# NTSB MIA06LA106: Piper PA-23-250, N5033Y, Caribbean Sea, May 10, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: May 10, 2006, 19:30 local (23:30 UTC) - Place: Caribbean Sea - Coordinates: 18.033332, -65.900001 - Nearby events: https://openairdocs.org/map.md?lat=18.0333&lon=-65.9000&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 20, 2007 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 63695 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA06LA106 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63695/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63695 - Page: https://openairdocs.org/ntsb/MIA06LA106 ## Probable cause The failure of the pilot to maintain control of the airplane. A contributing factor in the accident was the spatial disorientation of the pilot, resulting in the in-flight loss of control. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - spatial disorientation, pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The instrument rated pilot departed VFR approximately 1 minute after the end of civil twilight, and approximately 9 minutes after departure, the pilot contacted San Juan CERAP and requested flight following to the destination airport. The controller advised the pilot to resume own navigation, and approximately 12 minutes after takeoff, the pilot advised the controller, "San Juan Approach ah, 5033Y ah I'm kinda lost ah I lost my bearing out here I need direct." The controller provided a heading of 140 degrees, which the pilot acknowledged; however, the recorded radar data indicates the airplane flew a south-southwesterly heading for approximately 2 minutes 21 seconds, and the flight descended to 1,600 feet. The remainder of the recorded radar data indicates that the heading and altitude changed numerous times, with the lowest recorded altitude being 300 feet. The controller then attempted to have the pilot proceed to the departure airport, but he did not acknowledge the transmission from the controller. The last recorded radar target indicated the airplane was at 2,000 feet, and was located at 17 degrees 57 minutes 41 seconds North latitude and 064 degrees 59 minutes 04 seconds West longitude. A search for the occupants and wreckage was performed by the U.S. Coast Guard; no debris or bodies was ever recovered. Level 1-4 showers had occurred over the Caribbean Sea between the departure and destination airports during the hour prior to departure, but there was no significant echoes along the airplane's flight route while airborne. Additionally, low-level clouds resulting from the previous precipitation was probably in the area. ## Factual narrative HISTORY OF FLIGHT On May 10, 2006, about 1930 eastern daylight time (EDT), a Piper PA-23-250, N5033Y, registered to and operated by a private individual, was lost from radio and radar contact while over the Caribbean Sea approximately 18 miles south-southeast from Cyril E. King Airport (TIST), Charlotte Amalie, St. Thomas, U.S.V.I. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight from TIST to Henry E. Rohlsen Airport (TISX), Christiansted, St. Croix, U.S.V.I. The airplane is presumed destroyed and the commercial-rated pilot, and 1 passenger are presumed to be fatally injured. The flight originated about 1908, from TIST. The flight departed from runway 28, and proceeded south of TIST. NTSB review of recorded two-way communications between the pilot and San Juan Combined Enroute Approach Control (San Juan CERAP) facility revealed that at approximately 1916:21, the pilot contacted the facility and provided the registration and airplane's altitude. There was no reply from the facility. At approximately 1917:19, the pilot again contacted the San Juan CERAP facility and provided the airplane's registration. At approximately 1917:23, the controller advised the pilot that the flight was radar identified, and to resume his own navigation. The controller also advised the pilot that automated terminal information service (ATIS) "Papa" was current at TISX, and provided an altimeter setting of 29.93 inHg. The pilot acknowledged the altimeter setting, and requested flight following. The controller acknowledged the pilot's request, and again advised him to resume his own navigation to TISX. At approximately 1919:47, the pilot again contacted the San Juan CERAP facility and provided the airplane's call sign. The controller acknowledged the pilot, and at approximately 1919:51, the pilot contacted San Juan CERAP and advised the controller, "San Juan Approach ah, 5033Y ah I'm kinda lost ah I lost my bearing out here I need direct." The controller asked the pilot if he wanted to proceed to St. Croix; he responded yes. At approximately 1920:01, the controller advised the pilot to turn to heading 140 degrees, which the pilot acknowledged. At approximately 1920:45, the controller questioned the pilot about the altitude, and advised him that the minimum vectoring altitude (MVA) in that area was 1,500 feet. The pilot did not acknowledge that transmission. The controller attempted numerous times to establish contact with the pilot; he did not reply. Further review of recorded two-way communications between the pilot and San Juan CERAP revealed at approximately 1921:34, the controller advised the pilot to "ident." At approximately 1921:44, the controller advised the pilot that he was receiving his transmitter, and to fly heading 150 degrees for a vector towards TISX. The controller also advised the pilot that the minimum vectoring altitude in that area was 1,500 feet, and the controller suggested he climb "a little bit." The pilot did not acknowledge that transmission. At approximately 1922:25, the controller advised the pilot to fly heading 160 degrees and to ident. The controller then immediately repeated the instruction to ident; the pilot did not reply. The controller repeated attempted to communicate with the pilot and asked him to ident; there was no reply from the pilot. At approximately 2323:57, the pilot contacted San Juan CERAP and advised the controller that apparently his transponder was not working. The controller advised the pilot that he could hear him loud and clear, and to turn right to heading 190 degrees for a vector towards TISX; the pilot did not acknowledge that transmission. At approximately 1924:06, the controller repeatedly attempted to communicate with the pilot; there was no response. The controller also established contact with the departure and destination airports air traffic control towers to see if the pilot had contact them; each replied the pilot had not contacted them. At approximately 1926:11, the controller broadcast in the blind on the frequency for the pilot and advised him to fly heading 350 degrees for a vector towards TIST; the pilot did not reply. The controller repeated numerous times for the pilot to fly heading 350 degrees for a heading to TIST; there was no reply. At approximately 1927:22, the controller asked the flightcrew of another airplane to establish contact with the pilot; there was no recorded reply. At approximately 1928:54, the controller broadcast on guard frequency 121.5; there was no reply. At approximately 1928:24; the flightcrew of the assisting airplane asked the controller if the airplane could be seen on the controller's radar screen. The controller replied he did not. A transcription of communications was not prepared. NTSB review San Juan CERAP recorded radar data for discrete transponder code assigned to the airplane (4714) revealed the first radar return with altitude occurred at 1909:37. The airplane at that time was at 100 feet, and was located near the approach end of runway 28. The radar data indicates that the flight continued on a westerly heading climbing to 500 feet, then made a left climbing turn. The airplane climbed to 2,600 feet, and turned to a heading of approximately 085 degrees, which occurred at 1914:19. At that time the airplane was located at 18 degrees 14 minutes 37 seconds North longitude and 064 degrees 55 minutes 57 seconds West longitude. The recorded radar data indicates that the airplane turned to the right flying on southwesterly heading, and descended to approximately 2,100 feet. The radar data further indicates that from 1917:19, to 1919:01, the heading changed from 200 to 223 degrees, and the airplane descended to 1,800 feet. Between 1919:01, and 1919:53, the heading changed from 223 degrees to 199 degrees. Between 1920:03, to 1922:24, the airplane proceeded on a south-southwesterly heading and descended to 1,600 feet. Between 1922:24, to 1924:35, the airplane turned right and the heading changed from 221 degrees to 292 degrees. During that time the flight descended from 1,600 to 600 feet. Further review of recorded radar data revealed that between 1924:35, to 1924:49, the heading changed from 292 degrees to 344 degrees, and the airplane descended from 600 to 300 feet. Between 1924:49, to 1925:50, the heading changed to the right from 344 degrees to 137 degrees, and the altitude increased from 300 to 600 feet. Between 1925:50, and 1926:51, the heading changed from 137 degrees to 058 degrees, and there was no altitude display. Between 1926:51, and 1927:57, the heading changed from 058 degrees to 093 degrees; there was no altitude display. Between 1927:57, and 1928:53, the altitude increased to 1,900 feet, and the heading changed from 093 degrees to 118 degrees. Between 1928:53, and 1929:17, the altitude increased from 1,900 to 2,200, and the heading changed from 118 degrees to 103 degrees. Between 1919:17, to 1929:31, the heading changed from 103 degrees to 104 degrees, and the altitude decreased from 2,200 to 2,000 feet. The last recorded radar target with altitude readout occurred at 1929:31. The airplane at that time was at 2,000 feet, and was located at 17 degrees 57 minutes 41 seconds North latitude and 064 degrees 59 minutes 04 seconds West longitude. A search for the occupants and wreckage was performed by the U.S. Coast Guard (Coast Guard) and Civil Air Patrol (CAP); no wreckage/debris, nor occupants were located. The Coast Guard suspended the search on May 12, 2006, at 1845 EDT. PERSONNEL INFORMATION The pilot was the holder of a commercial pilot certificate with airplane multi-engine land, and instrument airplane ratings. He was also the holder of a private pilot certificate with airplane single engine land rating. No pilot logbook was located; therefore, no determination was made as to his night or instrument recen ## Aircraft - Registration: [N5033Y](https://openairdocs.org/deregistered/N5033Y-2013-03-19), registration cancelled 2013-03-19, S/N 27-2039, built 1962 (OpenAirDocs) - Reported make and model: Piper PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 27-2039 - Airframe hours: 3313 - Engines: Lycoming IO-540-G1A5 290 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Victor A. Tuitt - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2006 - Departed: TIST, St. Thomas - Destination: TISX, St. Croix ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; commercial, private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 1, 2005; flight hours: 350 total ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 100° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Altimeter: 29.95 inHg - Observed at: TISX ## Docket (6 files) The files NTSB released with the investigation on December 7, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63695. 3.4 MB in all. - Supplement S (item 1, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285161&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Weather Reports and Records (item 2, .PDF, 694 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285162&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Statement from Dave Hollaway (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285164&FileExtension=.PDF&FileName=Statement%20from%20Dave%20Hollaway-Redacted.PDF - Radar Data (item 4, .PDF, 625 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285165&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Maintenance Records (item 5, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285650&FileExtension=.PDF&FileName=Maintenance%20Records-Redacted.PDF - ATC Audio segment, San Juan Combined Enroute ATC Audio segment, San Juan Combined Enroute Approach Control, in MP3 format (item 6, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40285682&FileExtension=.PDF&FileName=ATC%20Audio%20segment,%20San%20Juan%20Combined%20Enroute%20ATC%20Audio%20segment,%20San%20Juan%20Combined%20Enroute%20Approach%20Control,%20in%20MP3%20format-Master.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.