MIA04FA100
MIA04FA100

HISTORY OF FLIGHT

On June 21, 2004, about 1359 central daylight time, a Piper PA-23-250, N54134, registered to Mobo LLC, and operated by a private individual as a Title 14 CFR Part 91 personal flight, crashed in the vicinity of Baker, Florida. Visual meteorological conditions prevailed, there were thunderstorms in the area, and an instrument flight rules flight plan was filed. The airline transport-rated flight instructor/pilot-in-command and the private-rated pilot received fatal injuries, and the airplane was destroyed. The flight originated in Marianna, Florida, the same day, about 1300.

According to information obtained from the FAA, the pilot of N54134 had contacted the Gainesville, Florida, Automated Flight Service Station at 12:52, to file a instrument flight rules flight plan to Lockhart, TX. At the time he filed the flight plan, he reported having 6 hours of fuel onboard, and estimated his time en-route to be 3 hours and 30 minutes. The pilot did not request a weather briefing at that time, and records showed that he informed the weather briefer that he had already received a standard briefing, however no record of him having received a briefing was found.

Shortly after taking off from the Mariana Airport, N54134 was receiving air traffic control services from Cairns Radar Approach Control, Fort Rucker, Alabama. At 13:38:57, and prior to entering Eglin Air Force Base Radar Control Facility's (ERCF) airspace, the Cairns Approach controller called ERCF and advised the Coordinator that N54134 was deviating to the right of course for weather. The ERCF Coordinator acknowledged and advised the ERCF North Approach sector controller. Shortly afterward, the pilot of N54134 reported to North Approach "with you at eight thousand". The controller acknowledged. At this time, the airplane was about 38 miles east of the Crestview (KCEW) Very High Frequency Omnidirectional Range TACAN navigational aid (VORTAC), about 2 miles north of airway V198, and on a course of approximately 290 degrees.

At 13:45:41, the North Approach controller issued mutual traffic advisories to the flight crew of N54134, and a twin engine Cessna passing overhead. The airplanes were about 22 miles northeast of the KCEW VORTAC and about 25 miles northeast of the observed weather radar returns.

At 1348:31, the North Approach controller asked the crew of N54134 "how much farther are you going to go before you start your turn back on course?" The pilot replied, "I would say about ten more miles, sir. We got a bumper right in front of us". The airplane was about 19 miles northeast of KCEW, on a course of 290 at 8,000 feet. The area of observed weather returns extended from the KCEW VORTAC to the southwest.

At 1350:34, a pilot of N54134 said "I would like a block from eight...", with the remaining portion of the transmission being unintelligible due to a transmission from the pilot of another flight, and after repeating the request, and explaining that it was "for turbulence", the controller approved the request.

At 1351:53, North Approach controller, had an exchange of communications with the crew of a Sabreliner, and also at that time, the Eglin AF Auxiliary Field #3 Duke (EGI) tower controller reported lightning within five miles of the EGI airport. In addition, At this time N54134 was about 13 miles north east of the Crestview VORTAC, at 8,000 feet, and began a turn to the left. At 1352:11, the pilot of N54134 said he was "turning back to intercept".

At 1353:06, North Approach asked the pilot of N54134 "do you still need the block eight to nine thousand?" The pilot replied he did not, and North Approach cleared the pilot to maintain 8,000 feet. At this time the airplane was on a course of about 210 which would intercept airway V198 about 5.5 miles east of the Crestview VORTAC. The airplane was northeast of the Crestview VORTAC, and the observed weather echoes, by about 9 miles and the weather echoes had moved to the east of the Crestview VORTAC.

At 1355:48, the pilot of N54134, told North Approach "I'm going to have to maintain this heading for eight to ten more miles before turning back to [the Crestview VOR]". The airplane was less than one mile north of the centerline of V198, at 8,000 feet, about 5.5 miles east of the Crestview VORTAC, on a course of about 210 degrees. Radar data showed that the airplane was just entering the area of observed Levels 1 and 2 precipitation, with the heavier levels at the 1 o'clock and 10 o'clock positions about four to five miles away. North Approach acknowledged and instructed the pilot to advise when he could turn back on course.

At 1356:29, the North Approach Assist controller (NAA) called the Pensacola Terminal Radar Approach Control (TRACON) and advised the controller that N54134 was "six miles south of Crestview...deviating South for weather". The Pensacola controller said, "he's going to have to go all the way to the coast in your airspace to get around that weather". NAA replied "That's what we explained, that's what we're trying to tell him but we're going to vector him around it". The Pensacola controller acknowledged. The airplane was directly between the Crestview VORTAC and KCEW, at 8,000 feet on a course of 210 degrees. Level 4 weather returns were on either side of the airplane.

At 1357:00, the Pensacola controller said "Tell him everyone is going around north of that stuff". NAA replied, "We tried to tell him, he didn't want to listen. There's one born everyday". The airplane was about 3.7 miles due west of KCEW, and had begun a right turn to a course of about 260 degrees.

At 1357:40, the airplane was about 3.7 miles southeast of the Crestview VORTAC, at 8,000 feet, and on a course of about 285 degrees. The pilot of N54134 requested "a course of one eighty to the left for weather". North Approach replied "is that a one eight zero heading?" The pilot responded "one eight zero," and North Approach approved the request. The airplane was entering the eastern edge of an area of Level 4 returns.

At 1358:01, the airplane began a descent and a turn to the left. Radar indicated that the airplane had made a left descending turn of about 0.6 miles in diameter. The airplane turned more than 180 degrees in about 19 seconds, and the calculated vertical rate of mode C change exceeded 5,000 feet per minute. The last radar target was received at 1358:54, about 53 seconds after the initiation of the turn, at coordinates 30 42.19N 086 38.23W. Mode C altitude information on the last target was not received, and an "ident" bit was transmitted. All radar targets in the turn maneuver were in an area of depicted Level 4 weather returns.

At 1359:38, North Approach said "radar contact lost, report...say radial and DME (distance) off ah, Crestview VORTAC". No reply was received. North Approach continued to call to the pilot on available radio frequencies. North Approach, the North Approach Assist controller, the ERCF Coordinator, and the Supervisor phoned adjacent facilities and airports to attempt to locate the airplane. Other aircraft in the area were requested to assist, and the supervisor contacted the sheriff's department and highway patrol. At 1410, the sheriff reported the wreckage was located in Baker, Florida.

According to the North Approach Radar Controller, nothing was unusual about the weather or the volume of air traffic experienced on June 21. He said his workload was moderate with about four or five aircraft and that he was on position for about two to three minutes when the pilot of N54134 contacted him. The controller said that after he signed on to position, the coordinator controller advised him that N54134 was enroute from the east to the west, but was deviating to the north around weather. The controller further stated that he would normally advise a pilot of observed weather returns, but did not do so for N5134. He acknowledged that to do so is a required additional duty of an air traffic controller and that he had not issued similar advisories to other pilots in the same general area. He said he did not issue a weather advisory to N54134 because in his opinion, "the pilot was seeing everything out there [and] telling [me] what he needed to do".

According to the North Radar Assist Controller, he was advised that N54134 was deviating westbound for weather and said that no other aircraft were deviating at that time, but others did afterwards. The controller further stated that level 4 was the most severe weather display he saw near the time of the accident and noted that the area was generally moving to the east-northeast.

See the NTSB Air Traffic Control Group Chairman's Factual Report.

PERSONNEL INFORMATION

FAA records showed that the pilot-in-command/flight instructor held an FAA airline transport pilot certificate, with an airplane multiengine land rating, and a commercial pilot certificate with single engine land and instrument airplane ratings. He also held a flight instructor certificate with single engine and multiengine land and instrument airplane ratings. He held an FAA type rating in the CE-500. He also held an FAA second class medical certificate, with the stated limitation "Holder Shall Wear Corrective Lenses", issued on October 27, 2003. The flight instructor's personal flight logbook was not obtained by the NTSB, but at the time of his application for a medical certificate, he reported having accumulated about 30,000 hours of flight time.

FAA records showed that the pilot/owner held an FAA private pilot certificate, with airplane single engine and multiengine land ratings, issued on November 25, 2003. He did not hold an instrument rating. He held an FAA third class medical certificate, issued on April 23, 2003, with no stated waivers or limitations. His personal flight log was recovered, and at the time of the last entry, he had recorded 261 total flight hours.

AIRCRAFT INFORMATION

N54134 was a 1974 Piper PA-23-250, serial number 27-7405442. Records obtained from the operator showed that the airplane had received a 100-hour inspection on December 11, 2003, and at that time it had accumulated a total flight time of about 4,992 hours. An annual inspection had been performed on airplane on July 9, 2003.

Both the left and right engines were 250-horsepower Avco Lycoming IO-540-C4B5, serial numbers L-12217-48A and L-12179-48A respectively. At the time of the last 100-hour inspection, both engines has accumulated 4,902 total hours, of which 1,118 hours had been accumulated since major overhaul. The airplane was also equipped with two 2-bladed constant speed Hartzell propellers. The left propeller's serial number was BP-7115, and the right one's serial number was BP-7063.

METEOROLOGICAL INFORMATION

A Convective SIGMET had been issued at 12:55 and was valid until 14:55 on the day of the accident, and was for the vicinity of the accident location. It indicated that a line of thunderstorms showing little movement was present from 50 miles southeast of Semmes, Alabama, to 10 miles northwest of Crestview, Florida, with tops extending to 40,000 feet.

An AIRMET for turbulence was issued at 1345 on the day of the accident. It indicated that no significant turbulence was expected outside of convective activity. This AIRMET was valid until 15:00.

The Crestview (CEW), Florida, and Pensacola (PNS), Florida, Automated Surface Observing Systems (ASOS) were the closest ASOS stations to the accident location. CEW was approximately 6 miles away from the accident site on a heading of 101 degrees, and KPNS was roughly 34 miles away on a heading of 237degrees.

The Pensacola, Florida 1353 surface weather observation was winds from 230 degrees at 13 knots, visibility 9 statute miles, thunderstorms, light rain; sky condition, few at 3,200 feet, broken at 4,400 feet, and broken at 5,500 feet; temperature.29 degrees C, dew point temperature 24 degrees C, altimeter setting 29.92 inHg; Remarks, thunderstorm began at 1323 and rain began at 1352Z, thunderstorm southwest to northeast moving east southeast, rain in the vicinity.

Surface observations from the Duke Field/Eglin (EGI), Florida, weather station are courtesy of the 46th Weather Squadron and were available on the WDS system at the time of the accident. This weather station was about 10 miles away from the accident location at 147 degrees. The Crestview Bob Sikes Airport, Crestview, Florida 13:53 surface weather observation stated the wind was from 270 degrees at 9 knots; visibility 9 miles, weather: thunderstorm, few clouds at 5,500 feet, lightning in the distance, southwest and west, thunderstorm began at 33 minutes after the hour. Crestview, Florida is located 8 miles to the east of the accident site.

The Duke Field, Florida 14:09 special weather observation was wind from 290 degrees at 15 knots; visibility 7 miles; weather thunderstorm, light rain; sky condition broken at 3,500 feet, cumulonimbus, broken at 12,000 feet, and broken at 30,000 feet; temperature 28 degrees C; dew point temperature 21 degrees C; altimeter setting.29.91 inHg; Remarks: occasional lightning cloud to ground, in cloud, and cloud to cloud southwest to north, thunderstorm overhead moving east, towering cumulus all quadrants. Duke Field is located 12 miles southeast of the accident site.

A weather radar Plan Position Indicator (PPI) image from MOB valid at 1357, revealed a level 5 thunderstorm in the vicinity of the accident location. Overlaying the flight track of N54134 on the PPI showed that the aircraft flew directly into an area of strong reflectivities. An 1357, Range Height Indicator (RHI) display showed that N54134 penetrated a very intense portion of the storm. The RHI display showed core reflectivities greater than or equal to 50 dBZ extended above and below 8,000 feet (the approximate flight level of the N54134 prior to the upset.

Satellite data showed the existence of thunderstorms in the region of the accident, and specifically, satellite imagery showed the existence of vertically developed clouds near the accident site. The combination of satellite imagery and radar displays indicated that the most intense portion of the thunderstorms were embedded within lighter precipitation, and N54134's track was consistent with the airplane being in Instrument Meteorological Conditions (IMC) at the time of the accident. See the NTSB Meteorological Factual Report.

WRECKAGE AND IMPACT

An onscene investigation was conducted on June 22 and 23, 2004. The wreckage was generally located in geographic position 30 degrees, 47.204 minutes North latitude, and 086 degrees, 38.161 minutes West Longitude. The area consisted of sparsely placed residential homes, trees and thick vegetation. Portions of all major aircraft structures were found recovered and examined, except for the leading edge and outboard tip of the left wing. The wreckage was dispersed over an approximate nineteen-acre area to the left and right of a line drawn between the area where the last radar contact had occurred and the main wreckage site. The main wreckage site, which comprised of the fuselage, was located in a wooded area approximately 6.7 miles west of the Bob Sikes Airport, Crestview, FL. The overall debris path was approximately .4 miles long on a northwest heading and the initial pieces along the path were the vertical fin, rudder, and left aileron. There was no evidence of a post crash fire in the area of the main wreckage site or at any of the secondary locations and no evidence or any patterns like those typically associated with an in-flight fire were identified.

The aircraft had separated into eight major sections pieces; the fuselage, right wing and left wing to just outboard of the engine mounts,; the left outboard wing; the left engine and propeller; the left aileron; the empennage and stabilator; the vertical stabilizer and rudder; the rudder balance weight; and the left wing tip, which was not recovered.

All four corners (minus the left wing tip) of the aircraft were identified, surveyed and photographed. The fuselage, wings, engines, landing gear and, empennage structure were identified along with all of the control surface structure. No evidence of an in-flight fire was noted and all of the fracture surfaces that were examined exhibited evidence of overload. The fuselage was located along an approximate heading of 011 degrees relative to the location of the last known radar contact. The fuselage was found inverted at the accident site and was pointing toward a heading of about 180 degrees. The entire upper fuselage was crushed inward to about the lower edge of the window. Visible impact damage was noted, consistent with there having been contact with trees, and wrinkling of fuselage skin panels was also observed. The empennage had separated from the main portion of the fuselage, and was not collocated at the main wreckage site. Fuselage stringers on the empennage side of the fracture were bent down and to the left, and no ground scars were present in the area of the main wreckage.

The main entry, baggage, and landing gear doors were found attached to the appropriate mating airplane structure, and the right main landing gear door was found in the closed position. The nose gear door was found in the open position. The left main landing gear door was fragmented into several pieces with the gear in a partially extended position. All of the landing gear were found attached to the aircraft. The nose and left main landing gear were found partially extended and the right main landing was found in the stowed position.

The inboard 8 foot 8 inches of the left wing remained attached to the fuselage along with the leading edge structure. The wing outboard of station 80 separated into three sections and was found on the wreckage path. A 3-ft section of the upper skin just outboard of the left engine nacelle was missing. The 3-ft section of the lower skin just outboard of the left engine nacelle with the lower cap and front spar web was found with the fuselage and inboard section of the wing. The web section exhibited evidence of buckling along the front spar. Similar evidence of buckling was found on the rear spar. The lower cap of this section had separated at the outboard end from the vertical flange and exhibited slightly downward bending. Black smear transfers and scrape marks were observed near the fuel filler port. The left wingtip had separated from the wing and was not recovered.

The right wing was attached at the forward and main spar. The aft attachment was separated by impact. The right wing tip separated from the wing but was located inverted directly beside the wing. The upper skin was creased from leading edge to trailing edge at about wing station 144.

Located to the right of the line joining the last known radar contact and the main wreckage site and prior to the main wreckage site were the empennage and stabilator on an approximate heading from the main wreckage site of 139.0 degrees true at a distance of approximately 515 feet, the left aileron on an approximate heading of 144.0 degrees true at a distance of approximately 1140 feet. The vertical stabilizer and rudder where found suspended in a tree.

The empennage separated near bulkhead station 45, and the separation area displayed a torsional twist clockwise. The vertical stabilizer and rudder had separated from the empennage and were located along the flight path on an approximate heading of 126.0 degrees and at a distance of about 1,355 feet from the main wreckage site. Both the rear spar caps were fractured at the vertical-stabilizer-to-empennage attach location. About 23 in of the upper portion of the vertical stabilizer exhibited impact damage on the leading edge and the left side. There were scratch marks and a black smear about 14 in from the top of the vertical stabilizer in an up and aft direction.

All of the movable control surfaces were located and identified. The left aileron separated from the left wing at the hinge points and was located along the flight path. The aileron was bent up and aft near the middle attach point. The bellcrank was found among the main wreckage and was separated from the wing. Both cables remained attached to the bellcrank. The aileron stops had impact dings. The balance weight was attached and showed signs of damage.

The right aileron was attached to its attachments. The push pull rod was separated at the bellcrank. This area of the wing had impact damage. The bellcrank stops were in-place. The aft bellcrank arm was broken and separated. The control cable was attached to the bellcrank and the balance cable was attached to the broken bellcrank arm. The balance weight was attached. Both the left and right flaps were found in the up position and were attached to the inboard tracks and to the actuator torque tube bars. Both flaps showed evidence of upward bending at approximately wing station 69.

The stabilator including trim tabs was attached to the aft part of the empennage. The stabilator tips were separated and not located. The fuselage stringers that remained attached to the empennage were bent down and to the left. The left stabilator leading edge de-ice boot exhibited impact damage and was torn at 9 in and 20 in from the root. The upper skin panel exhibited scrape marks from the leading edge to the trailing edge and a 2-in diameter hole was observed. Neither of the stabilator's tip fairings were found. The rudder remained attached to the vertical stabilizer and damage was observed at the upper and lower hinge locations. Above the upper hinge the rudder was bent to the right, consistent with the damage on the vertical stabilizer. The rudder balance weight was detached from the rudder and found approximately .14 miles south of the main wreckage. See the NTSB Structures group Chairman's Factual Report.

The left propeller remained attached to the engine. The propeller governor control cable had separated in overload. The control was damaged, separated, and spring-loaded back to the high RPM position. The gasket screen was clean. The drive coupling remained intact. The unit rotated by hand with damage resistance. The propeller was in the feather position and both blades were bent slightly upward. The right propeller remained attached to the engine. The propeller governor was intact, secured, and not removed. The control was observed in a high RPM position.

The left engine and portions of the engine mount were located to the left of the line joining the last known radar contact and the main wreckage site and beyond the main wreckage site on an approximate heading of 280.0 degrees true at a distance of about 584 ft. The left engine showed signs of an inverted and level impact with the ground. Examination of the engine showed that the pushrod tubes were crushed. The #1, #4, and #6 push rods were removed for a continuity check. All accessory components sustained impact damage. Crank rotation established continuity and all cylinders produced compression. Internal examination of the engine using a bore scope revealed no anomalies to the cylinders and piston domes. The oil suction screen was found clean, the oil cooler hoses were tight, and the oil cooler was impact damaged. The damage sustained to both the left and right magnetos precluded testing. The bottom plugs were removed from the left engine. The sparkplugs exhibited normal wear and gap spacing. The ignition harness had incurred impact damage.

The right engine and engine mount had remained attached to the wing nacelle and were located at the main wreckage site. The top side of the cowling was crushed, and as with the left engine, there was no evidence of a post-crash fire. The cowl was removed for examination, and all accessory components were intact. Crank rotation established continuity and all cylinders produced compression. Internal examination of the engine using a bore scope revealed no anomalies to the cylinders and piston domes. The injector inlet was found clean and clear of debris and fuel was observed in the fuel flow divider. The starter and alternator were secure and displayed no pre-impact anomalies. The vacuum pump was intact, secure, and rotated when the engine was turned. The oil filter and oil suction screen were found clean and clear of debris. The oil cooler was secured and the oil cooler hoses were tight. Both the left and right magnetos were removed and operated on all terminals.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of both pilots was performed by a pathologist with the District 1 Medical Examiner's Office, Ft. Walton Beach, Florida. The cause of death in both cases was attributed to massive multiple blunt force injuries. No findings, which could be considered causal, were reported.

The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from both pilots. The specimens from both pilots were tested for carbon monoxide, cyanide, ethanol, and drugs. Quinine and diphenhydramine were found to be present in specimens obtained from the private-rated pilot.

TESTS AND RESEARCH

FAA Order 7110.65 2-6-4 Weather and Chaff Services, as well as the Aeronautical Information Manual section 7-1-15. ATC Inflight Weather Avoidance Assistance, specifies weather related advisory services that ATC controllers provide.

ADDITIONAL INFORMATION

On July 9, 2004, the NTSB released the wreckage of N54134 to Atlanta Air Salvage. Mr. Todd Thaxton, Recovery Manager has acknowledged receipt of the wreckage.

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