N635BDPiper PA-32R-300 · 1976

On April 5, 2023, at 2137 eastern daylight time, a Piper PA-32R-300, N635BD, was destroyed when it was involved in an accident near Venice, Florida. The commercial pilot and three passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

Earlier on the day of the accident, the airplane departed Albert Whitted Airport (SPG), St. Petersburg, Florida, and flew to Venice Municipal Airport (VNC), Venice, Florida. The accident occurred during the climb out from runway 23 on the return flight to SPG while the airplane was operating under night visual flight rules.

About 1540, a friend of the pilot received a text message that the pilot was flying with friends to VNC for dinner and would probably arrive between 1740 and 1800 hours. After they arrived, he picked them up in his vehicle, and he, the pilot, and the three passengers went to dinner. The pilot did not drink any alcohol. About 2050, he retrieved his vehicle from parking and picked up the pilot and his three passengers at the entrance to the restaurant and drove them back to the airport.

He then watched the pilot and front-seat passenger conduct a preflight inspection of the airplane, checking the leading edges, vertical and horizontal surfaces, landing gear, propeller, and oil quantity, and also look inside the cowling. The pilot’s friend estimated that the preflight took about 10 minutes. He became concerned as he saw the pilot and front-seat passenger use their iPhones to light and inspect the right-wing flap nearest the fuselage. But after some examination, the pilot stepped up and entered the right door with the front seat passenger right behind him.

Shortly after 2119, the pilot’s friend heard the engine start and saw a black puff of smoke come from the exhaust as the engine began to idle and cough roughly. It appeared after some acceleration it was not firing on all cylinders consistently. When he heard the engine rpm increase, he thought that something did not seem right. He continued to listen to the engine, and the rough idle seemed to smooth out with increased rpm. He then heard the rpm increase and decrease, likely as the pilot checked the magnetos. The airplane then idled for a few more minutes and began moving forward. The airplane paused for a moment and then taxied toward runway 23. The witness lost sight of the airplane before departure but continued to listen on the common traffic advisory frequency (CTAF). He lost track of time waiting for them to take off, but heard the pilot transmit on the CTAF frequency his intent to depart: “Venice Traffic, 635 Bravo Delta, Departing 230, Straight out.”

Several witnesses described seeing the airplane takeoff. One witness stated the airplane was about 300 to 400 ft above the ground when it stopped gaining altitude. The airplane then turned to the north before it impacted the water. Another witness recalled seeing the airplane rocking back and forth before it entered a right turn and descended straight down into the water.

Examination of video from security cameras at the Venice Airport Festival Grounds and the Venice Fishing Pier revealed that the airplane took off over dark water with no discernable horizon, began a shallow climb, then started a right turn. The runway lights turned off after the airplane departed. The airplane’s altitude peaked, then the airplane entered a rapid descent and impacted the water.

ADS-B track data provided by the Federal Aviation Administration (FAA), indicated that the airplane lifted off from the runway about 2136 and climbed on the runway heading until reaching a barometric altitude of about 300 ft and a ground speed of about 103 knots. The airplane entered a right turn and, at 2136:40.9, began to descend. Over the next 14 seconds, the track data indicated that the rate of descent and ground speed increased. The last data, recorded at 2136:54.6, showed the airplane at 100 ft, with a ground speed of about 136 knots and a vertical descent rate of 3,008 feet per minute.

According to FAA records, the pilot’s most recent FAA second-class medical certificate was issued on June 3, 2016. On June 17, 2021, the pilot received certification under the FAA BasicMed program.

No pilot logbooks were recovered or provided. A review of flight time information from an aviation insurance policy that began on May 15, 2022 (about 11 months before the accident) indicated that the pilot had accrued about 1,566 total hours of flight time, of which 250 hours were in tailwheel-equipped airplanes, 225 hours were in retractable gear airplanes, 15.9 hours were in multi-engine airplanes, and 15 hours were in the accident airplane make and model. Further review indicated the pilot had flown 15 hours in the last 12 months, but it did not indicate how many hours of night flight, or actual and simulated instrument time, the pilot had accrued.

No maintenance logbooks were recovered or provided. A review of historical business records (an aircraft status report, and copies of previous maintenance logbook entries) obtained from a maintenance and repair organization indicated that the airplane's most recent annual inspection was completed on September 15, 2022. At the time of the inspection, the airplane had accrued 5307.3 total hours of operation and the engine had accrued 134.5 hours since major overhaul.

A review of the 2135 recorded weather at VNC, recorded about 2 minutes before the accident, indicated that the winds were calm, visibility was 10 miles, and skies were clear.

Astronomical data indicated that the moon was full the night of the accident and moonrise had occurred about 2 hours 4 minutes before the accident; however, around the time of the accident the moon was at an altitude of 25° and at an azimuth of 109.68°, which would have been low on the eastern horizon, behind and to the left of the airplane.

No maintenance logbooks were recovered or provided. A review of historical business records (an aircraft status report, and copies of previous maintenance logbook entries) obtained from a maintenance and repair organization indicated that the airplane's most recent annual inspection was completed on September 15, 2022. At the time of the inspection, the airplane had accrued 5307.3 total hours of operation and the engine had accrued 134.5 hours since major overhaul.

Local emergency services and Sea Tow Venice (a local Sea Tow franchise that provided boat towing services) recovered most of the wreckage from the floor of the Gulf of America, at a depth of about 23 ft. The wreckage was then moved to a secure facility for examination.

Postaccident examination of the wreckage identified all major airplane components and control surfaces except for the right wing, right aileron, right flap, sections of the main fuselage, and parts of the fuel system.

The fuselage had been destroyed by impact; the top portion of the cabin and right wing were not recovered. The left wing was impact separated. The empennage was also impact separated approximately 12 ft from the rear of the airplane. The two rear seats and one seat back that were recovered were impact separated.

The rudder pedal cables remained attached to the rudder bar and had separated at the rear cabin separation area. The left rudder cable had separated at the turnbuckle. The right rudder cable displayed evidence of tensile overload.

Both stabilator control cables were attached to the T-bar and were separated at the rear cabin area. The rear stabilator control cable displayed evidence of tensile overload, and the forward stabilator control cable was separated at the turnbuckle.

The aileron control chain was separated from its sprockets. Both cables remained attached to the aileron control chain and were separated in the main cabin area. The separation areas displayed evidence of tensile overload.

Examination of the vacuum-powered attitude indicator revealed that the gyro was in place, would rotate, and displayed evidence of rotational scoring. Examination of the electric turn and bank indicator also revealed that the gyro had remained in place and rotational scoring was evident.

Flight control continuity was established from all primary flight control surfaces (except the right aileron, which was not recovered) to the control column and rudder pedals except for impact and recovery related separations.

The left wing was separated from the fuselage and exhibited outboard leading-edge damage. The flap remained in place and the aileron inboard section remained attached to the inboard hinge. Aileron continuity was established from the inboard aileron section to the wing root. Both cables separations at the wing root displayed evidence of tensile overload. The pitot mast was field tested with low pressure air and was free from blockage. The inboard fuel tank finger screen was free from blockage.

The vertical stabilizer and rudder remained attached to the empennage, and rudder continuity was established from the rudder to the empennage separation area. The right rudder cable separation displayed evidence of tensile overload, and the left rudder cable was separated at the turnbuckle.

The stabilator was twisted counterclockwise from the airframe. Stabilator continuity was established from the stabilator to the empennage separation area. The top stabilator cable was separated at the turnbuckle and the bottom stabilator cable displayed tensile overload. The stabilator trim jack screw displayed 8 threads (1 inch), consistent with a neutral to nose-up trim position.

Examination of the propeller and engine revealed that the two-bladed propeller had remained attached to the engine. Both blades were bent and twisted towards the face side. One blade (the “B” blade) exhibited leading-edge gouging on the outboard portion of the blade, consistent with the propeller impacting the No. 3 cylinder while rotating during the impact sequence.

The engine incurred impact and water damage. The recovery team filled the engine with diesel fuel for preservation after recovery.

Valvetrain and geartrain components were found to operate during crankshaft rotation. Thumb compression and suction were produced on all cylinders. Fuel was found in the fuel servo and in the inlet fuel line. The oil finger screen and oil filter element were free from blockage.

The engine-driven fuel pump was manually field tested and operational. The cable ends of the mixture, throttle, and propeller governor had all remained attached to their respective components.

Both magnetos were water damaged but produced spark during rotation. The engine-driven vacuum pump was functional, and air pressure and suction were felt through the respective ports when rotated. The electric auxiliary vacuum pump rotated then jammed when power was applied. The pump was disassembled and was found to be contaminated with sand.

During the examinations, no evidence of any preimpact failures or malfunctions of the airframe, engine, or propeller were discovered.

FAA Airplane Flying Handbook

According to the FAA Airplane Flying Handbook (FAA-H-8083-3C), crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, not only from the standpoint of landing (ditching) in the water, but also because with little or no lighting the horizon blends with the water, in which case depth perception and orientation become difficult. During poor visibility conditions over water, the horizon could become obscured, which could result in a loss of orientation. Even on clear nights, the stars may be reflected on the water surface, which could appear as a continuous array of lights, thus making the horizon difficult to identify.

Pilot's Handbook of Aeronautical Knowledge

The FAA Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25C), states 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. In a classic example, a pilot may believe the airplane is in level flight, when, in reality, it is in a gradual turn. If the airspeed increases, the pilot may experience a postural sensation of a level dive and pull back on the stick, which tightens the turn and creates increasing G-loads. If recovery is not initiated, a steep spiral will develop. This is sometimes called the graveyard spiral, because if the pilot fails to recognize that the airplane is in a spiral and fails to return the airplane to wings-level flight, the airplane will eventually strike the ground. If the horizon becomes visible again, the pilot will have an opportunity to return the airplane to straight-and-level flight and continued visual contact with the horizon will allow the pilot to maintain straight-and-level flight. However, if contact with the horizon is lost again, the inner ear may fool the pilot into thinking the airplane has started a bank in the other direction, causing the graveyard spiral to begin all over again.

The Handbook also advised that prevention is usually the best remedy for spatial disorientation, and "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." A pilot can reduce susceptibility to disorienting illusions through training and awareness and learning to rely totally on flight instruments.

The airplane was not equipped with a cockpit voice recorder or flight data recorder nor was it required to be. It was, however, equipped with a J.P. Instruments panel-mounted engine data monitor (EDM), which could record up to 24 parameters related to engine operations.

The unit could calculate, in real-time, horsepower, fuel used, shock cooling rate, and exhaust gas temperature differentials between the highest and lowest cylinder temperatures. The calculations were also based on aircraft installation.

The unit contained non-volatile memory for data storage of the parameters recorded and calculated. The memory could store up to 20 hours of data.

The EDM recording contained 237 power cycles from May 3, 2015, through April 5, 2023. The accident event was the last recording, and its duration was about 11 minutes at a 10-second sample rate.

Review of the recorded data indicated that the engine was producing power during the accident event. No anomalies with the engine operation were identified that would have resulted in the accident.

Medical Case Review

According to the FAA medical case review, the 64-year-old pilot’s last aviation medical examination was June 3, 2016. At that time, he reported having type II diabetes and high cholesterol. He reported taking simvastatin, a prescription medication commonly used to treat high cholesterol; saxagliptin and metformin, prescription oral medications commonly used to help control blood sugar in type II diabetes; and aspirin, an over-the-counter anti-inflammatory medication commonly used to treat pain and fever and decrease cardiovascular risk.

At the time of the examination, the pilot’s hemoglobin A1c (HbA1c) was 7.8%. The Aviation Medical Examiner (AME) issued him a second-class medical certificate via AME-Assisted Special Issuance (AASI), with the limitation that the medical certificate was not valid for any class after June 30, 2017. The medical certificate was no longer valid at the time of the accident.

The pilot completed a BasicMed course and had reported completing a BasicMed Comprehensive Medical Examination Checklist (CMEC), most recently in June 2021.

According to the FAA medical case review, the pilot received a Letter of Eligibility in 2004 for diet-controlled diabetes mellitus. In 2011, the pilot received an Authorization for Special Issuance for second-class medical certification for diabetes treated with oral medication; he was granted another authorization in 2015.

Autopsy Report

The State of Florida District Twelve Medical Examiner’s Office performed the pilot’s autopsy. According to the pilot’s autopsy report, the cause of death was blunt impact injuries, and his manner of death was accident. Examination of his coronary arteries revealed 50%-60% stenosis of the four major coronary arteries and/or their distal branches from atherosclerotic plaque. The aorta was found to have multiple areas of complex atherosclerotic plaque without an aneurysm. Examination of the brain, lungs and remainder of the heart identified no other significant natural disease.

Toxicological Testing

At the request of the District Twelve Medical Examiner’s Office, the University of Florida Forensic Toxicology Laboratory performed toxicological testing of the pilot’s cavity blood and bile. According to the autopsy report, no tested-for substances were detected.

The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem cavity blood and vitreous fluid of the pilot. Ethanol was detected in cavity blood at 0.013 g/dL, and ethanol was not detected in vitreous fluid. Glucose was detected in vitreous fluid at 162 mg/dL and the HbA1c was 12.1% in cavity blood.

Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury and can cause an affected toxicological specimen to test positive for ethanol while another specimen from the same person tests negative.

Autopilot

The airplane was equipped with a Trio Avionics two-axis autopilot system designed for navigation and altitude control. The system included back-lighted buttons and illuminated faceplate nomenclature.

According to the manufacturer, the minimum engagement altitude of the autopilot was 500 ft above ground level. Data indicated the airplane did not reach the minimum engagement altitude during the flight. The autopilot had horizontal and vertical navigation capabilities including altitude control, climb/descent functions with airspeed limiting, and altitude pre-select.

The autopilot was also equipped with a “Recover Mode;” should a pilot inadvertently enter a cloud and become obscured or disoriented, they could activate the “Recover Mode” by pressing a RECOVER button on the instrument panel. This would immediately cause the airplane to seek a wings-level attitude and the autopilot would enter the ALT HLD (altitude hold) mode.

Review of the operation manual for the autopilot indicated that the autopilot must be turned on for Recover Mode to function. Examination of the autopilot revealed that the “On/Off Switch” was in the Off position.