# NTSB ERA21LA111: Piper PA-28-161, N266ND, Boynton Beach, FL, January 25, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: January 24, 2021, 20:00 local (Jan 25, 2021, 01:00 UTC) - Place: Boynton Beach, FL - Coordinates: 26.54121, -80.03705 - Nearby events: https://openairdocs.org/map.md?lat=26.5412&lon=-80.0370&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Piper, Lycoming - NTSB case key (mKey): 102547 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA111 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102547/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102547 - Page: https://openairdocs.org/ntsb/ERA21LA111 ## Probable cause The pilot’s controlled flight into the ocean at night due to his unrecognized spatial disorientation. Contributing to the accident was the pilot’s distraction with the tuning of his transponder while maneuvering over an area with reduced visual references. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-161, 6 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7102803), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Perception/orientation/illusion: temporal disorientation](https://openairdocs.org/ntsb-findings/02022020): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/02022020/cases.md?model=7102803), [All aircraft, 1 case](https://openairdocs.org/ntsb-findings/02022020/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA-28-161, 7 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102803), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-28-161, 6 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102803), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis While in cruise flight about 1,000 ft on a southbound heading over land in night visual meteorological conditions, the pilot requested flight following services and routing to the north “along the shoreline.” Air traffic control approved the request, issued the altimeter setting, and instructed the pilot to proceed offshore and “follow the shoreline northbound at or below 500 feet.” The pilot acknowledged the instructions and repeated the altimeter setting as the airplane began a descending left turn to the east. The target identified as the accident airplane continued an eastbound descent on a heading about perpendicular to the shoreline when the controller assigned the airplane a new transponder code. When the pilot acknowledged the transponder code instructions, the airplane was at 300 ft and descending and displayed a transponder code one digit off that which was assigned. At that time, the airplane was crossing the beach at 225 ft and descending. Once over water, the airplane’s track depicted a shallow, descending left turn. Soon after, radar contact was lost and there were no further communications with the airplane. Onboard video revealed that the descent was initiated by multiple reductions in engine rpm as the airplane turned to the east, consistent with the controller’s instructions to fly offshore and continue north below 500 ft; however, no sounds consistent with an increase in engine rpm to arrest the descent occurred after the airplane began tracking toward the ocean, nor in the final moments of flight as the airplane initiated a turn toward the north well below 500 ft. Given the dark nighttime conditions, the pilot’s lack of instrument experience likely focused his attention outside the aircraft. In a low-wing airplane, cultural/ambient lighting on the ground ahead of the airplane would have provided some cues of both altitude and attitude; however, the availability of those cues would have rapidly decreased as the airplane neared the shoreline. The circumstances of this accident suggest that the pilot over-relied on outside references and did not effectively reference the altimeter. The controller’s instructions to reset the transponder code about the same time the airplane was descending through 500 ft, although routine, likely served as an operational distraction to a pilot with his limited experience. His efforts to reset the transponder likely further diverted his attention away from the altimeter, and the pilot allowed the airplane to descend into the water. ## Factual narrative On January 24, 2021, about 2000 eastern standard time, a Piper PA-28-161, N266ND, was substantially damaged when it was involved in an accident near Boynton Beach, Florida. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of air traffic control voice, Automatic Dependent Surveillance-Broadcast (ADS-B), and weather data revealed that the airplane departed under visual flight rules and turned to a southerly heading before contacting air traffic control. While in cruise flight about 1,000 ft, the pilot requested visual flight rules flight following and routing “along the shoreline.” The controller approved the request, issued the altimeter setting, and instructed the pilot to proceed offshore and “follow the shoreline northbound at or below 500 feet.” At 1958:37, the pilot acknowledged the instructions and repeated the altimeter setting as the airplane began a descending left turn to the east. The target identified as the accident airplane continued an eastbound descent on a heading about perpendicular to the shoreline when the controller assigned the airplane a new transponder code. When the pilot acknowledged, the airplane was at 300 ft and descending. At 1959:25, the accident airplane displayed a transponder code one digit off of the assigned code. At that time, the airplane was crossing the beach at 225 ft and descending. Once over water, the airplane’s track depicted a shallow, descending left turn. At 2000:00, the controller repeated the transponder instructions, but the airplane’s target had disappeared and there were no further communications with the airplane. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. The pilot’s most recent FAA first class medical certificate was issued October 4, 2019. The pilot was enrolled at 2Fly Airborne in an airline pilot training curriculum and, according to school records, had accrued about 190 total hours of flight experience, 95 hours of which were in the accident airplane make and model. The pilot earned his instrument airplane rating on January 20, 2021. Review of the pilot’s logbook revealed that he had accrued 19.8 total hours of night flying experience, of which 8.9 hours was in the accident airplane make and model. He had accrued 8.0 hours of solo flight experience at night. According to FAA records, the airplane was manufactured in 2000 and was equipped with a Lycoming O-320-D3G, 160-horsepower engine that drove a fixed-pitch propeller. The airplane’s most recent 100-hour inspection was completed January 7, 2021, at 16,366 total aircraft hours. At 1953, weather recorded at West Palm Beach International Airport (PBI), 9 miles north of the accident site, included scattered clouds at 2,000 ft above ground level (agl) and 25,000 ft agl. The visibility was 10 miles. The temperature was23°C, the dew point was 19°C, and the altimeter setting was 30.11 inches of mercury. At the location of the accident, for an observer at sea level, sunset occurred at 1757 and civil twilight ended at 1821. Moonrise occurred at 1509 and moonset occurred at 0430 on January 25, 2021. At the time of the accident, the moon was located at an altitude of 42.28° and an azimuth of 278.50°, with 87.1 percent of its disk illuminated. The airplane was recovered by a commercial salvage operator January 26, 2021, and was examined at their facility under the supervision of two FAA inspectors. The engine cowlings were impact-damaged, the engine mounts were broken, and the engine rested in a “nose-down” attitude in relation to the airframe. The cockpit and cabin areas appeared intact. The pilot’s seatbelt and shoulder harness were not buckled/attached and appeared intact. Flight control continuity was confirmed from the cockpit to all flight control surfaces. The right wing was separated by impact and remained attached by the aileron control cable and electrical harness. Wing-mount fractures revealed failure features consistent with overload. The main and standby vacuum pumps and the vacuum-operated attitude indicator were disassembled and revealed no pre-impact anomalies. The electric fuel boost pump operated normally with electrical power applied. The engine was rotated by hand at the propeller and continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed at each cylinder using the thumb method. The position of each magneto was confirmed before they were removed, drained, dried, and remounted in their as-found positions. Ignition timing was confirmed, and when actuated, both magnetos produced spark at all terminal leads. The carburetor was damaged by impact, but the engine controls all remained attached. The engine-driven fuel pump was removed and functioned as designed when actuated by hand. Examination of the airframe and engine revealed no pre-impact mechanical anomalies. The Palm Beach County Sheriff’s Office (PBSO) recovered an on-board video recorder from the airplane, successfully downloaded the data, and forwarded a video of the accident flight. The view was directly out the front windscreen and did not capture the airplane’s instrument panel. From engine start, taxi, takeoff, initial climb, and final descent, the sound of the engine was smooth and continuous throughout. Changes in engine sound were consistent with the changes in flight mode. During the final portion of the flight, the airplane was in cruise flight on a southerly heading over a well-lit north/south interstate highway that bisected a developed urban/suburban area. To the east, the coastline was discernable due to its illumination. The water beyond was black with no visible horizon. There was no ambient light on or above the water providing illumination. The engine sound reduced, and the view was consistent with a shallow turnand descent on an easterly heading. The airplane crossed the coastline with illuminated homes and roadways clearly visible, but once over the water, the view in the windscreen was completely black with no discernable horizon. The attitude of the airplane could not be determined. For the final 25 seconds of the recording, the view remained completely black, while the sound of the engine was smooth and continuous until water contact. According to the Australian Transport Safety Bureau, “An overview of spatial disorientation as a factor in aviation accidents and incidents”: Types of spatial disorientation Three basic types of SD have been described, for the purposes of classification. These types are Type I (unrecognized), Type II (recognized) and Type III (incapacitating). Type I (unrecognized) In this form of disorientation, the pilot is unaware that they are disoriented or that they have lost situational awareness. The pilot, unaware of the problem, continues to fly the aircraft as normal. This is particularly dangerous, as the pilot will not take any appropriate corrective action, since they do not perceive that there is in fact a problem. The fully functioning aircraft is then flown into the ground, with often fatal results. This form of SD is clearly dangerous, and accounts for the majority of SD accidents and fatalities (Braithwaite et al., 1998b). ## Aircraft - Registration: [N266ND](https://openairdocs.org/deregistered/N266ND-2022-09-19), registration cancelled 2022-09-19, S/N 2842066, built 2000 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 (NO SERIES) - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2842066 - Year built: 2000 - Airframe hours: 16366 - Engines: Lycoming O-320-DG3 160 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: 2Fly Airborne - Registered owner: Euro 2000 Inc - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, January 7, 2021, 77.2 hours before - Departed: LNA, Lantana, FL - Destination: Merritt Island, FL - Flight plan: Company VFR - Airport: LNA, Palm Beach County Park, runway 10/28, 3,489 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: left; toxicology performed; flight hours: 190 total, 95 in this make and model, 101 in the last 90 days, 15 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 90° at 7 knots - Visibility: 10 statute miles - Temperature: 73 °F, dew point 66 °F - Altimeter: 30.11 inHg - Observed at: KPBI, 9 nm away - METAR: KPBI 250053Z 09007KT 10SM SCT020 SCT250 23/19 A3011 RMK AO2 SLP194 T02280189 $ ## 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 20210124001639A](https://openairdocs.org/incident/20210124001639A), Jan 24, 2021: Piper PA-28-161, Boynton Beach, FL, Destroyed, 1 fatal. Final summary During the investigation it was learned that the airman had limited night experience and only showed 6.4 hours of solo time in a Piper PA-28. The… ## Docket (12 files) The files NTSB released with the investigation on January 25, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102547. 19.7 MB in all. - Meteorology specialist's factual report (item 1, PDF, 8 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11924485&FileExtension=pdf&FileName=WX_ERA21LA111_Specialists_Factual-Rel.pdf - ATC specialists factual report (item 2, PDF, 5 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12846156&FileExtension=pdf&FileName=ERA21LA111%20-%20ATC%20Specialists%20Factual%20Report-Rel.pdf - ATC sr - attachment 1 - partial transcript (item 3, PDF, 2 pages, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12845763&FileExtension=pdf&FileName=ERA21LA111%20-%20ATC%20SR%20-%20Attachment%201%20-%20Patial%20Transcript-Rel.pdf - ATC sr - attachment 2 - ADS-B data (item 4, XLSX, 482 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12846507&FileExtension=xlsx&FileName=ERA21FA111%20-%20ATC%20Attachment%202%20-%20ADS-B%20Data-Rel.xlsx - Air traffic control accident package (excerpts) (item 5, PDF, 17 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14974506&FileExtension=pdf&FileName=ATC_N266ND_Package_excerpt_Redacted-Rel.pdf - FAA inspector's statement (item 6, PDF, 11 pages, 577 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12934334&FileExtension=pdf&FileName=Inspector%20Statement%20N266ND%20-%20Final_Redacted-Rel.pdf - Maintenance status report (item 7, PDF, 1 page, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12935014&FileExtension=pdf&FileName=N266ND%20MTX%20recent%20status%2001.24.21-Rel.pdf - Toxicological report (item 8, PDF, 1 page, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12934428&FileExtension=pdf&FileName=Pilot%20Tox_Redacted-Rel.pdf - Photo array (item 9, PDF, 3 pages, 11.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12935285&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Statement of party representatives to NTSB investigation Lycoming (item 10, PDF, 1 page, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12936189&FileExtension=pdf&FileName=Party%20Form%20Lycoming_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation Piper (item 11, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12982745&FileExtension=pdf&FileName=Signed%20Party%20Form%20Piper_Redacted-Rel.pdf - Image recorder summary - specialist's factual report (item 12, PDF, 3 pages, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14968244&FileExtension=pdf&FileName=Video_Factual-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.