot had received 17 hours of banner tow flight training, He completed a .6-hour solo banner tow training flight in the airport vicinity 3 days before the accident. ## Factual narrative Banner Tow Information/Banner Examination The operator reported that, when flying north, the typical procedure is to fly at 500 to 700 ft mean sea level (msl) while offshore. The pilot typically performs a climbing right turn to 1,000 ft msl, followed by a descending right turn to a southerly heading flying between 500 and 700 ft msl unless instructed by air traffic control (ATC). At no time during a banner tow flight, except for takeoff or landing or when authorized by ATC, is the airplane expected to be below 500 ft above ground level (agl). The typical power setting when towing a banner the size of the accident banner was to maintain between 2,000 and 2,200 rpm. Examination of the lead pole of the banner revealed no damage from the rudder or any damage along the length of the pole. The 59.5 ft-long bridle was inspected and only the lower rope was cut. Inspection of the banner revealed normal wear. The No. 1 banner release mechanism operated normally. NTSB Sound Spectrum Study A sound spectrum study from the video recording was performed and correlated with company tracking data for time and position information. The sound from the start of the video until the building impact was about 22 seconds, and the airplane was over land for about 19 seconds. The engine rpm initially was about 2,200. During the time the airplane was flying over land, the engine power increased to and remained above 2,300 rpm for about 12 seconds, then increased to about 2,500 rpm, decreased slightly, then began to increase to about 2,450 rpm at the time of impact. The maximum engine rpm (red line speed) was 2,575. The airplane was equipped with a "Live View GPS Tracker" system. The exhaust system consisted of pipes with no muffler on either side. On March 1, 2019, about 1141 eastern standard time, a Piper PA-25-235, N145AB, was destroyed when it was involved in an accident near Fort Lauderdale, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 banner tow flight. The pilot was scheduled to complete a 2-hour flight towing a "medium size" company banner, which was 30 feet high by 90 feet long, near Hollywood Beach, Fort Lauderdale Beach, and north to the Commercial Boulevard Pier, which was the northernmost point of the route. The operator reported that, after taking off, the pilot conducted 5 or 6 practice banner pick-ups, then picked up the accident banner about 1059. Company tracking data and Federal Aviation Administration (FAA) radar data indicated that the flight proceeded due east to the beach, where the pilot performed several circuits near Hollywood Beach. Review of the track data revealed that, at the southern end of the second circuit, the pilot began a right turn to return to a northerly direction but changed to a left turn and then proceeded in a northerly direction. He made several more circuits, then at 1125:00, the pilot initiated a right turn and proceeded north toward Commercial BoulevardPier. At 1137:23, while over water south of the Commercial Boulevard Pier, the pilot initiated a right turn and flew in a south-southwesterly direction less than 1/2 nautical mile from the beach. At 1140:02, when the flight was south of Oakland Park Boulevard, about 0.4 nautical mile east-southeast from the accident site, flying about 1/4 mile offshore, he initiated a right turn. (The pilot had been taught to fly ½ miles from the shore during his training flights.) The airplane proceeded over land while towing the banner and FAA radar data indicated it descended to 250 ft mean sea level. The company tracking data indicated that while flying over land the airplane proceeded in a northwesterly direction until about 1140:32. At that time, just north of NE 30th Street, about 380 ft east-southeast of the accident site, the airplane turned left and proceeded in a west-northwesterly direction about 54 miles per hour (mph) groundspeed. A witness who was on a boat about 0.6 nautical mile northeast of the accident site noted that the airplane was flying at a much lower altitude and came closer to the shore as it flew south. An individual who was with the witness estimated that the airplane was about 200 ft overhead. At that time, they reported there was no sputtering or backfire from the engine, adding that it was "steady and loud." The airplane flew south, then made a right turn followed by a "sharp" left turn. During the left turn, the banner went upside down and dropped. The airplane disappeared from their view. An individual walking on the beach near the accident site took video footage of the airplane flying low south of her position. The airplane performed a shallow right turn and flew over land. The engine sounded normal during the turn, but she reported that it "quit" about 10 seconds before she perceived the impact. She did not see any smoke trailing the airplane while she observed it in flight. Witnesses near the accident site provided differing accounts of engine operation. The accounts varied from hearing the engine with no sputtering or other sounds of distress, a sputtering sound, an engine that was operating at a low power setting, or an engine which sounded "very strange" and "not smooth." The airplane impacted the east face of a 19-story building at the 16th and 17th floors and came to rest on the second floor level. There was no in-flight contact between the pilot and any company personnel around the accident time. A postmortem examination of the pilot was performed by the Broward County Medical Examiner's Office. The cause of death was reported to be blunt head trauma." Forensic toxicology was performed on specimens of the pilot by the FAA Forensic Sciences Laboratory. The FAA toxicology report indicated testing for cyanide was not performed and the results were negative for carbon monoxide, volatiles, and tested for drugs. The pilot's first evaluation flight with the operator occurred on November 18, 2018. The flight duration was 1.1hours and covered full stalls, flight at critically low airspeeds, and maximum performance maneuvers. The flight was conducted in a Cessna 305A. He was hired and began his ground training on January 23, 2019. According to the "Banner Tow Pilot Training" form dated February 22, 2019, he received 20 hours of ground training and about 17 hours flight training, which included a 1.5-hour dual/solo banner tow flight. A "Verification Of Training And FAA Observation" form dated February 22, 2019, indicated that he had 1.5 hours banner tow time. He was trained to fly the operator's Cessna 305A and Piper PA-25 airplanes in banner tow operations and was put on the company's FAA Certificate of Waiver on February 28, 2019. The pilot’s logbook showed that he had completed a .6-hour practice solo banner tow flight in the vicinity of the airport on February 26, 2019. The accident flight was the pilot's first solo banner tow flight away from the banner tow box at North Perry Airport (HWO), Hollywood, Florida, where he conducted his training. Coworkers who interacted with the pilot before the flight reported he was excited and enthusiastic about it; one employee described that the pilot displayed an "appropriate level of nervousness." The airplane came to rest on the 2nd floor of an outside pool area that was under construction. The banner was found on the ground about 400 ft east-southeast of the building. The wreckage came to rest on its left side on a magnetic heading of 050°. The left wing exhibited extensive impact damage and was resting beneath the fuselage, while the right wing was elevated and sustained minimal impact damage. A slight amount of oil was noted on the upper surface of the right wing outboard of the lift strut. Both cockpit doors were found near the main wreckage. The fuel cap was separated from the fuel tank but remained attached by its chain. The oil filler cap and rod were separated from the engine but found in the immediate vicinity of the engine. The rod portion of the oil filler cap and rod was bent near the cap. Both wing lift struts, the aileron flight control cables, and the left flap bellcrank were cut to facilitate recovery. There was no evidence of bird remains on either wing, horizontal stabilizer, vertical stabilizer, or in the cockpit area. The engine remained partially attached to the airframe. The engine mount was impact damaged and the engine was displaced about 25° to 30° in a clockwise direction. The propeller was separated from the engine and a piece about 15 inches in length was fractured off. The separated propeller and fractured propeller piece were found in close proximity to the main wreckage. The position of the engine precluded visual examination of the mixture control cable. Flight control continuity was confirmed from each control surface to each cockpit control, except where cut for recovery. The left flap control cable was connected at the handle and bellcrank near the control surface, while the right flapcontrol cable was connected at the flap control handle and at the bellcrank near the control surface, but exhibited tension overload at the wing root. The stall warning system revealed no evidence of pre-impact failure or malfunction. The 75-gallon capacity aluminum fuel tank was bulged and ruptured on the forward end consistent with hydraulic deformation. No fuel remained in the tank. Only drops of fuel, a slight amount of water, and some ferrous and non-ferrous slivers were found inside the strainer bowl. The fuel strainer screen was unobstructed. No obstructions were noted from the fuel tank to the fuel strainer and to the carburetor bowl. The auxiliary fuel pump was electrically tested and could be heard operating; it was not functionally tested. About 2 ounces of blue-colored liquid consistent with 100LL aviation fuel were drained from the auxiliary fuel pump. Examination of the engine following recovery revealed impact damage to the crankshaft flange and to the No. 6 cylinder, which precluded 360° rotation of the crankshaft. Borescope examination of each cylinder revealed no anomalies. Examination of the lubrication, ignition, valve train, air induction, and exhaust systems revealed no evidence of preimpact failure or malfunction. The carburetor was fractured from engine but was suspended by its attached throttle cable and carburetor heat cable. The mixture cable was detached from its attachment hardware, which was still in place. The mixture control lever was near its midrange position when first viewed. The carburetor inlet screen was impact-damaged and a section could not be removed and remained inside the inlet housing. The section of inlet screen that remained was free of obstructions. The carburetor bowl contained about 2 ounces of fuel which tested negative for the presence of water. Propeller blade No. 1 (as marked by the manufacturer) was twisted toward low pitch. Heavy coarse chordwise scratches were noted on the cambered side of the blade. It exhibited a slight aft bend near the hub, and a slight forward bend about 2/3 span. Slight chordwise scratches were noted on the aft side of the blade. The No. 2 propeller blade was fractured about 25.5 inches from the center of the propeller hub. Heavy coarse chordwise scratches were noted on the cambered side of the blade. The blade tip was curled about 270°. Coarse chordwise scratches were also noted on the aft side of the blade near the fracture surface. The leading edge exhibited a gouge near the tip, and a section of blade was missing from the trailing edge. The propeller spinner exhibited signs of rotation. ## Aircraft - Registration: [N145AB](https://openairdocs.org/aircraft/N145AB), registered now, S/N 25-3137, built 1965 (OpenAirDocs) - Reported make and model: PIPER PA25 (235) - Registry model: [Piper PA-25-235](https://openairdocs.org/model/piper-pa-25-235) (registry code 7102504) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 25-3137 - Year built: 1965 - Airframe hours: 9711.6 - Engines: Lycoming O-540-B2B5 235 horsepower reciprocating - Damage: Destroyed - Flight: Banner tow, Part 91 - Operator: Aerial Banners North, Inc. - Registered owner: Aerial Banners, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 25, 2019, 3 hours before - Departed: HWO, Hollywood, FL - Destination: HWO, Hollywood, FL - Flight plan: Company VFR - Equipment: Satellite tracking device, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review August 15, 2018; seat: center; restraint: 3-point; toxicology performed; flight hours: 312.7 total ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 3,100 ft broken - Temperature: 81 °F, dew point 66 °F - Altimeter: 30.13 inHg - Observed at: FLL, 6 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 20190301000729A](https://openairdocs.org/incident/20190301000729A), Mar 1, 2019: Piper PA-25-235, Fort Lauderdale, FL, Destroyed, 1 fatal. On March 1, 2019, a Piper PA-25-235 flew into a condominium building in Fort Lauderdale Florida while operating under banner towing authorization. The accident… ## Docket (17 files) The files NTSB released with the investigation on December 15, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99044. 39.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 12.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7752889&FileExtension=pdf&FileName=NTSB%20REPORT%20145AB_Recd%203_18_2019_Redacted-Rel.pdf - Witness statement (item 2, PDF, 2 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10001123&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - NTSB record of conversations (item 3, PDF, 26 pages, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10012570&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - FAA record of conversations (item 4, PDF, 8 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10003009&FileExtension=pdf&FileName=FAA%20Record%20of%20Conversations_Redacted-Rel.pdf - Statements from operator (item 5, PDF, 7 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10002137&FileExtension=pdf&FileName=Statements%20from%20Operator_Redacted-Rel.pdf - Video segment with sound (item 6, MOV, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10006731&FileExtension=MOV&FileName=IMG_0769-Rel.MOV - Pilot training records (item 7, PDF, 4 pages, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10068805&FileExtension=pdf&FileName=Pilot%20Training%20Records_Redacted-Rel.pdf - Excerpts from pilot logbook (item 8, PDF, 4 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11504348&FileExtension=pdf&FileName=Excerpts%20from%20Pilot%20Logbook_Redacted-Rel.pdf - Weather reports and records (item 9, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10001214&FileExtension=pdf&FileName=Weather%20Reports%20and%20Records-Rel.pdf - Investigative photographs (item 10, PDF, 12 pages, 12 photos, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10069358&FileExtension=pdf&FileName=Investigative%20Photographs-Rel.pdf - Tower documentation report (item 11, PDF, 15 pages, 12 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10068778&FileExtension=pdf&FileName=Tower%20Documentation%20for%20NTSB_Redacted-Rel.pdf - Memorandum for record - cockpit examination (item 12, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10000176&FileExtension=pdf&FileName=Master%20Memorandum%20For%20Record%20-%20Cockpit%20Examination-Rel.pdf - Toxicological reports (item 13, PDF, 2 pages, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10000991&FileExtension=pdf&FileName=Toxicology%20Reports_Redacted-Rel.pdf - Sound spectrum study (item 14, PDF, 13 pages, 794 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10089619&FileExtension=pdf&FileName=spectrum%20study%20dms-Rel.pdf - Company GPS tracking tabular data (item 15, CSV, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10089851&FileExtension=csv&FileName=N145AB%2020190301-Rel.csv - Statement of party representatives to NTSB investigation (item 16, PDF, 10 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10069049&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15, and NTSB evidence control forms (item 17, PDF, 3 pages, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10078832&FileExtension=pdf&FileName=Wreckage%20Release%20and%20Evidence%20Forms_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.