# NTSB FTW98FA170: Piper PA-28-235, N21LL, New Orleans, LA, April 3, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 2, 1998, 22:32 local (Apr 3, 1998, 04:32 UTC) - Place: New Orleans, LA - Location: 29.9546° N, 90.0751° W: Placed by OpenAirDocs: center of New Orleans, LA, within about 7 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=29.9546&lon=-90.0751&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 1 minor - Status: Completed, report September 28, 1999 - Report: Approved by Office Director - NTSB case key (mKey): 20411 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW98FA170 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20411/pdf - Page: https://openairdocs.org/ntsb/FTW98FA170 ## Probable cause The pilot's inability to maintain control of the airplane after experiencing spatial disorientation. Factors were the total failure of the vacuum pump, fog, drizzle, and night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, approach - engine accessories,vacuum pump - failure,total (cause) - flight/nav instruments,attitude indicator - inoperative - flight/nav instruments,directional gyro - inoperative - Loss of control - in flight, approach - weather condition - fog - weather condition - drizzle/mist - light condition - night - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The airplane impacted a lake following an uncontrolled descent after the pilot experienced spatial disorientation at night. The pilot was an instrument approach to runway 18R when he reported to air traffic control that he had a 'full failure;'. One minute later he reported a 'static failure,' and shortly afterwards he stated that the 'DG' was out of order. Air traffic control then lost radio and radar contact with the airplane. The controller who was tracking the airplane stated that it appeared as if the airplane was 'going around in circles,' just before it disappeared from the radar scope. A survivor was rescued from the lake the following morning and reported that the pilot tapped on the instrument 'with the blue horizon' and stated that 'this instrument is not working.' A post-accident examination of the vacuum pump, by the NTSB Materials Laboratory, revealed that the vacuum pump failed in-flight. Post accident examination of the electrically driven turn coordinator did not produce sufficient evidence to determine whether or not it was functioning at impact. ## Factual narrative HISTORY OF FLIGHT On April 2, 1998, at 2232 central standard time, a Piper PA-28-235 single engine airplane, N21LL, was destroyed when it impacted Lake Pontchartrain during an uncontrolled descent, near New Orleans, Louisiana. The airplane was owned by Altair Aviation Inc., and operated by North American Flight Academy of Denton, Texas. The instrument rated commercial pilot and two passengers sustained fatal injuries. One passenger received minor injuries. Night instrument meteorological conditions prevailed for the Title 14 CFR Part 91 flight, for which an IFR flight plan was filed. The personal cross country flight originated from the Denton Municipal Airport, Denton, Texas, at 1855. On April 2, 1998, at 2225, N21LL accepted a clearance from New Orleans Approach Control for the ILS runway 18R approach at the Lakefront Airport, New Orleans, Louisiana. Subsequently, at 2228, the pilot reported to New Orleans Approach Control that he had a "full failure." One minute later the pilot stated that he had a "static failure," and at 2230 he stated that his "DG" was "out of order." At 2231, New Orleans Approach Control lost radio contact with N21LL. At 2232, New Orleans Approach Control lost radar contact with N21LL. The last radar return showed the airplane at 800 feet above Lake Pontchartrain. The controller who was tracking N21LL stated that it appeared as if the airplane was "going around in circles" at the time the airplane disappeared from the radar scope. Search and rescue teams reported that the airplane came to rest on the bottom of Lake Pontchartrain, which is between 15 and 20 feet deep, in an inverted position On April 3, 1998, approximately 1030, a survivor was rescued from the lake 3 miles from Goose Point, Lacombe, Louisiana. The survivor reported that the flight's destination was the Lakefront Airport, New Orleans, Louisiana. She stated that the flight was normal until "late" in the flight when the pilot tapped on the instrument "with the blue horizon" and stated that it was "not working." PERSONNEL INFORMATION The pilot held a valid second class medical certificate, dated May 23, 1997. According to the medical application he had accumulated a total of 300 flight hours. A renter information form was provided by the operator. The form was signed by the pilot in September of 1996, although the only aircraft check-out recorded on the sheet occurred on April 2, 1998. The form indicated that the pilot had accumulated a total of 202 flight hours, of which 30 hours were in complex type airplanes. Additionally, the form stated that the pilot had completed a biennial flight review in August of 1997. According to a family member the pilot had accumulated a total of approximately 450 flight hours. On September 9, 1997, the pilot obtained a commercial pilot certificate. The certificate indicated that the pilot held single-engine land, multi-engine land, and instrument ratings. Attempts to locate the pilots flight logbook, to verify instrument and night flight time, were unsuccessful. The surviving passenger, who was seated in the left rear seat, stated that the purpose of the flight was for her daughter to visit the Tulane University in Louisiana, where she was a prospective student. The surviving passengers daughter, who sustained fatal injuries, was seated in the right front seat. The passenger seated in the right rear seat, who sustained fatal injuries, was an alumni of the Tulane University, and was going to accompany the mother and daughter during their tour of the university. AIRCRAFT INFORMATION The yellow and green, 1969 Piper PA-28-235, serial number 28-11235, underwent an annual inspection on March 4, 1998, and had accumulated a total of 3,503.32 hours at the time of the accident. The last altimeter and static check (as required by 14 CFR Part 91.411) was performed on December 8, 1997. The airplane was powered by a 235-horsepower Lycoming O-540-B4B5 engine. The engine had accumulated a total of 1,602.6 hours since major overhaul, as of March 4, 1998. Additionally, the airplane was equipped with a Hartzell model number HC-C2YK-1BF, two bladed, constant speed propeller. The airplane was equipped with an engine driven dry air pressure vacuum pump. The vacuum pump provided power to the directional gyro (heading indicator) and the artificial horizon (attitude indicator). The vacuum pump was an Airborne model number 211CC, serial number 7J4527. According to the aircraft logbook, the pump was installed on the engine on September 27, 1982, and had accumulated a total of 1,241.5 hours at the time of the accident. Additionally, the vacuum system was not equipped with a backup power source. METEOROLOGICAL INFORMATION On April 2, 1998, at 1907, the pilot received a standard IFR weather briefing and filed an IFR flight plan for a flight from Denton, Texas, to the Lakefront Airport, New Orleans, Louisiana, with the Fort Worth Flight Service Station. At 2226, a pilot, who executed the ILS runway 18R approach at the Lakefront Airport, reported that he broke out of the cloud layer while descending through 700 feet. At 2230, a pilot, who was in the vicinity of the airport, reported that the cloud tops were "about eight [or] nine thousand [feet]." At 2251, approximately 19 minutes after the accident occurred, the weather observation facility located at the Lakefront Airport recorded the following conditions: winds from 160 degrees at 8 knots, visibility 3 miles, light rain and mist(fog), ceiling 600 feet broken, 1500 feet overcast, temperature 73 degrees Fahrenheit and dewpoint 72 degrees Fahrenheit. The remarks portion of the sequence report stated: ceiling 500 feet variable 800 feet. At 2253, approximately 21 minutes after the accident occurred, the weather observation facility located at the New Orleans International Airport (Moisant Field), located approximately 15 nautical miles southwest of the accident site, recorded the following conditions: winds from 160 degrees at 8 knots, visibility 2 miles, light rain and mist(fog), ceiling 600 feet broken, 1,500 feet overcast, temperature 73 degrees Fahrenheit and dewpoint 72 degrees Fahrenheit. The remarks portion of the sequence report stated: surface visibility 3 miles. COMMUNICATIONS The following times and accounts were extracted from an FAA certified transcript of radio communications between New Orleans Approach Control and the pilot of N21LL. 2225:03: N21LL was cleared for the ILS runway 18R approach at the Lakefront Airport. The pilot acknowledged the clearance and was then informed by the controller that the airplane which had just executed the ILS 18R approach broke out at seven hundred feet. 2228:02: The controller asked N21LL if the airplane was established on the localizer, and the pilot responded, "negative." The controller stated that the approach clearance was cancelled and instructed the pilot to fly a heading of 270 degrees and maintain an altitude of two thousand feet. 2228:20: The pilot of N21LL stated "Mam, I have a full failure at this time and I'm climbing straight up, I hope." 2229:15: The pilot of N21LL stated "I'm just trying to keep this thing straight up, I'm having a static failure." 2230:06: The pilot of N21LL stated "Turning to a heading of two seven zero degrees and my DG is out of order." 2231:25: The pilot of N21LL reported that the airplane was "crashing." Multiple attempts by the controller at New Orleans Approach Control to contact the pilot were unsuccessful. See the attached FAA certified radio communications transcript for additional details. RADAR According to radar data provided by the New Orleans Air Traffic Control Facility, the last image of the aircraft was observed at 800 feet, North 30 degrees 13.70 minutes Latitude and West 090 degrees 01.00 minutes Longitude, approximately 8 miles north of the Lakefront Ai ## Aircraft - Registration: [N21LL](https://openairdocs.org/deregistered/N21LL-1998-12-09), registration cancelled 1998-12-09, S/N 2811235 (OpenAirDocs) - Reported make and model: Piper PA-28-235 - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Category: Airplane - Serial number: 28-11235 - Airframe hours: 3503 - Engines: Lycoming O-540-B4B5 235 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: North American Flight Academy - Registered owner: Altair Aviation Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 4, 1998, 31 hours before - Departed: DTO, DENTON, TX - Destination: NEW, LAKEFRONT, LA - Flight plan: IFR - Airport: NEW, Lakefront Airport, runway 18R, 6,879 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 300 total, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 160° at 8 knots - Visibility: 3 statute miles - Lowest ceiling: 600 ft broken - Temperature: 73 °F, dew point 72 °F - Altimeter: 29.00 inHg - Observed at: NEW, 13 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 19980402039069A](https://openairdocs.org/incident/19980402039069A), Apr 2, 1998: Piper PA28235, New Orleans, LA, Destroyed, 3 fatal. The airplane impacted a lake following an uncontrolled descent after the pilot experienced spatial disorientation at night. At 2228 the pilot reported to air… 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.