Aviation Accident Summaries

Aviation Accident Summary MIA06LA106

Aircraft #1

N5033Y

Piper PA-23-250

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 Information

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 recency of experience. He was issued a third class medical certificate on August 10, 2005, with a limitation to have available glasses for near vision. The pilot listed a total flight time of 350 hours on the last medical application. AIRCRAFT INFORMATION The airplane was manufactured in 1962 by Piper Aircraft Corporation as model PA-23-250, and was designated serial number 27-2039. It was certificated in the normal category, and was equipped with two Lycoming IO-540-G1A5 engines rated at 290 horsepower when operated at 2,575 rpm. It was also equipped with two constant speed Hartzell HC-A3VK-2B propellers. NTSB review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on February 9, 2006. The airplane total time at that time was estimated to be 3,313 hours. The time since the inspection could not be determined. METEOROLOGICAL INFORMATION According to a NTSB Weather Data, on the day and area of the accident, sunset and the end of civil twilight occurred at 1843 and 1907 hours, respectively. A review of the Visible GOES-12 Image at 1815 EDT, which was the last visible image before darkness, indicates that overcast clouds existed along the airplane's flight route. Am Infrared image taken at 1902 EDT, or approximately 6 minutes before the flight departed, confirms that overcast clouds existed along the airplane's flight path. The cloud top temperatures ranged from -36 degrees to -48 degrees Celsius, which equate to tops between 32,000 and 37,000 feet. An Infrared image taken at 1915 EDT, or approximately 15 minutes before the accident indicates the cloud top were from 29,500 to 37,500. An Infrared image taken at 1932 EDT, or approximately 2 minutes after the accident indicates the cloud tops were between 27,000 and 40,000 feet. The NTSB Weather Data further indicates that WSR-88D Radar Images for approximately 1 hour prior to the airplane's departure indicate video integrated processor (VIP) level 1-4 (light to heavy) rain showers in the vicinity of the airplane's route between the departure and destination airports. The weather data indicates the showers were diminishing in intensity during the period. Weather radar images taken of the airplane's route of flight indicate that light showers were occurring just offshore of the departure airport when the flight departed. No significant showers were depicted along the airplane's flight route. A surface observation weather report (METAR) taken at the destination airport (TISX) on the day of the accident at 1853, or approximately 15 minutes before the flight departed, indicates that the visibility was 10 statute miles, clear skies existed, and the altimeter setting was 29.93 inHg. COMMUNICATIONS The pilot was last in contact with San Juan CERAP. WRECKAGE AND IMPACT INFORMATION The wreckage was not located/recovered. MEDICAL AND PATHOLOGICAL INFORMATION The pilot and passenger were not recovered; therefore, postmortem examinations were not performed.

Probable Cause and Findings

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.

 

Source: NTSB Aviation Accident Database

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