# NTSB MIA05FA024: Socata TB 20, N1905S, Key West, FL, November 5, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 4, 2004, 19:27 local (Nov 5, 2004, 00:27 UTC) - Place: Key West, FL - Coordinates: 24.485277, -81.790275 - Nearby events: https://openairdocs.org/map.md?lat=24.4853&lon=-81.7903&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 29, 2006 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office, Textron Lycoming, Socata Aircraft - NTSB case key (mKey): 60526 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA05FA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60526/pdf - Page: https://openairdocs.org/ntsb/MIA05FA024 ## Probable cause The pilot's failure to maintain aircraft control as a result of spatial disorientation. A related factor was the dark, night conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - light condition - dark night (contributing factor) - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The airplane departed with an IFR clearance from Runway 9, and after takeoff turned to a heading of 180 degrees and climbed to 1,900 feet. Approximately 25 seconds before the last radar target was recorded, the flight was cleared to turn right to a heading of 360 degrees. The recorded radar targets occurred every 12 seconds; there was no report of a failure or malfunction of the radar site at or after the last recorded radar target. There was no distress call made by the pilot. The airplane crashed into the Straits of Florida; the wreckage was located approximately .55 nautical mile and 278 degrees from the last recorded radar target. The fuselage and both wings were fragmented. No evidence of preimpact failure or malfunction was noted to the airframe, engine, or flight instruments. Additionally, no heat or fire damage was noted to any recovered piece of the wreckage. The airplane was equipped with a standby electrically controlled vacuum pump, and also a standby electrically operated attitude indicator installed on the co-pilot's side of the instrument panel. The pilot's and co-pilot's attitude indicators each powered by a separate source both depicted postaccident the airplane in a steep nose-down attitude and right bank angle of approximately 60 degrees. The turn coordinator also indicated a bank angle greater than standard rate. The tachometer and airspeed indications both exceeded maximum limitations. The instrument rated pilot had accumulated a total flight time of 829 hours, 16 hours of which were accumulated on the accident airplane from April to November of 2004. The pilot's most recent logbook could not be located and no information was obtained regarding the pilot's currency on flying by instruments. According to the aircraft logbook, a new engine-driven vacuum pump was installed in July 2003. Altimeter, automatic pressure altitude reporting system, and static pressure system inspections, as well as transponder inspections and tests due every 24 calendar months, were last recorded as occurring in October 2002. The airplane was scheduled for an annual inspection 4 days after the accident. Dark night conditions existed in the area where the airplane was lost from radar. ## Factual narrative HISTORY OF FLIGHT On November 4, 2004, about 1927 eastern standard time, a SOCATA TB 20, N1905S, registered to and operated by Megapede USA, Inc., crashed into the Straits of Florida approximately 5.13 statute miles and 199 degrees from the Key West International Airport, Key West, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight from Key West International Airport, to Sarasota/Bradenton International Airport, Sarasota, Florida. The airplane was destroyed by impact, and the private-rated pilot and one passenger were fatally injured. The flight originated about 1923, from Key West International Airport. According to a transcription of communications with Key West International Airport (KEYW) Air Traffic Control Tower (ATCT), the pilot established contact with the tower at 1915:29, and advised the controller that the aircraft was IFR, had ATIS information Delta, and was ready to taxi. The controller advised the pilot to taxi to runway 09, and cleared the flight to the destination airport as filed, to maintain 6,000 feet, and provided the departure frequency and discrete transponder code (0040). The pilot correctly repeated the IFR clearance then requested, "... will I be able to get a right turn out so that I can do a climbing circle over Key West." The controller advised the pilot that he was going to coordinate with approach control. At 1922:27, the pilot contacted the tower and advised the controller that the flight was ready for departure. At 1922:49, the controller cleared the flight for takeoff, which was acknowledged by the pilot. The controller advised Naval Air Station Key West approach control that the aircraft was, "... rolling", and, "... he's going southbound one eighty." At 1924:17, the tower controller advised the pilot to fly heading 180 degrees and to contact departure control. The pilot responded, "zero five sierra one eight zero on the heading departure." There was no further communications with the KEYW ATCT. According to a transcription of communications with the Naval Air Station Key West Air Traffic Control Facility (NAS ATCF), at 1924:28, the pilot established contact with the facility. The airplane was radar identified and the pilot was advised to continue heading 180 degrees. At the pilot's request, the controller repeated the instruction to fly heading 180 degrees. The pilot acknowledged the heading of 180 degrees. At 1925:15, the NAS ATCF controller asked the pilot the current heading to which he replied, "zero five sierra is on a heading of one eight zero." At 1926:36, the NAS ATCF controller advised the pilot to turn right heading 360 degrees and when able to proceed direct to Lee County VORTAC, which the pilot correctly read back. At 1928:47, the NAS ATCF controller advised the pilot that the facility was not receiving the transponder beacon return and to reset the transponder code to 0040; the pilot did not acknowledge this, and there were no further transmissions from the pilot of the accident airplane. At 1933:34, the NAS ATCF controller contacted the KEYW ATCT and asked the controller, "... do you see his code anywhere." The KEYW ATCT controller advised the NAS ATCF controller, "I do not see him out [there] flying anywhere." The controller made repeated broadcasts to the pilot of the accident airplane; the pilot did not respond. Review of NTSB obtained recorded radar data revealed that discrete transponder returns associated with the accident airplane while airborne were noted from 1924:01, when the airplane was at 100 feet mean sea level (msl), to 1927:01, when the airplane was at 1,900 feet msl. The recorded radar data depicts that after departing Key West International Airport to the east, the airplane banked to the right and flew in a southwesterly direction between approximately 1924:49, and 1925:13. The radar data then depicts the airplane flying in a southerly direction from 1925:25, to 1927:01, where the last recorded transponder return was located at 24 degrees 29.032 minutes North latitude and 081 degrees 46.242 minutes West longitude. The recorded radar targets occur every 12 seconds; a total of 16 radar targets with altitude depicted are noted. There was no record of a malfunction of the radar site at the time of or after the last radar target. PERSONNEL INFORMATION The pilot was the holder of a private pilot certificate with ratings airplane single-engine land and instrument airplane. A review of his airman file revealed he failed instrument approach procedures during his first attempt to obtain the instrument rating on September 12, 2000. He obtained his instrument rating the following day. He was issued a third class medical certificate on April 15, 2004, with the restriction "must wear corrective lenses." A review of the application for his last medical certificate revealed he listed a total flight time of 813 hours. A review of provided copies of the pilot's first two logbooks that began with his first logged flight in January 1982, and ends with his last logged flight in October 2001, revealed he logged a total time of 651.3 hours, and 39.4 hours night time. The logbooks did not reflect any actual instrument flight time logged, but he did log 51.2 hours simulated instrument time. The pilot's most recent pilot logbook was not located; therefore, no determination was made whether he was instrument current. As previously reported, the pilot indicated a total flight time of 813 hours on the April 15, 2004, application for his medical certificate. Information provided by the owner of the airplane revealed that from April 22, 2004, to the date of the accident, the accident pilot flew the airplane approximately 16 hours. Prior to the flight on the accident date from Sarasota to Key West, Florida, the accident pilot last flew the airplane on October 22, 2004. On October 14, 2004, the accident pilot flew the airplane a total of .93 hour, and in an e-mail from him to the airplane owner, reported performing "three full-stop night landings at SRQ." According to FAA records, the passenger did not hold any pilot certificate. Immediate relatives advised the NTSB that she would typically sit in the copilot seat during a flight. AIRCRAFT INFORMATION The airplane was manufactured in June 1999, by Socata Group Aerospatiale as model TB 20, and was designated serial number 1905. A U.S. standard airworthiness certificate was issued on July 13, 1999, and it was certificated in the normal category. The airplane was equipped with a Lycoming TIO-540-C4D5D engine rated at 250 horsepower at 2,575 rpm, and a Hartzell HC-C2YK-1BF constant speed propeller with F8477-4 propeller blades. The airplane was also equipped with a King KFC 150 2-axis autopilot system with altitude hold, and a backup electrically operated attitude indicator installed on the copilot's side of the instrument panel. An electrically operated standby vacuum pump was installed in accordance with Supplemental Type Certificate SA 7628SW on March 17, 2000. A review of the maintenance records revealed that on October 29, 2002, the altimeter and automatic pressure reporting and static system inspections and the transponder inspection were complied with. On July 8, 2003, the engine-driven vacuum pump was replaced, and on the same date the repaired propeller was installed. The airplane was last inspected in accordance with an annual inspection on November 28, 2003. The aircraft total time at that time was recorded to be 535.46 hours. The airplane had accumulated approximately 145 hours since the inspection at the time of the accident; the airplane total time at the time of the accident was approximately 681 hours. The airplane owner reported that he last flew the airplane on October 22nd and 23rd, 2004, on flights from Sarasota, Florida, to Gulfport, Mississippi (Gulfport), the ## Aircraft - Registration: [N1905S](https://openairdocs.org/deregistered/N1905S-2007-09-28), registration cancelled 2007-09-28, S/N 1905, built 1999 (OpenAirDocs) - Reported make and model: SOCATA TB 20 - Registry model: [Socata TB-20 TRINIDAD](https://openairdocs.org/model/socata-tb-20-trinidad) (registry code 8680695) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1905 - Airframe hours: 680.5 - Engines: Lycoming IO-540-C4D5D 250 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Marc Paquin - Registered owner: Megapede USA, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 2003, 145.04 hours before - Departed: KEYW, Key West, FL - Destination: KSRQ, Sarasota, FL - Flight plan: IFR - Airport: KEYW, Key West International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; flight hours: 829 total, 16 in this make and model ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 90° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: KEYW, 4 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 20041104027889A](https://openairdocs.org/incident/20041104027889A), Nov 4, 2004: Socata TB20TRINIDAD, Key West, FL, Destroyed, 2 fatal. (-23) On 11/04/2004 at approx. 0015Z N1905S a TB-20-20 trinidad contacted Key West (eyw) tower requesting an IFR clearance to sarasota, FL. The pilot requested… 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.