# NTSB ERA19LA093: Piper PA32RT, N3016L, Atlantic Ocean (Atlantic Ocean), February 1, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: February 1, 2019, 13:15 local (18:15 UTC) - Place: Atlantic Ocean (Atlantic Ocean) - Coordinates: 37.634956, -72.86087 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.6350&lon=-72.8609&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Inflight upset](https://openairdocs.org/ntsb-events/271) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report September 23, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper, FAA/AVP - NTSB case key (mKey): 98936 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98936/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98936 - Page: https://openairdocs.org/ntsb/ERA19LA093 ## Probable cause The pilot's loss of control due to spatial disorientation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-32RT-300, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7103215), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/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-32RT-300, 2 cases](https://openairdocs.org/ntsb-findings/03033010/cases.md?model=7103215), [All aircraft, 100 cases](https://openairdocs.org/ntsb-findings/03033010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Inflight upset](https://openairdocs.org/ntsb-events/271) (defining event); cases with it: [Piper PA-32RT-300, 1 case](https://openairdocs.org/ntsb-events/271/sequence.md?model=7103215), [All aircraft, 74 cases](https://openairdocs.org/ntsb-events/271/sequence.md) ## Analysis The pilot departed under visual flight rules before obtaining an instrument flight rules (IFR) clearance from air traffic control into an area of moderate rain showers and thunderstorms over the open ocean. A review of radar and voice communication data revealed the pilot struggled to maintain assigned headings throughout the duration of the flight. When queried by air traffic control, the pilot stated that the wind was "squirrely," and later stated that the heading deviations were the result of autopilot and instrument issues; however, the pilot declared that he was "fine" and declined offers of assistance from air traffic control. The directional changes became increasingly divergent until the radar track depicted a rapid, tightening, descending right turn, during which radar contact was lost. The wreckage was not located after the accident despite a search undertaken by air and sea assets, thus the wreckage could not be examined. The precipitation and restricted visibility conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane's erratic flight track, which included directional changes inconsistent with progress toward the destination, and the rapidly descending right turn depicted on radar are consistent with the known effects of spatial disorientation. It is likely that the pilot's decision to initiate the flight into an area of restricted visibility and thunderstorms resulted in his loss of airplane control due to spatial disorientation. ## Factual narrative The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude. The FAA's Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. On February 1, 2019, about 1315 eastern standard time, a Piper PA-32RT-300, N3016L, was presumed destroyed after radar contact was lost over the Atlantic Ocean. The private pilot and passenger were presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of voice, radar, and weather data revealed that the airplane departed Palm Beach County Park Airport (LNA), West Palm Beach, Florida, under visual flight rules about 1300. The pilot subsequently obtained an instrument flight rules (IFR) clearance to Leonard M. Thompson International Airport (MYAM), Marsh Harbour, The Bahamas. The controller cleared the airplane to progressively higher altitudes and provided vectors to avoid areas of precipitation in its flight path. About 1305, the controller instructed the pilot to fly heading 080° to avoid weather and described an area of light and moderate precipitation at the pilot's eleven o'clock position and 10 miles ahead. The pilot acknowledged. About 2 minutes later, the controller instructed the pilot to turn 10° to the right in order to stay away from the precipitation. About 1309, the controller instructed the pilot to turn another 10° right to remain clear of precipitation. The pilot read back the instructions and said, "I don't know what happened my autopilot it just kicked off." The controller acknowledged the pilot and instructed him to climb and maintain 6,000 ft; the pilot repeated the altitude assignment. About 1310, the controller again instructed the pilot to turn 10° right for weather and stated that the airplane did not appear to be on the correct heading. The pilot stated that he was "really fighting" to maintain heading. One minute later, the controller informed the pilot that theairplane had turned south and asked if he required assistance. The pilot replied, "it's just really squirrelly up here it's weird." About 1312, the pilot contacted the controller and stated that there were some "really weird winds up here." The controller advised that the airplane was turning north toward an area of heavier precipitation and instructed the pilot to turn south toward "any heading." The pilot stated that the airplane was having autopilot issues and that he was going to turn off the autopilot and fly manually. About 1313, the controller advised the pilot that it appeared the airplane was heading eastbound and instructed him to maintain 6,000 ft. The controller also stated that he would advise the center controller that the airplane was having "some sort of an autopilot issue." About 1314, the controller advised the pilot that the airplane had turned back to the northwest and asked the pilot if he was going to return to an eastbound heading. The pilot responded that he was "fine," that his instruments were "acting really goofy" and that he would turn the airplane to a 090° heading. The controller instructed the pilot to maintain 6,000 ft and no higher than 7,000 ft. The pilot did not respond. Shortly thereafter, the airplane entered a sharp right turn from a northerly heading and began to descend. The radar track showed the airplane in an increasingly steep right turn as it rapidly descended and was lost from radar about 1315 in an area that depicted heavy precipitation. The United States Coast Guard conducted a search for the airplane by air and sea over an area of 1,115 square miles without success. After 36 hours, the search was suspended on February 3, 2019. The accident pilot received a weather briefing through Leidos Flight Service at 1200. The briefer provided the convective outlook, Center Weather Advisory, METARs, and winds aloft. The accident pilot asked about the line of weather off the coast and stated that if it was moving north, he would fly south of it. The briefer responded that the line of weather was "just sitting there." The accident pilot told the briefer he "saw that one little red blob out there." The approximate cloud-top heights over the accident site were 16,000 ft mean sea level (msl), and a National Weather Service National Composite Radar Mosaic for 1315 at the approximate location of the accident site depicted 35- to 55-decibel (dBZ) echoes above the accident site. Radar data indicated that the airplane first entered precipitation between 1303 and 1309; reflectivity values between 30 and 50 dBZ, or moderate to heavy rain intensity echoes, were located above the accident site at the accident time (See figure 1). The reflectivity bands were moving from south to north. Figure 1. KAMX WSR-88D 0.5° elevation scan initiated at 1309:27 with the accident site marked with a black circle, the accident flight track in pink The Center Weather Advisory valid for the accident site at the accident time warned of areasof moderate rain showers and isolated thunderstorms with heavy precipitation with tops to 28,000 ft. The pilot's personal logbook was not recovered, and neither his total instrument flight experience nor the recency of that experience could be determined. ## Aircraft - Registration: [N3016L](https://openairdocs.org/deregistered/N3016L-2019-05-17), registration cancelled 2019-05-17, S/N 32R-7985068, built 1979 (OpenAirDocs) - Reported make and model: Piper PA32RT (300) - Registry model: [Piper PA-32RT-300](https://openairdocs.org/model/piper-pa-32rt-300) (registry code 7103215) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7985068 - Year built: 1979 - Airframe hours: 3846.7 - Engines: Lycoiming IO-540-K1G5D 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 2, 2018 - Departed: LNA, West Palm Beach, FL - Destination: MHH, Marsh Harbour, AOBF - Flight plan: IFR - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; flight hours: 1,452 total, 400 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Temperature: 70 °F, dew point 66 °F - Altimeter: 30.18 inHg - Observed at: PBI, 20 nm away ## Docket (10 files) The files NTSB released with the investigation on September 1, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98936. 28.2 MB in all. - Weather Study Report (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486438&FileExtension=.PDF&FileName=Weather%20Study%20Report-Master.PDF - Weather Attachment 1 (item 2, .GIF, 10.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486439&FileExtension=.gif&FileName=Weather%20Attachment%201-Master.gif - Weather Attachment 2 (item 3, .GIF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486441&FileExtension=.gif&FileName=Weather%20Attachment%202-Master.gif - Weather Attachment 3 (item 4, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486440&FileExtension=.PDF&FileName=Weather%20Attachment%203-Master.PDF - Weather Attachment 4 (item 5, .PDF, 371 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486442&FileExtension=.PDF&FileName=Weather%20Attachment%204-Master.PDF - Weather Attachment 6 (item 6, ZIP, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486444&FileExtension=zip&FileName=Weather%20Attachment%206-Master - FAA Air Traffic Control Accident Package (item 7, .PDF, 7.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486446&FileExtension=.PDF&FileName=FAA%20Air%20Traffic%20Control%20Accident%20Package-Master.PDF - Air Traffic Control Raw Data (item 8, .CSV, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486447&FileExtension=.csv&FileName=Air%20Traffic%20Control%20Raw%20Data-Master.csv - Maintenance Records (Email Correspondence) (item 9, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486448&FileExtension=.PDF&FileName=Maintenance%20Records%20(Email%20Correspondence)%20-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40486449&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.