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December 31, 2018 · Piper PA 23 Undesignat · N2146P

Beaver Island, MI

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
December 31, 2018
Injury Outcomes
1 injury (1 fatality)
Location
Beaver Island, MI
Aircraft
Piper PA 23 Undesignat (1956)
Tail Number
N2146P
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
CEN19LA051

The instrument, multi-engine rated private pilot was departing into dark night visual meteorological conditions at the time of the accident. The airport was located in an area with minimal ground lighting with no discernable horizon visible after takeoff. Witnesses heard the airplane take off toward the west and subsequently turn to the north. They described the sound of the engines as "very loud." One witness added that the engines seemed to be operating normally. Another witness noted that the sound changed to a lower pitch similar to when a pilot transitions to climb power after takeoff. The sound ended abruptly when the airplane impacted a wooded area about 1/3 mile from the airport on a north-northeasterly heading. Examination of the airframe and engines did not reveal any anomalies consistent with a preimpact failure or malfunction. It is possible that the pilot experienced some level spatial disorientation which led to a loss of control and impact with the trees and terrain. However, it is also possible that the pilot became distracted configuring the airplane for climb during the initial turn after takeoff which led to the airplane entering an inadvertent descent and controlled flight into terrain. This scenario is consistent with the witness statement noting a transition to climb power immediately after takeoff. In addition, the earwitness reports did not describe a typical loss-of-control event. The lack of a visible horizon due to the dark night lighting conditions and lack of ground lights in the vicinity of the airport would have contributed to either scenario.

NTSB Probable Cause

The pilot's failure to maintain a positive rate of climb after takeoff which resulted in an impact with trees and terrain. Contributing to the accident was the pilot's inability to see a visible horizon due to the dark night lighting conditions and limited ground lights in the vicinity of the airport.

Full Narrative

HISTORY OF FLIGHTOn December 30, 2018, about 1948 eastern standard time, a Piper PA-23 airplane, N2146P, impacted trees and terrain shortly after takeoff from Beaver Island Airport (SJX), Beaver Island, Michigan. The pilot sustained fatal injuries. The airplane was destroyed. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Dark night visual meteorological conditions (VMC) prevailed. The flight was originating at the time of the accident and was destined for the Fitch H. Beach Airport (FPK), Charlotte, Michigan. Due to the government furlough, neither the National Transportation Safety Board, nor the Federal Aviation Administration responded to the accident site. The on-scene documentation for this accident was conducted by the Charlevoix County Sheriff's Department. A witness reported hearing the airplane for about 10 minutes before the sound of the engines increased dramatically. He added, "it was very loud." After taking off, the airplane seemed to turn to the right (north). Shortly afterward, the sound changed to a lower pitch similar to when a pilot adjusts the pitch of the propellers; then it went silent; although, he did not recall hearing the impact. A second witness noted that the airplane was "real loud." She subsequently drove past the airport and observed the airplane which appeared to be taking off to the west. Nothing seemed unusual during the time she saw it. She did not witness the accident and only heard about it later that evening. A third witness reported hearing the "distinct sound" of a twin-engine airplane. He noted that it was "plenty loud" and that the engines didn't seem to be having any difficulties. Shortly afterward, the sound of the engines abruptly "went quiet," after which he heard the airplane impacting the trees. The airplane impacted a wooded area about 1/3 mile north-northeast of the departure end of the runway. The impact path was oriented toward the north-northeast and was about 115 feet long. PERSONNEL INFORMATIONThe pilot's logbook was not available. On his most recent application for a Federal Aviation Administration (FAA) medical certificate, the pilot reported a total flight time of 5,468 hours, with 52.2 hours within the preceding 6 months. He held an instrument rating; however, his recent instrument experience could not be determined. In addition, his recent night flight experience was unknown. The pilot's family stated that he was familiar with the route of flight, having completed the trip between SJX and FPK at least twice per month. AIRCRAFT INFORMATIONAt the time of the most recent annual inspection on September 27, 2018, the airframe had accumulated 8,809 hours total time. The left and right engines had accumulated 4,223 hours and 2,333 hours total time, respectively. Both engines had accumulated 105 hours since overhaul. The airplane was equipped and had current inspections for flight under instrument flight rules. METEOROLOGICAL INFORMATIONBoth witnesses recalled that there was no precipitation at the time of the accident. One witness added that it was "very dark." Sunset occurred at 1707 on the day of the accident and civil twilight ended at 1741. The moon had set at 1328 and did not rise again until 0249 the following day. AIRPORT INFORMATIONAt the time of the most recent annual inspection on September 27, 2018, the airframe had accumulated 8,809 hours total time. The left and right engines had accumulated 4,223 hours and 2,333 hours total time, respectively. Both engines had accumulated 105 hours since overhaul. The airplane was equipped and had current inspections for flight under instrument flight rules. WRECKAGE AND IMPACT INFORMATIONThe fuselage was fragmented consistent with impact forces. The wings were separated from the fuselage at the roots and both engines had separated from their respective wing pylons. The horizontal stabilizers remained attached to the aft fuselage section; however, the vertical stabilizer was separated at the root. The fragmented debris was located along the impact path from the vicinity of the initial tree strike to the main wreckage. A post-recovery examination did not reveal any anomalies consistent with a preimpact failure or malfunction. No evidence of an in-flight structural failure was observed. ADDITIONAL INFORMATIONControllable-Pitch Propeller The Federal Aviation Administration (FAA) Airplane Flying Handbook noted that for airplanes equipped with constant speed propellers, the power output of the engine(s) is reduced when climbing out after takeoff by decreasing the manifold pressure (throttle control) and reducing the engine speed by increasing the propeller blade angle (prop control). Spatial Disorientation The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude. The FAA Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "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." MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy, performed on behalf of the Charlevoix County Medical Examiner, Boyne City, Michigan, attributed the pilot's death to multiple blunt injuries sustained in the accident. Toxicology testing performed by the FAA Forensic Sciences Laboratory identified atorvastatin in liver tissue. Atorvastatin is commonly prescribed to lower blood cholesterol/triglyceride levels and is not considered to be impairing.

Flight

Event TypeAccident
Event Time19:48 EST
Nearest AirportBeaver Island (1nm N)
Runway27
Runway Length4299 ft
Runway Width75 ft
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftPiper PA 23 Undesignat
Tail NumberN2146P
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsLycoming · O-360-A1D · Reciprocating · 180 | Lycoming · O-360-A1D · Reciprocating · 180
Seats4

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 72 · Third Class · Fatal

Conditions

ConditionsVMC
LightDark Night
Wind240° @ 8 kt, gusting 15 kt
Visibility10 sm
CeilingBroken clouds 2500 ft
Temperature / Dew Point34 C / 27 C
Altimeter29.92 inHg
Observation Time00:55
Weather SourceWFAC

Appendix: Source Data