NYC08FA148

NTSB accident investigation · Piper PA 28-161 · Venice, FL · March 25, 2008

Accident · FatalField investigationFinal report
Date
March 24, 2008, 20:40 local (Mar 25, 2008, 00:40 UTC)
Place
Venice, FL
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N465TCPiper PA 28-161
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Night
Status
Completed · report November 10, 2008
Report
Approved by Office Director
Parties
Piper Aircraft, Lycoming Engines, FAA/FSDO
FAA report
20080324836959A
Case key
67719

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 pilot's inflight loss of control for undetermined reasons.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-28-161: 14 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane departed the coastal airport on a dark night, and turned over open water, in a left traffic pattern for runway 31. During the initial climb, on a mid-field downwind leg for the runway, the airplane departed controlled flight and impacted the water. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The vacuum pump vanes were intact; however, the entire vacuum system could not be tested due to impact damage. During a previous flight, another pilot noted an error with the accident airplane's directional gyro (DG). Specifically, the DG moved approximately 10 degrees off for every 5 or 10 minutes of time that elapsed. The unit was replaced and the other pilot noted a DG error on a subsequent flight; however, it was not as bad as the previous flight. The National Transportation Safety Board received no other reports of the DG error. The accident pilot had approximately 4,000 hours of total flight experience and 2 hours of total flight time in 90 days prior to the accident flight.

Factual narrative

History of flight

On March 24, 2008, about 2040 eastern daylight time, a Piper PA-28-161, N465TC, was substantially damaged when it impacted water, shortly after takeoff from Venice Municipal Airport (VNC), Venice, Florida. The certificated commercial pilot was fatally injured. Night visual meteorological conditions prevailed and no flight plan was filed for the local personal flight conducted under 14 Code of Federal Regulations Part 91.

According to the president of a fixed based operator (FBO) at VNC, the pilot had recently completed a "check out" flight with a certified flight instructor (CFI), which allowed the pilot to rent the FBO's airplanes. The accident flight was the pilot's first solo flight in an FBO airplane.

According to information from the FBO and Federal Aviation Administration (FAA), the airplane departed runway 31, and was on a left downwind leg for runway 31, when it descended and impacted the Gulf of Mexico, approximately 1/2-mile west of the shore.

Primary radar targets were recorded at the Tampa, Florida FAA terminal radar approach control (TRACON). A target was recorded near the departure end of runway 31 at VNC, at 2038:41. Eleven additional targets were recorded, along a track consistent with a left traffic pattern for runway 31. The last radar target recorded was approximately mid-field, about 1 mile west of runway 31, at 2039:36. Although the primary radar targets were consistent with the accident flight, they could not be positively identified as the accident airplane. In addition, no altitude information was recorded, as they were primary radar targets only.

Personnel information

The pilot, age 64, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, instrument airplane, and glider aero tow. He also held a flight instructor certificate, with ratings for airplane single engine and instrument airplane. The pilot's most recent FAA second-class medical certificate was issued on November 5, 2007. At that time, he reported a total flight experience of 4,000 hours.

The pilot's most recent logbook was the only one recovered. It contained one entry, which was a 1-hour flight dated January 15, 2008. According to the logbook and a the CFI at the FBO, the 1-hour flight was a combination flight review and rental "check out." The instructor added that the flight was conducted at night and included unusual attitudes. The logbook noted the flight time as night; however, there was no reference to unusual attitude training. The logbook entry included "Power on/off stalls, Steep turns, Forced landings, Night landings 3 full stop." The instructor believed that the pilot may have flown one additional time in March 2008, but there were no other logbook entries.

Aircraft information

Review of the aircraft and engine logbooks revealed that the accident airplane's most recent 100-hour inspection was completed 3 days prior to the accident, at a total airframe time of 10,380.67 hours. According to the tachometer, the airplane flew an addition 8.5 hour since the inspection, until the accident. The airplane's most recent pitot static check was completed on May 1, 2006.

Another pilot had flown the accident airplane on January 30, 2008. During his rental "check out" flight, he noticed an error with the directional gyro (DG). Specifically, the DG would move approximately 10 degrees off for every 5 or 10 minutes of time that elapsed. After the flight, the pilot reported the problem to the FBO, and was told the unit would be replaced the following day. The pilot noticed the problem again when he subsequently flew the airplane on February 6, 2008; however, it was not as bad as previously noted.

Further review of the aircraft logbook revealed that the DG was replaced with an overhauled DG (S/N 7111) on February 1, 2008. The National Transportation Safety Board received no other reports of DG errors with the accident airplane.

Meteorological information

Sarasota Airport (SRQ) was located approximately 20 miles northwest of the accident site. The reported weather at SRQ, at 2053, was: wind from 340 degrees at 9 knots; visibility 10 miles; sky clear; temperature 14 degrees Celsius (C); dew point 2 degrees C; altimeter 30.19 inches of mercury.

Wreckage and impact information

The wreckage was recovered from the water on March 27, 2008, and examined the following day. The right wing exhibited extensive leading edge damage, and had separated from the airplane into two sections, consistent with impact damage. The left wing was cut from the airplane during the recovery process. The outboard half of right aileron remained attached to the right wing, while the inboard section of right aileron had separated and was not recovered. The approximate one-third inboard section of right flap remained partially attached to the right wing, while the outboard section of right flap had separated and was not recovered. The left wing sustained less leading edge damage than the right wing, and the entire left flap remained attached to the left wing. The entire left aileron had separated and was not recovered. The cockpit and cabin area were crushed, the empennage remained attached to the fuselage, and had sustained less damage than the cockpit and cabin.

Aileron control continuity was confirmed from the forward cockpit area, to the left and right wing roots, respectively. Rudder control continuity was confirmed from the rudder pedals to the rudder. Stabilator control continuity was confirmed from the forward cockpit area to the stabilator. Stabilator trim control continuity was confirmed from the trim wheel in the cockpit, to the stabilator trim jackscrew. Fifteen threads were measured on the stabilator trim jackscrew. According to a representative from the aircraft manufacturer, fifteen threads corresponded to a near full nose-up trim position, with sixteen threads equating to full nose up trim, and five threads equating to neutral trim.

Examination of the cockpit revealed that the fuel selector was positioned to the right fuel tank. The left fuel tank quantity gauge indicated 10 gallons, and the right fuel tank quantity gauge indicated 20 gallons. The flap handle was found in a flaps-retracted position. The throttle and mixture control were mid-range, and crushed consistent with impact. The magnetos were selected to "BOTH," the primer was in and locked, and the electric fuel pump was on. The airspeed indicator displayed 75 knots, the attitude indicator was tumbled to the right, and the vertical speed indicated displayed an approximate 2,000-foot-per-minute descent. The tachometer indicated 1,750 rpm, and 2,292.1 total engine hours. The altimeter displayed approximately negative 700 feet, with 30.28 in the Kollsman window.

The propeller remained attached to the engine, and the engine remained attached to the airframe. One propeller blade was bent aft, and the other exhibited little damage. The propeller was rotated by hand, and crankshaft, camshaft, and valve train continuity was confirmed. Thumb compression was attained on all cylinders except for the No. 2 cylinder, which had ingested sand. A borescope examination of the No. 2 cylinder did not reveal any mechanical defects. All eight spark plugs were removed from the engine; their electrodes remained intact and were gray in color. The carburetor was disassembled for inspection; the floats remained intact, and carburetor screen was absent of debris. Oil was noted throughout the engine, and examination of the oil filter did not reveal any metallic contamination. When the mechanical fuel pump was cycled by hand, it pumped water freely. The vacuum pump was disassembled for inspection, and sand was noted throughout the pump; however, all vanes remained intact. Both magnetos contained salt water, sand, and corrosion, which precluded a successful functional test.

Medical and pathological informatio

Aircraft

Registration
N465TC
Reported as
Piper PA 28-161
Category
Airplane
Serial number
28-7716150
Airframe hours
10,381
Engine
Lycoming O-320, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Florida Flight Training Center
Registered owner
Florida Flight Training Center
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 1, 2008 · 9 hours before
Departed
VNC · Venice, FL
Destination
VNC · Venice, FL
Airport
VNC · Venice Municipal Airport, runway 31, 4,999 × 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
64
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 1, 2008
Seat
Left
Toxicology
Performed
Flight hours
4,000 total · 2 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
340° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 36 °F
Altimeter
30.19 inHg
Observed at
SRQ, 20 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.