MIA04FA100

NTSB accident investigation · Piper PA-23-250 · Baker, FL · June 21, 2004

Accident · FatalField investigationFinal report
Date
June 21, 2004, 13:59 local (18:59 UTC)
Place
Baker, FL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N54134Piper PA-23-250
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
New Piper Aircraft Company, Flight Standards District Office, Textron Lycoming Engines
FAA report
20040621010529A
Case key
59475

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 flight crew's inadvertent flight into thunderstorms resulting in the design limits of the airplane being exceeded, loss of aircraft control and subsequent in-flight breakup. A factor in the accident was the lack of required advisory by ATC about a radar displayed area of weather echoes.

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 weatherCruise
Weather condition - clouds
In flight weather avoidance assistance - not relayedAtc personnel(non-faa)Factor
Weather condition - thunderstorm
Flight into adverse weather - inadvertentFlightcrewCause
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in commandCause
Airframe - overload
Loss of control - in flightDescent - uncontrolled
Aircraft control - not possibleCause
On ground/water encounter with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The flight crew were on a flight from Marianna, Florida, to Lockhart, Texas when they encountered level 4 thunderstorms at about 8,000 feet altitude, in the vicinity of the Crestview (KCEW) VOR, near Baker, Florida and then they crashed. The wreckage was dispersed over an approximate nineteen-acre area to the left and right of a line drawn between the area where the last radar contact had occurred and the main wreckage site. The main wreckage site, which comprised of the fuselage, was located in a wooded area approximately 6.7 miles west of the Bob Sikes Airport, Crestview, FL. The overall debris path was approximately .4 miles long on a northwest heading and the initial pieces along the path were the vertical fin, rudder, and left aileron. There was no evidence of a post crash fire in the area of the main wreckage site or at any of the secondary locations and no evidence or any patterns like those typically associated with an in-flight fire were identified. Level 4 weather returns had been on either side of the airplane. The airplane was about 3.7 miles due west of KCEW, and had begun a right turn to a course of about 260 degrees. At 1357:40, the airplane was about 3.7 miles southeast of the Crestview VORTAC, at 8,000 feet, and on a course of about 285 degrees. The pilot of the accident airplane requested "a course of one eighty to the left for weather". North Approach replied "is that a one eight zero heading?" The pilot responded "one eight zero," and North Approach approved the request. The airplane was entering the eastern edge of an area of Level 4 returns. At 1358:01, the airplane began a descent and a turn to the left. The last radar target was received at 1358:54, about 53 seconds after initiation of the turn, and all radar returns in the area depicted Level 4 weather activity at the time when air traffic control (ATC) lost communications with the accident airplane. According to the North Approach Radar Controller, who was communicating with the airplane, his workload was moderate on the day of the accident, with about four or five aircraft and that he had been on position for about two to three minutes when the pilot contacted him. The controller stated that he would normally advise a pilot of observed weather returns, but did not do so for the accident airplane or other pilots in the same general area. He said he did not issue a weather advisory to the accident airplane because in his opinion, "the pilot was seeing everything out there [and] telling [me] what he needed to do". Examination of the airframe, engines and flight controls did not reveal any preaccident failures or malfunction to any airplane systems.

Factual narrative

History of flight

On June 21, 2004, about 1359 central daylight time, a Piper PA-23-250, N54134, registered to Mobo LLC, and operated by a private individual as a Title 14 CFR Part 91 personal flight, crashed in the vicinity of Baker, Florida. Visual meteorological conditions prevailed, there were thunderstorms in the area, and an instrument flight rules flight plan was filed. The airline transport-rated flight instructor/pilot-in-command and the private-rated pilot received fatal injuries, and the airplane was destroyed. The flight originated in Marianna, Florida, the same day, about 1300.

According to information obtained from the FAA, the pilot of N54134 had contacted the Gainesville, Florida, Automated Flight Service Station at 12:52, to file a instrument flight rules flight plan to Lockhart, TX. At the time he filed the flight plan, he reported having 6 hours of fuel onboard, and estimated his time en-route to be 3 hours and 30 minutes. The pilot did not request a weather briefing at that time, and records showed that he informed the weather briefer that he had already received a standard briefing, however no record of him having received a briefing was found.

Shortly after taking off from the Mariana Airport, N54134 was receiving air traffic control services from Cairns Radar Approach Control, Fort Rucker, Alabama. At 13:38:57, and prior to entering Eglin Air Force Base Radar Control Facility's (ERCF) airspace, the Cairns Approach controller called ERCF and advised the Coordinator that N54134 was deviating to the right of course for weather. The ERCF Coordinator acknowledged and advised the ERCF North Approach sector controller. Shortly afterward, the pilot of N54134 reported to North Approach "with you at eight thousand". The controller acknowledged. At this time, the airplane was about 38 miles east of the Crestview (KCEW) Very High Frequency Omnidirectional Range TACAN navigational aid (VORTAC), about 2 miles north of airway V198, and on a course of approximately 290 degrees.

At 13:45:41, the North Approach controller issued mutual traffic advisories to the flight crew of N54134, and a twin engine Cessna passing overhead. The airplanes were about 22 miles northeast of the KCEW VORTAC and about 25 miles northeast of the observed weather radar returns.

At 1348:31, the North Approach controller asked the crew of N54134 "how much farther are you going to go before you start your turn back on course?" The pilot replied, "I would say about ten more miles, sir. We got a bumper right in front of us". The airplane was about 19 miles northeast of KCEW, on a course of 290 at 8,000 feet. The area of observed weather returns extended from the KCEW VORTAC to the southwest.

At 1350:34, a pilot of N54134 said "I would like a block from eight...", with the remaining portion of the transmission being unintelligible due to a transmission from the pilot of another flight, and after repeating the request, and explaining that it was "for turbulence", the controller approved the request.

At 1351:53, North Approach controller, had an exchange of communications with the crew of a Sabreliner, and also at that time, the Eglin AF Auxiliary Field #3 Duke (EGI) tower controller reported lightning within five miles of the EGI airport. In addition, At this time N54134 was about 13 miles north east of the Crestview VORTAC, at 8,000 feet, and began a turn to the left. At 1352:11, the pilot of N54134 said he was "turning back to intercept".

At 1353:06, North Approach asked the pilot of N54134 "do you still need the block eight to nine thousand?" The pilot replied he did not, and North Approach cleared the pilot to maintain 8,000 feet. At this time the airplane was on a course of about 210 which would intercept airway V198 about 5.5 miles east of the Crestview VORTAC. The airplane was northeast of the Crestview VORTAC, and the observed weather echoes, by about 9 miles and the weather echoes had moved to the east of the Crestview VORTAC.

At 1355:48, the pilot of N54134, told North Approach "I'm going to have to maintain this heading for eight to ten more miles before turning back to [the Crestview VOR]". The airplane was less than one mile north of the centerline of V198, at 8,000 feet, about 5.5 miles east of the Crestview VORTAC, on a course of about 210 degrees. Radar data showed that the airplane was just entering the area of observed Levels 1 and 2 precipitation, with the heavier levels at the 1 o'clock and 10 o'clock positions about four to five miles away. North Approach acknowledged and instructed the pilot to advise when he could turn back on course.

At 1356:29, the North Approach Assist controller (NAA) called the Pensacola Terminal Radar Approach Control (TRACON) and advised the controller that N54134 was "six miles south of Crestview...deviating South for weather". The Pensacola controller said, "he's going to have to go all the way to the coast in your airspace to get around that weather". NAA replied "That's what we explained, that's what we're trying to tell him but we're going to vector him around it". The Pensacola controller acknowledged. The airplane was directly between the Crestview VORTAC and KCEW, at 8,000 feet on a course of 210 degrees. Level 4 weather returns were on either side of the airplane.

At 1357:00, the Pensacola controller said "Tell him everyone is going around north of that stuff". NAA replied, "We tried to tell him, he didn't want to listen. There's one born everyday". The airplane was about 3.7 miles due west of KCEW, and had begun a right turn to a course of about 260 degrees.

At 1357:40, the airplane was about 3.7 miles southeast of the Crestview VORTAC, at 8,000 feet, and on a course of about 285 degrees. The pilot of N54134 requested "a course of one eighty to the left for weather". North Approach replied "is that a one eight zero heading?" The pilot responded "one eight zero," and North Approach approved the request. The airplane was entering the eastern edge of an area of Level 4 returns.

At 1358:01, the airplane began a descent and a turn to the left. Radar indicated that the airplane had made a left descending turn of about 0.6 miles in diameter. The airplane turned more than 180 degrees in about 19 seconds, and the calculated vertical rate of mode C change exceeded 5,000 feet per minute. The last radar target was received at 1358:54, about 53 seconds after the initiation of the turn, at coordinates 30 42.19N 086 38.23W. Mode C altitude information on the last target was not received, and an "ident" bit was transmitted. All radar targets in the turn maneuver were in an area of depicted Level 4 weather returns.

At 1359:38, North Approach said "radar contact lost, report...say radial and DME (distance) off ah, Crestview VORTAC". No reply was received. North Approach continued to call to the pilot on available radio frequencies. North Approach, the North Approach Assist controller, the ERCF Coordinator, and the Supervisor phoned adjacent facilities and airports to attempt to locate the airplane. Other aircraft in the area were requested to assist, and the supervisor contacted the sheriff's department and highway patrol. At 1410, the sheriff reported the wreckage was located in Baker, Florida.

According to the North Approach Radar Controller, nothing was unusual about the weather or the volume of air traffic experienced on June 21. He said his workload was moderate with about four or five aircraft and that he was on position for about two to three minutes when the pilot of N54134 contacted him. The controller said that after he signed on to position, the coordinator controller advised him that N54134 was enroute from the east to the west, but was deviating to the north around weather. The controller further stated that he would normally advise a pilot of observed weather returns, but did not do

Aircraft

Registration
N54134
Reported as
Piper PA-23-250
Category
Airplane
Serial number
27-7405442
Airframe hours
5,057
Engines
Lycoming IO-540-C4B5, 250 horsepower, reciprocatingLycoming IO-540-C4B5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Robert Thomajan
Registered owner
Mobo LLC
Airworthiness certificate
Special, Restricted (Special); Standard, Normal
Last inspection
100 hour · December 11, 2003 · 65 hours before
Departed
MAI · Marianna, FL
Destination
50R · Lockhart, TX
Flight plan
IFR

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
261 total · 151 in this make and model · 148 as pilot in command · 48 in the last 90 days · 32 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Age
66
Injuries
Fatal
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
30,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 9 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 73 °F
Altimeter
29.92 inHg
Observed at
CEW, 8 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.