MIA03FA071

NTSB accident investigation · Piper PA-28R-201T · Cedar Key, FL · March 4, 2003

Accident · FatalField investigationFinal report
Date
March 3, 2003, 19:29 local (Mar 4, 2003, 00:29 UTC)
Place
Cedar Key, FL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6369CPiper PA-28R-201T
Weather
Instrument (IMC) · Night
Status
Completed · report April 28, 2005
Report
Approved by Office Director
Parties
Teledyne Continental Motors, The New Piper Aircraft, Inc., FAA FSDO
FAA report
20030304002519A
Case key
56584

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadequate in-flight planning/decision by his continued VFR flight into instrument meteorological condition after receiving an in-flight weather advisory. Also causal was his failure to maintain aircraft control, which resulted in flight that exceeded the design limits of the aircraft and resulted in an in-flight breakup. Contributing factors were the pilot's overconfidence in his personal ability, and the failure of the National Weather Service to issue an Airmet to identify IFR conditions for the area of the accident.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherDescent
Preflight briefing service - not obtainedPilot in command
Hazardous weather advisory - not issuedNws personnelFactor
In-flight briefing service - disregardedPilot in commandCause
Weather condition - rain
Overconfidence in personal abilityPilot in commandFactor
Vfr flight into imc - continuedPilot in commandCause
Loss of control - in flightDescent
Aircraft control - not maintainedPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - water

Analysis

The flight experienced an in-flight breakup during a VFR flight into instrument meteorological conditions. The pilot did not obtain a preflight weather briefing before departure but he did obtain three in-flight weather briefings from the Miami Automated Flight Service Station. During one of the briefings he was provided information about the location of a front that existed along the intended route of flight. About 32 minutes before the accident, the non-instrument rated pilot advised the controller that he was flying in the clouds and was trying to maintain VFR. The pilot was asked if he wanted to obtain an IFR clearance and asked for assistance to avoid the clouds several times; he was advised what radar could and could not depict. About 1 minute before the accident, the controller advised the pilot that he was depicting a heavy weather echo at his twelve o'clock position and 2.5 miles. The pilot responded by stating that he needed assistance. The controller provided a heading for the pilot to fly but the pilot did not acknowledge that transmission. The controller then advised on the frequency for the pilot not to turn that tight and to level the wings. That transmission was also not acknowledged by the pilot. Recorded radar data shows the aircraft descended from 12,600 feet to 8,800 feet MSL, before the flight path entered an area of depicted weather echoes. The flight subsequently went into a left descending turn, reaching a descent rate in excess of 5000 feet per minute. Post-accident examination of the aircraft did not reveal evidence of mechanical malfunction. Review of the pilot's logbook revealed he logged 15 hours actual instrument flight time on 34 flights as pilot-in-command (PIC); the entries for these flights did not contain a signature by a certified flight instructor or safety pilot. He also logged actual instrument flight time as PIC before receiving his private pilot certificate. In the area and time of the accident, no SIGMET's, Convective SIGMET's, or Center Weather Advisories were in effect. The pilot's medical was expired at the time of the accident.

Factual narrative

History of flight

On March 3, 2003, about 1929 eastern standard time, a Piper PA-28R-201T, N6369C, registered to Cherry Hill Aviation, Inc., was lost from radar and radio contact with Jacksonville Air Route Traffic Control Center and crashed in the Gulf of Mexico near Cedar Key, Florida. Instrument meteorological conditions prevailed in the area at the time and no flight plan was filed for the 14 CFR Part 91 personal flight from Key West International Airport, Key West, Florida, to Tallahassee Regional Airport (KTLH), Tallahassee, Florida. The airplane was destroyed and the private-rated pilot and one passenger were fatally injured. The flight originated about 1733, from Key West International Airport.

After takeoff, air traffic control communications (ATC) were transferred to several air traffic control facilities including Miami Air Route Traffic Control Center (Miami ARTCC), Southwest Florida International Airport Air Traffic Control Tower (KRSW ATCT), and Jacksonville Air Route Traffic Control Center (Jacksonville ARTCC). Before establishing ATC communications with the KRSW ATCT, the pilot contacted the Miami Automated Flight Service Station En Route Flight Advisory Service (Miami AFSS EFAS), and was provided in part AIRMET, SIGMET, rain and thunderstorm information. The pilot established contact with the KRSW ATCT at approximately 1807, and while in contact with that facility, the pilot inquired about the weather conditions ahead to which he was advised of the limitations of the radar and that the only weather observed was located northeast of his position. The flight continued and ATC communications were transferred to the Miami ARTCC. While in contact with the R24 sector controller of that facility, the pilot advised the controller that he observed "buildups" that were located 70-80 miles ahead and questioned the best route by asking whether he needed to "...go ahead and make a turn inland now or ah if it looks like we will be alright." The controller replied, "ah there’s a big front it its ah covering the whole pan handle...." The pilot responded, "ok roger that um how’s it looking out ah on the in the gulf is it worse in the gulf or is it better over land." The controller replied, "it is a big long front that is extending out into the gulf and up towards new york." The pilot acknowledged the comment from the controller who then advised the pilot that the Federal Aviation Administration (FAA) Flight Service Station might have more information. The pilot requested to go off frequency for a period of time which was acknowledged by the controller. At approximately 1821, the pilot established contact again with the Miami AFSS EFAS and obtained pilot reports. The pilot re-established contact with the Miami ARTCC R24 sector controller, and ATC communications were then transferred to the R7 sector controller, then to the R8 sector controller of the Miami ARTCC.

While in contact with the Sector 8 controller, the pilot was advised by the controller, "...i am depicting some uh weather in the vicinity of tampa but I believe that's mainly at high altitude." The pilot reported, "ah roger that ah we are looking at some ah buildups up ahead it looks um if we kinda headed (garbled area of transmission) direct um tampa at this time um we might ah kinda go through it is that not accurate" The controller advised the pilot that the transmission from him was garbled and requested the pilot repeat his question. The pilot advised the controller that he was turning to a heading of 345 degrees which looked to him to fly between "...a couple of ah larger buildups is that ah are you painting that same picture." The controller replied, "yeah that looks like about just to the west of ah saint Petersburg about 3 miles or so", which the pilot acknowledged. The controller then advised the pilot that the higher intensity weather was located at higher altitudes, and if he needed anything different to let him know. The pilot then advised the controller that he would stay on a heading of 345 degrees, which was acknowledged by the controller. The pilot then contacted the controller and advised that, "...we are just ah coming up on some of these ah overcast buildups (portion unreadable) and want to ah check and see how its looking out there in front of us if ah it looks like its going to be fairly broken or ah if we need to get on down." The controller questioned if the pilot wanted to contact Flight Watch to which he replied, "ah yeah unless um unless you can tell us what you're painting there ah we'll be glad to ah check flight watch." The controller advised the pilot he was, "...welcome to check flight watch in addition to ah im showing ah a couple of cells ah but like I said that all appears to be high altitude it looks like from your present position a heading of about 310 or about 010 will keep you clear to the big stuff." The pilot replied that he wanted to be sure that he was not getting into too many overcast areas, was going to stay on a heading of 345 degrees, there was buildups to his left, and then he would be able to make a turn for Tallahassee. The controller did not acknowledge that transmission and ATC communications were then transferred to Jacksonville Air Route Traffic Control Center (Jacksonville ARTCC).

The pilot established contact with the Jacksonville ARTCC at 1855:10, and advised the controller that the flight was at "twelve five." The controller acknowledged that transmission and provided the pilot with an altimeter setting. The pilot then questioned the controller as to what type of weather his radar was depicting to which the controller responded that between his present position and Tallahassee, "...not that much some stuff off your ten o'clock and about 40 miles but looks like its not in your flight path right now." The pilot questioned the controller if he was depicting any cloud cover between his position and Tallahassee to which the controller responded, "i don't paint that uh all i paint is heavy [precipitation] on my radar...." At 1856:53, the non-instrumented rated pilot advised the controller, "...we are in a little bit of clouds here and uh trying to uh maintain vfr." At 1857:09, the controller questioned the pilot if he wanted to obtain an instrument flight rules clearance to which he responded, "well we'll uh give it just a second here"; the controller did not respond. At 1903:38, the pilot contacted the controller and questioned if a 336 heading would keep the flight out of, "...most of the weather." The controller questioned the pilot if wanted to stay "...vfr" and fly heading 336 to which the pilot replied, "...we're picking our way through it pretty good didn't want to make sure we're running ourselves into some little hole up ahead of us." The controller advised the pilot that weather radar does not depict "cloud cover", that VFR or IFR was available to him, and that if he continued VFR he would point out traffic to him. The pilot advised the controller that, "...we got a little uh reliability problem with ah with one of our instruments this afternoon so we're going to do our best to stay out of the ifr"; the controller did not acknowledge that transmission. At 1904:56, the pilot advised the controller that he would like to go to flight watch which the controller approved.

At 1905:06, the pilot contacted Miami AFSS EFAS and questioned what the weather radar depicted between his present position (approximately 30 miles northwest of Tampa International Airport), and Tallahassee. The briefing specialist advised the pilot that based on his position report the airplane appeared to be in an area of heavy rain showers and asked the pilot if he was encountering any precipitation. The pilot responded negative bit he did report some buildups to his left with scattered heavy cloud cover. The briefing specialist advised the pilot to expect continuous rain showers off an on for his route of flight with "activity" moving from

Aircraft

Registration
N6369C
Reported as
Piper PA-28R-201T
Category
Airplane
Serial number
28R-7803222
Engine
Continental TSIO-360-FB, 200 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Augustus R. Winchester
Registered owner
Cherry Hill Aviation, Inc.
Airworthiness certificate
Standard, Normal
Departed
KEYW · Key West, FL
Destination
KTLH · Talllahassee, FL

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
36
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Expired
Toxicology
Performed
Flight hours
682 total · 616 in this make and model · 646 as pilot in command

Weather

Conditions
Instrument (IMC) · Night
Wind
100° at 3 knots
Temperature
54 °F, dew point 52 °F
Altimeter
30.01 inHg
Observed at
KCTY

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.