Thursday, January 7, 2016

Piper PA-28R-200 Arrow II, N54380, Palm Beach Flight Training: Accident occurred August 10, 2015 in Florida Keys, Gulf of Mexico near Marathon, Florida

Edward "Russ" Elgin Jr.

NTSB Identification: ERA15FA299
14 CFR Part 91: General Aviation
Accident occurred Monday, August 10, 2015 in Marathon, FL
Aircraft: PIPER PA-28R, registration: N54380
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.


On August 10, 2015 about 0035 eastern daylight time, a Piper PA-28R-200, N54380, was destroyed when it impacted the water after takeoff from the Marathon Airport (MTH), Marathon, Florida. The private pilot, the sole occupant, was fatally injured. The flight had an intended destination of Palm Beach County Park Airport (LNA), West Palm Beach, Florida. Night visual meteorological conditions prevailed and a visual flight rules (VFR) flight plan had been filed. The airplane was owned by The Wildwood Helicopter Company, Inc. and operated by Palm Beach Flight Training. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

Airport security video recorded the airplane taxing out to the runway and began the takeoff roll, on runway 25, at 0034. A second video captured the airplane after it had already become airborne, a few feet above ground level, at an indicated time of 0034:17. The recording revealed the airplane climbing on the upwind leg of the traffic pattern, and began to turn right for the crosswind leg of the traffic pattern about 0034:59. At 0035:22, the airplane lights were no longer visible. The recording further revealed the absence of any visible horizon to the northwest of the airport. The video was further overlaid by a daytime screen shot, to verify that the view of the airplane was unhindered. The modified video revealed one tree had obstructed the actual impact with the water.

According to a representative of Palm Beach Flight Training, the pilot rented the airplane on August 9, 2015, departed about noon, and was not to return until Tuesday August 11, 2015.

According to an eyewitness, the airplane was observed descending into the water and the engine could be heard operating.


According to Federal Aviation Administration (FAA) and flight school records, the pilot held a private pilot certificate with an airplane single-engine land rating, which was issued December 20, 2012. He held an FAA third-class medical certificate, issued April 15, 2014, and was issued with a limitation of "Must have available glasses for near vision." At the time of the medical examination, the pilot reported 125.5 total hours of flight experience and 5.0 hours of flight experience in the 6 months prior to the medical certificate. Documentation provided by the flight school did not include any flight time, but did indicate that the pilot accomplished an airplane checkout on August 9, 2015. The pilot also received his "PIC [Pilot-in-command] in a complex airplane" endorsement on May 4, 2015 and had accomplished a flight review on December 17, 2014. At the time of this writing the pilot's flight time logbook had not been located, as such, his total and recent night flying experience could not be determined.

The pilot rented the airplane from Palm Beach Flight Training in the afternoon of August 9, 2015. The rental agreement provided by the flight school, dated September 6, 2009, contained the pilot's signature and included several limitations. One of the limitations was "There are not to be any night flights to or from the Bahamas or Florida Keys before sunrise or after sunset."


According to FAA and aircraft maintenance records, the airplane was issued an airworthiness certificate on November 15, 1973 and was originally registered to Wildwood Helicopter Company Inc. on October 25, 2013. It was powered by a Lycoming IO-360-C1C engine. It was also driven by a Hartzell propeller HC-C3YK-1RE/F7282. According to the maintenance records, the most recent annual inspection was conducted on November 14, 2014 with a recorded tachometer of 7,566.53 hours, which correlated to 8,817.07 hours total time in service. According to the operator, the last recorded 100-hour inspection was completed on July 10, 2015, at a recorded tachometer time of 7,561.53 hours. At the time of that entry, the airframe had accumulated 9,012.07 hours total time. The engine had accumulated 791.42 hours since major overhaul and 10,292.91 hours total time in service. The propeller had accumulated 2,382.92 hours total time in service. The tachometer was located within the instrument panel and indicated 7,578.91 hours.

According to fuel records located at MTH, the airplane was fueled with 16.8 gallons of "Avgas." The credit card receipt associated with the refueling had a time stamp of 1430:49, on August 9, 2015. The fuel order also indicated "Top off all tanks."


The 0054 recorded weather observation at MTH, included calm wind, visibility 10 miles, clear skies, temperature 29 degrees C, dew point 24 degrees C; barometric altimeter 29.95 inches of mercury.

According to the United States Naval Observatory, Sun and Moon Data, official sunset was at 2003 and end of civil twilight was 2027. The moonset occurred at 1703 and 15 percent of the moon disc may have been visible had the moon been above the horizon.


The airplane was found in the Florida Bay, in about 9 feet of water. The main wreckage was located at 24°43.8N and 081°04.6W. The debris path was fairly compact. The wreckage debris path was oriented on a line that ran parallel to the shore. However, due to tide changes it could not be accurately determined the original debris path in relation to the main wreckage, which was located on a 320 degree magnetic heading and about 1.5 miles from the MTH.

Examination revealed that the airplane exhibited impact and crush damage to both wings, cabin, and fuselage. The airplane was segmented into numerous pieces. The right side stabilator was damaged in the aft and positive direction at an approximate 45-degree angle. The right wing main spar exhibited an approximate 50-degree twist. Impact and crush damage was consistent with the airplane impacting the water in a right wing low, nose down attitude. An outboard portion of the left wing, left wing aileron, and main cabin door were unable to be located. Examination of the engine revealed crankshaft and valve train continuity from the propeller flange to the rear accessory pad. Thumb compression was noted on all cylinders. A fluid, similar in smell as 100LL Aviation fuel was present in all fuel lines and in the fuel pump. Flight control continuity was confirmed from the base of the control column to the aileron bellcrank, located in each wing and the stabilator. One of the two rudder cables exhibited tensile overload; however, rudder control continuity was confirmed from the pilot's rudder pedals to the rudder.

The airplane's instrument panel was examined and the as found indications were noted. The airspeed indicator was in place and indicated about 100 knots. The attitude indicator was found tumbled; however, the instrument case exhibited minimal damage and the unit was disassembled. Examination of the gyro and gyro case revealed no score marks; however, due to salt water saturation, corrosion was evident throughout the instrument case. The turn and bank indicator indicated a right wing low attitude. The directional gyro indicated about 325 degrees and the heading preselect indicator was found selected to 015 degrees.

The engine remained attached to the airplane with electrical and fuel lines, cables, and was collocated with the main wreckage. The propeller was impact separated at the propeller flange, and was located about 300 feet from the main wreckage. All three propeller blades exhibited cord wise bending. The vacuum pump was removed and rotated by hand. Suction was noted and the vanes were audible noted as having unimpeded movement during hand rotation.


An autopsy was performed on the pilot on August 11, 2015, by the Office of the Medical Examiner, located in Marathon, Florida. The autopsy findings included "Multiple blunt force injuries." The report listed the specific injuries.

Forensic toxicology was performed on specimens from the pilot, by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol nor drugs were detected in urine.


Spatial Disorientation

The FAA's Pilot's Handbook of Aeronautical Knowledge contained guidance which stated that "under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome."

The Handbook also advised, "unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided."

The FAA Airplane Flying Handbook (FAA-H-8083-3) described some hazards associated with flying when visual references, such as the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

FAA Publication "Spatial Disorientation Visual Illusions" (OK-11-1550) , states in part "false visual reference illusions may cause you to orient your aircraft in relation to a false horizon; these illusions are caused by flying over a banked cloud, night flying over featureless terrain with ground lights that are indistinguishable from a dark sky with stars, or night flying over a featureless terrain with a clearly defined pattern of ground lights and a dark starless sky." The publication further provides guidance on the prevention of spatial disorientation. One of the preventive measures was "When flying at night or in reduced visibility, use and rely on your flight instruments." It further states "if you experience a visual illusion during flight (most pilots do at one time or another), have confidence in your instruments and ignore all conflicting signals your body gives you. Accidents usually happen as a result of a pilot's indecision to rely on the instruments."

Although FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," was canceled in May 2015, it provided credible information. The tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface.

The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility conditions. Somatogravic illusions, those involving the semicircular canals of the vestibular system, were generally placed into one of four categories, one of which was the "graveyard spiral." According to the text, the graveyard spiral, "…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude.

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