# NTSB ERA19FA170: Piper PA 30, N7650Y, Naples, FL, May 11, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 11, 2019, 15:30 local (19:30 UTC) - Place: Naples, FL - Coordinates: 26.202499, -81.707221 - Nearby events: https://openairdocs.org/map.md?lat=26.2025&lon=-81.7072&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Birdstrike](https://openairdocs.org/ntsb-events/901) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Piper Aircraft, FAA/FSDO - NTSB case key (mKey): 99411 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA170 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99411/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99411 - Page: https://openairdocs.org/ntsb/ERA19FA170 ## Probable cause Incapacitation of the pilot due to a birdstrike through the windshield in front of the pilot's position, while on approach to land. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Windows-windshield system: flight compartment windows](https://openairdocs.org/ntsb-findings/01035610): Aircraft › Aircraft structures · Capability exceeded (probable cause); cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/01035610/cases.md?model=7103002), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01035610/cases.md) - [Object/animal/substance: animal(s)/bird(s)](https://openairdocs.org/ntsb-findings/03022045): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/03022045/cases.md?model=7103002), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/03022045/cases.md) - [Impairment/incapacitation: illness/injury](https://openairdocs.org/ntsb-findings/02012010): Personnel issues › Physical · Pilot (probable cause); cases with it: [Piper PA-30, 2 cases](https://openairdocs.org/ntsb-findings/02012010/cases.md?model=7103002), [All aircraft, 34 cases](https://openairdocs.org/ntsb-findings/02012010/cases.md) - [Selection/certification/testing: equip certification/testing](https://openairdocs.org/ntsb-findings/04012015): Organizational issues › Development · FAA/Regulator (probable cause); cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-findings/04012015/cases.md?model=7103002), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/04012015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Birdstrike](https://openairdocs.org/ntsb-events/901) (defining event); cases with it: [Piper PA-30, 1 case](https://openairdocs.org/ntsb-events/901/sequence.md?model=7103002), [All aircraft, 253 cases](https://openairdocs.org/ntsb-events/901/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-30, 37 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103002), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis While on approach to the destination airport in visual meteorological conditions, the airplane deviated unannounced from its intended flight path, descended, and impacted the ground. Postaccident examination of the airframe, flight controls, engines, engine systems, and propellers revealed no evidence of preimpact failure or malfunction. Remains of a 3.8-pound Black Vulture was found in the wreckage. A rear seat headrest and two inflatable lift vests located about 440 ft from the main wreckage were found to contain either DNA and/or microscopic feathers from a Black Vulture. Because the Black Vulture was located among the wreckage and because the airplane’s flight path deviation was unannounced, it is likely that the Black Vulture directly impacted and then penetrated the windshield in front of the pilot's position, which incapacitated him, resulting in an uncontrolled descent. The airplane was certificated in accordance with Civil Air Regulation 3, which specified no minimum standard for window or windshield structure strength, or bird penetration. ## Factual narrative The airplane was certificated in accordance with Civil Air Regulation 3, which specified no minimum standard for window or windshield structure strength, or bird penetration. The regulation specified windshields must be comprised of non-splintering safety glass. At the time of manufacture, the airplane was equipped with a two-piece windshield that was 0.125-inch thick. Subsequently, on January 15, 1979, a one-piece windshield was installed in accordance with Supplemental Type Certificate (STC) SA-209GL. As part of the STC, the center post was removed and not re-installed. According to the designer and manufacturer of the STC windshield, the design criteria consisted of testing loads by using the dynamic pressures and projected frontal area. There was no requirement for bird strike resistance; therefore, bird penetration testing was not performed.. HISTORY OF FLIGHT On May 11, 2019, about 1530 eastern daylight time, a Piper PA-30, N7650Y, was destroyed when it was involved in an accident near Naples, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to Federal Aviation Administration (FAA) communication and radar data, the airplane departed from Key West International Airport (EYW) for a cross-country flight to Naples Municipal Airport (APF). At 1513, the pilot established contact with the Southwest Florida International Airport (RSW) air traffic control tower and advised the controller that the airplane was at an altitude of 4,000 ft, with automated terminal information service tango. The controller advised the pilot to expect the RNAV runway 23 approach to APF, which he acknowledged. The flight continued toward APF, and at 1518, the pilot was advised that he would be vectored onto the downwind leg of the airport traffic pattern and would be following a Cessna Citation. Three minutes later, the pilot advised the controller that APF was in sight, and he requested a lower altitude. The pilot was instructed to descend and maintain 3,100 ft, followed by 2,000 ft, which he acknowledged. At 1527, the pilot was cleared for a visual approach to runway 23 and instructed to contact the APF air traffic control tower, which he did. About 1528, while flying at an altitude of about 2,185 ft mean sea level, the pilot advised the APF controller that he was on a 5.5-mile final, which was his last communication. The airplane continued toward APF and its altitude varied around 2,200 feet until 1529:42, at which time a gradual, arcing, left descending turn occurred. The last radar target was recorded at 1529:55, when the airplane was less than 0.25 nautical mile from the accident site at an altitude of 750 ft. The airplane impacted a residential area, immediately adjacent to a home, about 4.3 miles and 052° from the approach end of runway 23. According to a deputy with the Collier County Sheriff Department (CCSD) who was on a traffic stop with another CCSD employee about1,900 ft east-southeast of the accident site, he reported hearing a loud sound then a "thud." He looked up and saw something like silver Christmas tinsel floating. He never saw the airplane, and he did not hear any "clunking" sound from the engine(s). The other CCSD employee reported he too heard a thud sound, which he thought was a truck passing over a road. He did not see the airplane and did not hear any "sputter" sound. According to the home owner, he heard the noise from an airplane getting closer and swooping over his house, then he felt the house shake. He estimated that he heard the airplane for about 8 to 10 seconds; during that time he did not hear any abnormal sounds, and he did not hear any sputtering. He equated the sound to something similar to a mosquito-control airplane. A postmortem examination of the pilot was performed by the District Twenty Medical Examiner's Office, Collier County, Naples, Florida. The cause of death was listed as airplane crash. The autopsy noted the presence of black bird feathers. Forensic toxicology was performed on specimens of the pilot by the FAA Forensic Sciences Laboratory, Oklahoma City, Oklahoma, and also by the Miami-Dade County Medical Examiner’s Department. According to FAA's toxicology report, testing for carbon monoxide and cyanide was not performed. The results were negative for volatiles and tested for drugs. According to Miami-Dade ME's Department the results were negative for all tested for drugs. Several tree limbs immediately adjacent to the house were damaged; the highest was about 30 ft above ground level. Numerous tree limbs, 4 to 7 inches in diameter, exhibited 45° cuts consistent with propeller contact. A 14-ft-long ground scar, oriented on a magnetic heading of 172° was observed adjacent to the house, and was associated with both wing leading edges. Within the ground scar were two craters associated with each engine. The left crater contained a separated propeller blade, propeller hub with attached propeller blade, and a portion of crankshaft. The right crater contained a piece of flap, wing skin, engine nacelle, and part of a fuel bladder tank. Further examination of the accident site revealed fragmented parts of the airplane, including and windshield and other window pieces. All structural components necessary to sustain flight, and all primary and secondary flight controls remained attached or were located at the accident site. All primary flight control surfaces’ counterweights were accounted for except the right aileron. Examination of the right aileron bellcrank revealed neither stop was damaged. Examination of the flight control cables for roll, pitch, and yaw revealed they exhibited either tension overload or were cut for recovery; there was no evidence of preimpact failure or malfunction. The pitch trim actuator was extended 8 threads from the bottom which equated to full airplane nose down trim. The rudder trim actuator was separated, and the actuator rod was fracturedat the actuator. The flap actuator was separated from the airplane and the jackscrew was extended 1.750 inches, or 11 threads, which equated to between 0° and 10° of flap extension. Both main landing gear were retracted in their wheel wells; the nose landing gear actuator position could not be determined due to impact damage. Examination of the lower front window retainer revealed it was fragmented in three pieces. Screws were observed in place in the retainer. Examination of the upper window retainer revealed it was fractured and four screws were missing; however, the full span was accounted for. No window pieces were noted in either upper or lower retainer channel, and sealant was noted in the lower and upper channels. Recovered windshield pieces were examined and the maximum thickness was 0.250 inch. A dead bird weighing 3.8 pounds was located among the wreckage. Feathers were found adhering to a blanket located near the separated inboard section of the right wing. The bird and feathers were retained for analysis by the Smithsonian Institution Museum of Natural History. The rear seat headrest and two inflatable life vests were located about 440 ft north-northwest from the accident site. These items were swabbed for analysis by the Smithsonian Institution Museum of Natural History. Additionally, swabs from the upper surface of the glare shield and also from the interior portion of the upper headliner were also analyzed. According to a report from The Smithsonian Institution Museum of Natural History, the bird was a Black Vulture, and the swabs from the glare shield and the headliner, did not contain bird DNA or feathers. The swabs from the headrest and life vests contained either DNA and/or microscopic feathers from a Black Vulture. Examination of both engines and propellers revealed no evidence of preimpact failure or malfunction. ## Aircraft - Registration: [N7650Y](https://openairdocs.org/deregistered/N7650Y-2022-07-30), registration cancelled 2022-07-30, S/N 30-729, built 1965 (OpenAirDocs) - Reported make and model: Piper PA 30 (No Series) - Registry model: [Piper PA-30](https://openairdocs.org/model/piper-pa-30) (registry code 7103002) (OpenAirDocs) - Registry engine: [Lycoming IO-320 series](https://openairdocs.org/engine/lycoming-io-320-series) (registry code 41509, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 30-729 - Year built: 1965 - Airframe hours: 4681 - Engines: Lycoming IO-320-B1A 160 horsepower reciprocating; Lycoming IO-320-B1A 160 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 15, 2019, 89 hours before - Departed: EYW, Key West, FL - Destination: APF, Naples, FL - Flight plan: IFR - Airport: APF, Naples Municipal Airport - Equipment: Auto-pilot, Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review February 22, 2018; seat: left; restraint: lap only; toxicology performed; flight hours: 2,419 total ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 14 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 72 °F - Altimeter: 29.92 inHg - Turbulence: Unknown - Observed at: APF, 5 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 20190511004489A](https://openairdocs.org/incident/20190511004489A), May 11, 2019: Piper PA-30, Naples, FL, Destroyed, 1 fatal. On may 11, 2019, about 1530 eastern daylight time, a Piper PA-30, N7650Y, experienced an in-flight loss of control while on approach to Naples Airport (apf),… ## Docket (16 files) The files NTSB released with the investigation on December 9, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99411. 135 MB in all. - Record of NTSB conversations (item 1, PDF, 2 pages, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9178369&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - Excerpt from maintenance records documenting one piece windshield installation (item 2, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9177707&FileExtension=pdf&FileName=One%20Piece%20Windshield%20Logbook%20Entry_Redacted-Rel.pdf - NTSB prepared radar plots (item 3, PDF, 4 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9474824&FileExtension=pdf&FileName=NTSB%20Prepared%20Radar%20Plots-Rel.pdf - Tabular radar track data (item 4, CSV, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9475274&FileExtension=csv&FileName=N7650Y%20-%20Tabular%20Track%20Data%20V2-Rel.csv - Chronological summary of flight communications (item 5, PDF, 5 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9406699&FileExtension=pdf&FileName=Chronologiocal%20Summary%20of%20Communications%20v02-Rel.pdf - Report from smithsonian institution, national museum of natural history (item 6, PDF, 3 pages, 755 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9566301&FileExtension=pdf&FileName=Report%20from%20Smithsonian%20Institution_Redacted-Rel.pdf - Investigative photographs (item 7, PDF, 12 pages, 12 photos, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181360&FileExtension=pdf&FileName=Investigative%20Photographs-Rel.pdf - Memorandum for record - wreckage examination (item 8, PDF, 3 pages, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9177716&FileExtension=pdf&FileName=Memorandum%20For%20Record_ERA19FA170-Rel.pdf - Toxicological reports (item 9, PDF, 2 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9178352&FileExtension=pdf&FileName=Toxicology%20Reports_Redacted-Rel.pdf - Medical officer's factual report (item 10, PDF, 2 pages, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9178152&FileExtension=pdf&FileName=ERA19FA170_Medical%20Factual%20Report-Rel.pdf - UAS aerial imagery report (item 11, PDF, 5 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9410262&FileExtension=pdf&FileName=ERA19FA170%20-%20Naples%20Aerial%20Imagery%20Report-Rel.pdf - UAS imagery att 1 orthomosaic geotiff (item 12, TIF, 1 page, 49.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8680034&FileExtension=tif&FileName=Naples2_transparent_mosaic_group1-Rel.tif - UAS imagery att 2 orthomosaic google earth format (item 13, KMZ, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8680356&FileExtension=kmz&FileName=NaplesGoogleEarthwithCSMarkers-Rel.kmz - UAS imagery att 3 3D point cloud (item 14, ZIP, 69.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8680675&FileExtension=zip&FileName=Naples2_group1_densified_point_cloud-Rel.zip - Statement of party representatives to NTSB investigation (item 15, PDF, 9 pages, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9180040&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15, and NTSB evidence control forms (item 16, PDF, 4 pages, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9179727&FileExtension=pdf&FileName=Wreckage%20Release%20and%20Evidence%20Control%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.