MIA98FA239

NTSB accident investigation · Piper PA-44-180 · Daytona Beach, FL · September 7, 1998

Accident · FatalField investigationFinal report
Date
September 6, 1998, 23:23 local (Sep 7, 1998, 03:23 UTC)
Place
Daytona Beach, FL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N922ERPiper PA-44-180
Weather
Visual (VMC) · Night/bright
Status
Completed · report February 16, 2001
Report
Approved by Office Director
FAA report
19980906022839A
Case key
43893

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

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot's use of the aircraft to commit suicide.

Analysis

The pilot gained unauthorized access to the aircraft and departed the airport followed a short time later by a request to ATC for an ILS approach to runway 7 left. As the flight approached the runway it was observed at a high altitude and when questioned if he could get down and land, the pilot reported 'this will be my final landing.' Witnesses observed the aircraft fly over the end of the runway at about 600 feet and then descend in a nose low attitude until impact with the runway. Engine power was observed to go to full power as the aircraft descended. The pilot was observed to have consumed alcohol beverages prior to the accident and was found to have a alcohol level of .15 g/dl in the liver. The pilot left a note stating 'I do not want to live.' The Medical Examiners Office ruled the manner of death as suicide.

Factual narrative

The factual narrative1,290 words

History of the Flight

On September 6, 1998, about 2323 eastern daylight time, a Piper PA-44-180, N922ER, registered to Embry-Riddle Aeronautical University, crashed on runway 7 left at Daytona Beach International Airport, Daytona Beach, Florida, while on a Title 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The aircraft was destroyed and the commercial-rated pilot was fatally injured. The flight originated from Daytona Beach, the same day, about 2304.

Embry-Riddle Aeronautical University personnel stated the pilot was employed as a flight instructor. At 2249, the pilot attempted to use his issued key to gain access to the Embry-Riddle flight line. Due to the late hour, the security computer system would not allow him access. The pilot then climbed the 8-foot, barbed wire topped fence to the flight line and gained unauthorized access to N922ER.

At 2259:32, the pilot called the FAA Daytona Beach Control Tower and requested to taxi to the active runway for takeoff. The pilot was cleared to taxi to runway 7 left. The pilot of another Embry-Riddle aircraft observed the aircraft start taxiing from the ramp with one pilot, who was located in the right seat. At 2304:07, the pilot requested and was given takeoff clearance on runway 7 left. After takeoff the pilot flew east to the beach and then proceeded north along the beach. At 2308:52, when northeast of the airport, the pilot requested radar vectors for the instrument landing system (ILS) approach to runway 7 left. At 2316:50, the flight was cleared for the ILS 7 left approach and at 2318:13, the flight was cleared to land. At 2320:57, the FAA controller noticed the flight was at a higher than normal altitude on the approach and he asked the pilot if he would be able to "get down from there." The pilot replied, "and riddle nine two two roger this will be my final landing." The controller and witnesses observed the flight cross over the end of the runway at about 600 feet agl and then nose over and descend rapidly from which it collided with the runway in a nose down attitude. Witnesses located near the arrival end of the runway report hearing the engines go to full power as the aircraft started the descent.

Friends of the pilot stated after the accident that the pilot had been to a local restaurant and consumed alcoholic beverages. He was driven home about 2150. At 2220, the pilot obtained a note pad and returned to his bedroom. At 2235, the pilot left his apartment, stating he was going for a walk. He was not seen again. When the pilot's roommate was informed of the accident at about 0830 on September 7, 1998, he went into the pilot's room and found a note in which the pilot stated " I do not want to live."

Personnel Information

Information on the pilot is contained in this report under First Pilot Information and in attachments to this report.

Aircraft Information

Information on the aircraft is contained in this report under Aircraft Information and in attachments to this report.

Meteorological Information

Visual meteorological conditions prevailed at the time of the accident. The moon was at an altitude 27.8 degrees on a bearing of 117.1 degrees at the time of the accident. The moon had a 99 percent illumination. Additional meteorological information is contained in this report under Weather Information and in attachments to this report.

Wreckage and Impact Information

The aircraft crashed on the approach end of runway 7 left at Daytona Beach International Airport, Daytona Beach, Florida. Examination of the crash site showed the aircraft impacted the runway about 1,077 feet from the approach end of the runway. The initial impact point was to the left of the runway center line on about a 090-degree heading. The aircraft was in about a 30-40 degree nose down attitude at the time of impact. Slash marks were present in the runway surface from both propellers. The distance between the first two sets of slash marks from each propeller was about 41 inches. After impact the aircraft continued in a easterly direction, coming to rest about 850 feet from the initial impact point. General breakup of the aircraft occurred after initial impact and an explosion and fire occurred in both wing fuel tanks after impact.

All components of the aircraft which are necessary for flight were located on or around the main wreckage of the aircraft. Continuity of the aileron, rudder, stabilator, stabilator trim, and rudder trim flight control systems was established. All separation points within the flight control systems were consistent with overstress separation. The landing gear and wing flaps were in the retracted positions. The stabilator trim was set to 2 degrees tab down or aircraft nose up. The rudder trim system was damaged by impact forces and it could not be determined as to which position it was set to at the time of the accident.

Examination of the left engine and propeller showed the left propeller blades had damage consistent with rotation at a high engine power at the time of ground impact. The propeller separated from the engine during ground impact when the engine crankshaft propeller flange separated due to overstress. Examination of the engine showed the engine would not rotate due to impact damage. Disassembly of the engine confirmed continuity of the crankshaft, camshaft, valve train, and accessory drives. Each cylinder had the intake and exhaust valves in place and showed no signs of mechanical failure or malfunction. The left magneto separated from the engine during impact. The left magneto produced normal spark when rotated by hand. The right magneto was destroyed by impact forces. The spark plugs had deposit color consistent with normal engine operation. The carburetor was destroyed by impact forces. The propeller governor rotated and pumped oil when turned by hand.

Examination of the right engine and propeller showed the right propeller blades had damage consistent with rotation at a high engine power at the time of ground impact. The propeller separated from the engine during ground impact when the engine crankshaft propeller flange separated due to overstress. Examination of the engine showed the engine would not rotate due to impact damage. Removal of the cylinders allowed the engine to rotate. Continuity of the crankshaft, camshaft, and valve train was confirmed. Impact damage to the accessory drive section displaced the intermediate accessory drive gears which were not located or recovered. Examination of the crankshaft gear and camshaft showed no pre-impact damage. Each cylinder had the intake and exhaust valves in place and showed no signs of mechanical failure or malfunction. The left magneto separated from the engine during impact. The left magneto produced normal spark when rotated by hand. The right magneto was destroyed by impact forces. The spark plugs had deposit color consistent with normal engine operation. The carburetor and propeller governor were damaged by impact forces.

Examination of the left and right wing tip navigation lights and rear wing tip position lights showed each to have stretched light bulb filaments. Examination of the right front seat showed damage consistent with it being occupied at the time of the accident. The seat belt and shoulder harness were found unbuckled and without damage.

Medical and Pathological Information

Postmortem examination of the pilot was performed by Marie A. Herrmann, M.D., Associate Medical Examiner, Daytona Beach, Florida. The cause of death was attributed to multiple blunt force injuries. The manner of death was attributed to suicide.

Postmortem toxicology studies on specimens obtained from the pilot were performed by Bruce A. Goldberger, Ph.D., University of Florida, Gainesville, Florida, and Dennis V. Canfield, Ph.D., FAA Toxicology Laboratory, Oklahoma City, Oklahoma. The tests were positive for

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 collision with terrain/waterDescent
Terrain condition - runway
Suicide - intentionalPilot in commandCause

Aircraft

Registration
N922ER
Reported as
Piper PA-44-180
Category
Airplane
Serial number
4496009
Airframe hours
1,724
Engine
Lycoming O-360-A1H6, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Michael J. Nawrocki
Registered owner
Embry-Riddle Aero. Unv.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 31, 1998 · 4 hours before
Departed
DAB
Airport
DAB · Daytona Beach Int'L, runway 7L, 10,500 × 150 ft, asphalt

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
26
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Toxicology
Performed
Flight hours
984 total · 18 in this make and model · 883 as pilot in command · 171 in the last 90 days · 54 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/bright
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 79 °F
Altimeter
30.00 inHg
Observed at
DAB, 1 nm away

Docket · 36

The files NTSB released with the investigation on February 10, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.5 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 476 KBSupplement AItem 2 · .PDF · 268 KBSupplement BItem 3 · .PDF · 441 KBSupplement KItem 4 · .PDF · 435 KBWitness StatementsItem 5 · .PDF · 2.0 MBATC Controller StatementsItem 6 · .PDF · 179 KBTranscript of Radio CommunicationsItem 7 · .PDF · 125 KBReports from Federal Agencies: ATC InformationItem 8 · .PDF · 53 KBDaytona Beach International Airport Police Department ReportItem 9 · .PDF · 824 KBSheriff's Department ReportItem 10 · .PDF · 350 KBFire Department ReportItem 11 · .PDF · 150 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 12 · .PDF · 277 KBEmbry-Riddle Computer Gate LogItem 13 · .PDF · 88 KBWeather Reports and Records: Sun and Moon dataItem 14 · .PDF · 54 KBPropeller Slash AnalysisItem 15 · .PDF · 75 KBAircraft RecordsItem 16 · .PDF · 1.6 MBPilot RecordsItem 17 · .PDF · 1.6 MBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 530 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 79 KBToxicological ReportItem 20 · .PDF · 94 KBPhoto 1: View of initial impact point of N922ER on runway 7 left at Daytona Beach International Airport. View is to the east.Item 21 · .PDF · 118 KBPhoto 2: View of left engine propeller slash marks on runway.Item 22 · .PDF · 218 KBPhoto 3: View of right engine propeller slash marks on runway.Item 23 · .PDF · 215 KBPhoto 4: View from main wreckage down runway in direction aircraft came from.Item 24 · .PDF · 132 KBPhoto 5: View of main wreckage of N933ER.Item 25 · .PDF · 145 KBPhoto 6: Another view of main wreckage.Item 26 · .PDF · 121 KBPhoto 7: Another view of main wreckage.Item 27 · .PDF · 165 KBPhoto 8: Another view of main wreckage. Note landing gear retracted.Item 28 · .PDF · 200 KBPhoto 9: Another view of main wreckage.Item 29 · .PDF · 182 KBPhoto 10: View of nose area. Note nose gear is retracted.Item 30 · .PDF · 207 KBPhoto 11: View of left engine prior to disassembly. Note propeller flange separated from engine during impact.Item 31 · .PDF · 163 KBPhoto 12: View of right engine prior to disassembly. Note propeller flange separated from engine during impact. No negative.Item 32 · .PDF · 174 KBPhoto 13: View of left engine and propeller after disassembly.Item 33 · .PDF · 175 KBPhoto 14: View of right propeller after disassembly.Item 34 · .PDF · 165 KBPhoto 15: View of manifold pressure gauge and tachometer. No negative.Item 35 · .PDF · 163 KBPhoto 16: View of crushed right front seat tracks and seat.Item 36 · .PDF · 160 KB

FAA reports on this event · 1

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