N2173SPiper PA-44-180 · 1979

On July 13, 2017, about 2258 eastern daylight time, a Piper PA-44-180, N2173S, was destroyed during an inflight breakup near Marineland, Florida. The flight instructor and private pilot receiving instruction were fatally injured. The airplane was registered to and operated by Sunrise Aviation, Inc., Ormond Beach, Florida, as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. Visual meteorological conditions prevailed and no flight plan was filed for the cross-country flight, which originated from Brunswick, Georgia, at an undetermined time with an intended destination of Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida.

A representative from the operator reported that the accident flight was a roundtrip night cross-country instructional flight from OMN to Brunswick. Following one landing at Brunswick, the flight was to return to OMN as part of the pilot's initial commercial multi-engine rating training course. According to the company's flight training syllabus, the flight should have consisted of dead reckoning, pilotage, performance planning, GPS or VOR navigation, cross-country planning, normal takeoff and landings, intercepting and tracking navigational systems, and instrument procedures.

Federal Aviation Administration (FAA) air traffic control (ATC) audio communications and ground tracking radar information, which also included Automatic Dependent Surveillance-Broadcast (ADS-B) data were reviewed. The airplane was on a southerly course along the coastline at altitudes between 5,500 ft and 5,700 ft mean sea level (msl). At 2250, the flight contacted ATC and advised that they were at 5,500 ft, which the controller acknowledged. At 2257:36, the data showed the airplane began to descend. The pilot radioed the controller 26 seconds later and stated that they were starting down and had the OMN lights in sight. At 2258:27, the airplane climbed from 5,200 ft to 5,600 ft msl over the course of 4 seconds. The airplane remained at 5,600 ft msl for about 3 seconds then initiated a descending right turn, which continued for about 11 seconds. At 2258:45, the airplane had descended to 3,000 ft msl. The last ADS-B data point, recorded at 2258:46, showed the flight at 3,600 ft msl, about 0.3 mile northwest of the main wreckage. See Figure 1.

Between 2259:29 and 2259:48, the controller unsuccessfully attempted to establish radio communication with the accident airplane. The FAA issued an alert notice (ALNOT) shortly thereafter. The main wreckage was located by law enforcement air units about 1141 the following day.

Figure 1: Radar data showing final airplane flightpath

Flight Instructor

The flight instructor, age 70, held an airline transport pilot certificate with airplane single-engine land and airplane single-engine sea ratings, along with commercial pilot privileges for airplane multi-engine land and glider. He also held a flight instructor certificate with airplane single- and multi-engine and instrument ratings. A third-class FAA airman medical certificate was issued to the instructor on June 4, 2016, with the limitation, "must have available glasses for near vision." On the application for that medical certificate, the instructor reported 34,830 total hours of flight experience, of which 400 hours were in the previous 6 months. The flight instructor's logbook was not located.

Pilot Receiving Instruction

The pilot receiving instruction, age 27, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He was issued a second-class FAA medical certificate on August 17, 2016 with no limitations. A review of flight school records revealed that, as of July 12, 2017, he had accumulated 131.2 hours of flight experience, of which 7 hours were in multi-engine airplanes.

The four-seat, low-wing, retractable gear, twin-engine airplane, serial number 44-7995245, was manufactured in 1979. The airplane was powered by 180-horsepower O-360-E1A6D and LO-360-F1A6D engines. Both engines were equipped with Hartzell constant-speed, 2-bladed propellers. The airplane was equipped with two 55-gallon fuel tanks.

Review of the airframe and engine maintenance logbooks revealed that the most recent annual inspection was completed on June 12, 2017, at an airframe total time of 9,460.5 hours and right engine tachometer hour reading of 9,460.5 hours. At the time of the inspection, the left engine had accumulated 2,174.0 hours since major overhaul and had an engine total time of 6,724.5 hours; the right engine had accumulated 3,122.4 hours since major overhaul and had an engine total time of 9,958.7 hours.

Using reported weights of both occupants (223 lbs and 185 lbs), an airplane empty weight of 2,460 lbs, and an estimated fuel load of 72 gallons (full fuel minus about 2 hours of flight time), the airplane was estimated to weigh about 3,285 lbs at the time of the accident. Maximum gross weight is 3,801 pounds.

Recorded weather observation data from Daytona Beach International Airport (DAB), Daytona Beach, Florida, located about 30 miles south of the accident site, at 2253 included wind from 090° at 3 knots, 10 statute miles visibility, a broken cloud layer at 25,000 ft, temperature 28°C, dew point 26°C, and an altimeter setting of 30.15 inches of mercury.

The four-seat, low-wing, retractable gear, twin-engine airplane, serial number 44-7995245, was manufactured in 1979. The airplane was powered by 180-horsepower O-360-E1A6D and LO-360-F1A6D engines. Both engines were equipped with Hartzell constant-speed, 2-bladed propellers. The airplane was equipped with two 55-gallon fuel tanks.

Review of the airframe and engine maintenance logbooks revealed that the most recent annual inspection was completed on June 12, 2017, at an airframe total time of 9,460.5 hours and right engine tachometer hour reading of 9,460.5 hours. At the time of the inspection, the left engine had accumulated 2,174.0 hours since major overhaul and had an engine total time of 6,724.5 hours; the right engine had accumulated 3,122.4 hours since major overhaul and had an engine total time of 9,958.7 hours.

Using reported weights of both occupants (223 lbs and 185 lbs), an airplane empty weight of 2,460 lbs, and an estimated fuel load of 72 gallons (full fuel minus about 2 hours of flight time), the airplane was estimated to weigh about 3,285 lbs at the time of the accident. Maximum gross weight is 3,801 pounds.

The airplane impacted terrain about 25 miles north of OMN. The main wreckage came to rest inverted within a heavily wooded area. Trees directly above the wreckage were broken, consistent with little to no forward movement of the airplane at impact. The outboard portions of the left and right wings, baggage door, and a portion of the right side of the stabilator were located throughout a 0.5-mile-long and 0.2-mile-wide debris path in water and marshland northwest of the main wreckage. The fuselage came to rest inverted on a heading about 022° magnetic. Various debris, including fragments of the left stabilator, were located within about 50 ft of the fuselage. The wreckage was recovered to a secure location for further examination.

Fuselage

Examination of the recovered wreckage revealed that the roof structure was compressed into the cabin seating area. The fuselage was partially separated at fuselage station (FS) 156. The instrument panel was crushed aft into the front seat area. The cabin door and baggage area door were separated. Both the left and right inboard portion of the wings remained attached to the fuselage structure.

Both left and right seat control wheel horns were fragmented. The T-bar remained attached to the fuselage hinge point. The horizontal section was fragmented. The aileron control cables remained attached to the T-bar chain. The stabilator cables remained attached to the T-bar assembly. The rudder pedals were impact damaged. The rudder cables remained attached to the rudder cable assembly.

The left engine fuel selector valve lever was in the "on" position, and the right engine fuel selector valve lever was in the "off" position. The fuel selector valve positions could not be verified due to impact damage and mount separation at the fuselage. Air was applied to the fuel selector valves and continuity was established throughout each valve.

Left Wing

The outboard left wing was recovered about 0.48 mile west-northwest of the main wreckage. The main spar was fractured about wing station (WS) 105. The fiberglass wingtip was separated from the outboard wing at WS 206.7 and recovered mostly intact and undamaged. The left aileron was separated from the left outboard wing at the hinge points. Three sections of the left aileron were recovered, spanning from the inboard end about WS 106 to about WS 181. The outboard portion (25 inches) of the left aileron, including the aileron balance weight, was not recovered.

The main spar, leading edge, and upper and lower skins between about WS 105 and WS 130 were damaged and deformed up and aft indicative of an upward (positive) separation of the left outboard wing. There were several fractures and twisting deformation of the main spar structure in this area. The main spar inboard of the fracture point, between about WS 93 and WS 105, was deformed aft and down. A semicircular impact impression and tree debris were embedded in the wing structure in this area.

The aileron cables remained attached to the bellcrank and there was tearing of the WS 93 rib in an aft direction at the normal cable pass-through locations. The fractured ends of the aileron control and balance cables had a splayed appearance consistent with tension overload. The main spar fracture surfaces all had a dull, grainy appearance consistent with overstress separation. There was no evidence of any pre-existing corrosion or cracking on any of the fracture surfaces.

Right Wing

A large portion of the right outboard wing was recovered about 0.39 mile west-northwest of the main wreckage. The main spar upper cap was fractured about WS 126 and the lower cap was fractured about WS 148. The leading edge nose skin and ribs and lower leading edge skin were separated as a unit from the right outboard wing and recovered about 0.6 mile west-northwest of the main wreckage. A smaller piece of the leading edge lower skin about 3 ft long was also separated outboard of WS 170. The fiberglass wingtip was separated from the outboard wing at WS 206.7 and only the upper half was recovered. The right aileron was separated from the wing at the hinge points. The entire aileron was recovered; however, it was separated into two pieces at the center hinge point. The main spar inboard of the fracture point was deformed up and aft outboard of WS 105, indicative of an upward (positive) separation of the right outboard wing.

The aileron cables remained attached to the bellcrank and there were two cable tears through the upper wing skin inboard of the fracture point. The fractured ends of the aileron control and balance cables had a splayed, broomstraw appearance consistent with tension overload. The main spar fracture surfaces all exhibited a dull, grainy appearance consistent with overstress separation. There was no evidence of any pre-existing corrosion or cracking on any of the fracture surfaces.

Empennage

The vertical stabilizer was separated from the fuselage but remained connected to the fuselage by the electrical wiring. The two vertical stabilizer forward spar bolts remained installed in the stabilizer; however, they were pulled through the fuselage fitting in an upward direction. The vertical stabilizer rear attach fitting remained attached to the fuselage and was deformed aft and to the left. All the rivets that attached the fitting to the vertical stabilizer rear spar were sheared. The rudder was separated from the vertical stabilizer at the hinge points and was recovered at the main wreckage site. The rudder trim tab remained attached. The upper 12 to 18 inches of the vertical stabilizer and rudder were damaged and deformed to the left.

The horizontal stabilator hinge and counterweight was torn from the upper end of the vertical stabilizer and recovered at the main wreckage site. The left stabilator was torn into several pieces and was found wrapped around a tree at the main wreckage site. The left 28 inches and the center 29 inches of the trim tab were separated from the stabilator and recovered at the main wreckage site. The right side of the stabilator was separated from the empennage and recovered mostly intact about 0.6 mile west-northwest of the main wreckage. About 47 inches of the trim tab remained attached to the right stabilator. The right stabilator skins were buckled and there were impact impressions in the leading edge. The stabilator spar was fractured about right buttock line 7. The upper spar cap and upper stabilator skin were deformed and curled upward at the fracture point and the lower spar cap and lower stabilator skin had no obvious deformation. Matching of the fracture surfaces was indicative of upward direction separation to the left. The stabilator spar fracture surfaces all displayed a dull, grainy appearance consistent with overstress separation.

Flight Control Continuity

Flight control continuity was established throughout the airframe from the cockpit controls to all primary flight control surfaces. Numerous separations of the control system were observed. All areas of separation exhibited signatures consistent with overload separation.

Engine Examination

Left Engine

The left engine remained attached to the engine mount. The propeller assembly was partially separated from the engine just forward of the nose case and the crankshaft was fractured through about two-thirds of its circumference. The upper portion of the engine exhibited impact damage, mostly to the pushrod tubes. The upper spark plugs, vacuum pump, propeller governor, propeller, and fuel pump were removed from the engine. The crankshaft was rotated using the propeller flange. Rotational continuity was established throughout the engine and valve train. The No. 2 cylinder pushrods were damaged and would not allow for movement of the intake and exhaust rocker arm and valve when the crankshaft was rotated. After the No. 2 cylinder rocker arms were removed, thumb compression and suction was obtained on all four cylinders. All four cylinders were examined internally using a lighted borescope and were found unremarkable. Residual oil was present within the engine. The oil suction screen and oil filter were free of metallic debris.

The carburetor was impact separated and fractured across the throttle bore. The throttle and mixture control cables were separated; however, the cables remained attached to the respective control arms. The carburetor fuel inlet screen was missing, and the housing exhibited impact damage. The internal plastic float was intact and contained a blue liquid within 2 of the 3 bays. One bay was almost full of the liquid and the other bay was about one-third full. No fuel or debris was observed within the carburetor float bowl.

The engine-driven fuel pump base remained attached to the engine. The pump section of the governor was impact separated. The pump was partially disassembled and all internal components examined were unremarkable. Residual liquid consistent with fuel was observed within the fuel pump.

The top and bottom spark plugs were removed and examined. All four upper plugs were fractured and impact damaged. All eight spark plug electrodes exhibited worn normal signatures. All of the spark plugs exhibited dark gray deposits within the electrode area except for the No. 4 top spark plug; the electrode was separated consistent with impact damage.

The magneto remained attached to the engine and exhibited impact damage which precluded functional testing. All internal components were present and unremarkable.

The propeller governor base remained attached to the engine. The upper portion of the governor was fractured. The cable was separated however remained attached to the actuator arm. The propeller governor screen was free of debris.

The vacuum pump remained attached to the engine with external damage noted. The drive shaft was intact. The vacuum pump was disassembled. The carbon rotor was fractured, and the vanes remained intact.

Right Engine

The right engine remained attached to the engine mount. The propeller assembly was separated from the engine just forward of the nose case. The magneto and carburetor were separated from their respective mounts. The upper portion of the engine exhibited impact damage, mostly to the pushrod tubes. The upper spark plugs, vacuum pump, propeller governor, and fuel pump were removed from the engine. The crankshaft was rotated using a hand tool attached to an accessory drive mount pad. Rotational continuity was established throughout the engine and valve train. The No. 4 intake valve, No. 1 exhaust valve, and No. 3 intake and exhaust valve pushrods exhibited impact damage and would not allow for movement of the rocker arm and valve when the crankshaft was rotated. The rocker arms were removed and thumb compression and suction was obtained on all four cylinders. All four cylinders were examined internally using a lighted borescope and were found unremarkable. Residual oil was present within the engine. The oil suction screen and oil filter were free of metallic debris. The oil cooler hoses were secure to both the engine and oil cooler.

The carburetor was impact separated and fractured across the throttle bore. The throttle and mixture control cables were separated but remained attached to the respective control arms. The carburetor fuel inlet screen was partially crushed and exposed to elements, but was found free of debris. The internal plastic float was intact. No fuel or debris was observed within the carburetor float bowl.

The top and bottom spark plugs were removed and examined. All four upper plugs were fractured and impact damaged. All eight spark plug electrodes exhibited worn normal signatures. The number 1 upper and lower spark plugs exhibited darker deposits within the electrode area than the remainder of the spark plugs which exhibited light gray deposits.

The magneto was separated from the engine and exhibited impact damage which precluded functional testing. All internal components were present and unremarkable.

The engine-driven fuel pump base remained attached to the engine. The pump section of the governor was impact separated. The pump was partially disassembled, and all internal components examined were unremarkable. A liquid consistent with 100LL aviation fuel was observed within the fuel line from the engine-driven fuel pump to the carburetor.

The propeller governor base remained attached to the engine. The upper portion of the governor was fractured. The cable was separated but remained attached to the actuator arm. The propeller governor screen was free of debris.

The vacuum pump remained attached to the engine with no external damage noted. The drive shaft was intact. The vacuum pump was disassembled. The carbon rotor was fractured, and the vanes remained intact.

Propellers

Left

Examination of the left propeller revealed that all six mounting studs were present with no apparent damage to the propeller mounting flange. Both blades were bent aft and twisted leading edge down in varying degrees. The propeller pitch change mechanism appeared to be on the start lock. Blade one was rotated beyond the low pitch stop angle and the counterweight punctured the cylinder. The left propeller had chordwise/rotational abrasion on the camber side of the blades and witness marks indicating blade angle in the low range of normal operation.

Right

The right propeller was fractured from the engine aft of the crankshaft propeller mounting flange. The starter ring gear and crankshaft flange were still attached. All six mounting studs were present with no apparent damage to the propeller mounting flange. Blade one was bent aft and twisted. Blade two was unremarkable. The propeller pitch change mechanism appeared to be on the start lock. Blade one was rotated beyond the low pitch stop angle and the counterweight punctured the cylinder. The cylinder base appeared partially separated from the hub mounting area adjacent to blade one. The right propeller had chordwise/rotational abrasion on the camber side of the blades and witness marks indicating blade angle in the low range of normal operation.

An autopsy of the flight instructor was performed by the Flagler County Medical Examiner, St. Augustine, Florida. The autopsy report indicated that the pilot's cause of death was multiple blunt force injuries. The National Medical Services (NMS) Laboratory performed testing as part of the autopsy. Testing of a liver specimen detected ethanol at 0.087 gm/dl.

Toxicology testing on specimens recovered from the flight instructor performed at the FAA Forensic Sciences Laboratory identified the following: anhydroecgonine methyl ester in liver, a product formed when cocaine is smoked; benzoylecgonine, the primary inactive metabolite of cocaine, at 22 ng/mg in liver and 25 ng/mg in muscle; ecgonine methyl ester, an inactive metabolite of cocaine, in liver; levamisole, a veterinary medicine and common cutting agent used to dilute the purity of street cocaine, in liver; delta-9-tetrahydrocannabinol (THC), the primary psychoactive compound in marijuana, was detected in muscle at 108 ng/mg but was inconclusive in liver; and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH), the primary inactive metabolite of THC, was detected in in muscle at 4.5 ng/mg, in liver at 63.7 ng/mg, and in urine at 184.3 ng/ml. No ethanol was detected in the flight instructor's urine.

Cocaine is a strong central nervous system stimulant. Initial effects include euphoria, excitation, general arousal, dizziness, increased focus and alertness. At higher doses, effects may include psychosis, confusion, delusions, hallucinations, fear, antisocial behavior, and aggressiveness. Late effects, beginning within 1 to 2 hours after use, include dysphoria, depression, agitation, nervousness, drug craving, general central nervous system depression, fatigue, and insomnia. Additionally, more negative performance effects are expected after higher doses, with chronic ingestion, and during drug withdrawal, including agitation, anxiety, distress, inability to focus on divided attention tasks, inability to follow directions, confusion, hostility, time distortion, and poor balance and coordination.

Marijuana is a psychoactive central nervous system depressant. Concentrations of THC and THC-COOH are very dependent on pattern of use as well as dose. Concentrations vary depending on the potency of marijuana and the way the drug is used; however, peak plasma concentrations of 100-200 ng/mL are routinely encountered shortly after smoking. Plasma concentrations of THC decline rapidly and are often less than 5 ng/ml after 3 hours. Determination of accurate blood levels from known tissue levels is not possible at this time due to limited research and the drug's complex distribution and metabolism. Following smoking marijuana, most behavioral and physiological effects return to baseline levels within 3-5 hours after drug use, although some studies have demonstrated residual effects in specific behaviors up to 24 hours, such as complex divided attention tasks. In long-term users, even after periods of abstinence, selective attention (ability to filter out irrelevant information) has been shown to be adversely affected with increasing duration of use, and speed of information processing has been shown to be impaired with increasing frequency of use.

During an interview with the instructor's son, he reported that his family, including his father, were casual users of marijuana. He said that he knew of previous instances that his father used cocaine; however, he did not know when his father had last used either substance.

The use of cocaine and marijuana is prohibited under 14 CFR 91.17, which prohibits a person to act or attempt to act as a crew member of a civil aircraft while using any drug that affects the person's faculties in any ways contrary to safety.

Ethanol is primarily a social drug with a powerful central nervous system depressant. After absorption, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. Ethanol may also be produced in the body after death by microbial activity, however, vitreous humor and urine do not suffer from such production to any significant extent in relation to other tissues.

Pilot Receiving Instruction

An external-only examination autopsy of the pilot receiving instruction was performed by the Flagler County Medical Examiner, St. Augustine, Florida. The autopsy report indicated that the pilot's cause of death was multiple blunt force injuries.

Toxicology testing by the FAA Forensic Sciences Laboratory was not performed.

The airplane's design maneuvering speeds (VA) was 133 kts for a heavy airplane (3,800 lbs) and 112 kts for a lighter configuration (2,700 lbs; given the airplane's estimated weight at the time of the accident, (about 3,250 to 3,350 lbs), the design maneuvering speed was between 112 and 133 kts. The maximum structural cruising speed (Vno) was 165 kts.

An NTSB performance study calculated the airplane's indicated airspeed based on radar and ADS-B data. The study found that the airplane was flying at an altitude about 5,500 ft and an airspeed just above 130 kts with some variation. At 2257:36, the airplane began to descend and its airspeed increased to a maximum of 144 kts at 2257:59. At 2258:27, the airplane began to rapidly climb at a rate of 6,000 ft per minute (fpm) over the next 4 seconds from 5,200 ft to 5,600 ft before beginning its final descent. From 2258:32 to 2258:45, the rate of descent was in excess of 10,000 fpm. During this descent, the airplane exceeded Vno at 2258:39. The end of the radar and ADS-B data showed different flight paths; when combined, they show a right descending turn at the end of the flight.For more information, see the Performance Study within the public docket for this accident.