NTSB Factual Report

HISTORY OF FLIGHT

On November 4, 2004, about 1927 eastern standard time, a SOCATA TB 20, N1905S, registered to and operated by Megapede USA, Inc., crashed into the Straits of Florida approximately 5.13 statute miles and 199 degrees from the Key West International Airport, Key West, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight from Key West International Airport, to Sarasota/Bradenton International Airport, Sarasota, Florida. The airplane was destroyed by impact, and the private-rated pilot and one passenger were fatally injured. The flight originated about 1923, from Key West International Airport.

According to a transcription of communications with Key West International Airport (KEYW) Air Traffic Control Tower (ATCT), the pilot established contact with the tower at 1915:29, and advised the controller that the aircraft was IFR, had ATIS information Delta, and was ready to taxi. The controller advised the pilot to taxi to runway 09, and cleared the flight to the destination airport as filed, to maintain 6,000 feet, and provided the departure frequency and discrete transponder code (0040). The pilot correctly repeated the IFR clearance then requested, "... will I be able to get a right turn out so that I can do a climbing circle over Key West." The controller advised the pilot that he was going to coordinate with approach control. At 1922:27, the pilot contacted the tower and advised the controller that the flight was ready for departure. At 1922:49, the controller cleared the flight for takeoff, which was acknowledged by the pilot. The controller advised Naval Air Station Key West approach control that the aircraft was, "... rolling", and, "... he's going southbound one eighty." At 1924:17, the tower controller advised the pilot to fly heading 180 degrees and to contact departure control. The pilot responded, "zero five sierra one eight zero on the heading departure." There was no further communications with the KEYW ATCT.

According to a transcription of communications with the Naval Air Station Key West Air Traffic Control Facility (NAS ATCF), at 1924:28, the pilot established contact with the facility. The airplane was radar identified and the pilot was advised to continue heading 180 degrees. At the pilot's request, the controller repeated the instruction to fly heading 180 degrees. The pilot acknowledged the heading of 180 degrees. At 1925:15, the NAS ATCF controller asked the pilot the current heading to which he replied, "zero five sierra is on a heading of one eight zero." At 1926:36, the NAS ATCF controller advised the pilot to turn right heading 360 degrees and when able to proceed direct to Lee County VORTAC, which the pilot correctly read back. At 1928:47, the NAS ATCF controller advised the pilot that the facility was not receiving the transponder beacon return and to reset the transponder code to 0040; the pilot did not acknowledge this, and there were no further transmissions from the pilot of the accident airplane. At 1933:34, the NAS ATCF controller contacted the KEYW ATCT and asked the controller, "... do you see his code anywhere." The KEYW ATCT controller advised the NAS ATCF controller, "I do not see him out [there] flying anywhere." The controller made repeated broadcasts to the pilot of the accident airplane; the pilot did not respond.

Review of NTSB obtained recorded radar data revealed that discrete transponder returns associated with the accident airplane while airborne were noted from 1924:01, when the airplane was at 100 feet mean sea level (msl), to 1927:01, when the airplane was at 1,900 feet msl. The recorded radar data depicts that after departing Key West International Airport to the east, the airplane banked to the right and flew in a southwesterly direction between approximately 1924:49, and 1925:13. The radar data then depicts the airplane flying in a southerly direction from 1925:25, to 1927:01, where the last recorded transponder return was located at 24 degrees 29.032 minutes North latitude and 081 degrees 46.242 minutes West longitude. The recorded radar targets occur every 12 seconds; a total of 16 radar targets with altitude depicted are noted. There was no record of a malfunction of the radar site at the time of or after the last radar target.

PERSONNEL INFORMATION

The pilot was the holder of a private pilot certificate with ratings airplane single-engine land and instrument airplane. A review of his airman file revealed he failed instrument approach procedures during his first attempt to obtain the instrument rating on September 12, 2000. He obtained his instrument rating the following day. He was issued a third class medical certificate on April 15, 2004, with the restriction "must wear corrective lenses." A review of the application for his last medical certificate revealed he listed a total flight time of 813 hours.

A review of provided copies of the pilot's first two logbooks that began with his first logged flight in January 1982, and ends with his last logged flight in October 2001, revealed he logged a total time of 651.3 hours, and 39.4 hours night time. The logbooks did not reflect any actual instrument flight time logged, but he did log 51.2 hours simulated instrument time. The pilot's most recent pilot logbook was not located; therefore, no determination was made whether he was instrument current.

As previously reported, the pilot indicated a total flight time of 813 hours on the April 15, 2004, application for his medical certificate. Information provided by the owner of the airplane revealed that from April 22, 2004, to the date of the accident, the accident pilot flew the airplane approximately 16 hours. Prior to the flight on the accident date from Sarasota to Key West, Florida, the accident pilot last flew the airplane on October 22, 2004. On October 14, 2004, the accident pilot flew the airplane a total of .93 hour, and in an e-mail from him to the airplane owner, reported performing "three full-stop night landings at SRQ."

According to FAA records, the passenger did not hold any pilot certificate. Immediate relatives advised the NTSB that she would typically sit in the copilot seat during a flight.

AIRCRAFT INFORMATION

The airplane was manufactured in June 1999, by Socata Group Aerospatiale as model TB 20, and was designated serial number 1905. A U.S. standard airworthiness certificate was issued on July 13, 1999, and it was certificated in the normal category. The airplane was equipped with a Lycoming TIO-540-C4D5D engine rated at 250 horsepower at 2,575 rpm, and a Hartzell HC-C2YK-1BF constant speed propeller with F8477-4 propeller blades. The airplane was also equipped with a King KFC 150 2-axis autopilot system with altitude hold, and a backup electrically operated attitude indicator installed on the copilot's side of the instrument panel. An electrically operated standby vacuum pump was installed in accordance with Supplemental Type Certificate SA 7628SW on March 17, 2000.

A review of the maintenance records revealed that on October 29, 2002, the altimeter and automatic pressure reporting and static system inspections and the transponder inspection were complied with. On July 8, 2003, the engine-driven vacuum pump was replaced, and on the same date the repaired propeller was installed. The airplane was last inspected in accordance with an annual inspection on November 28, 2003. The aircraft total time at that time was recorded to be 535.46 hours. The airplane had accumulated approximately 145 hours since the inspection at the time of the accident; the airplane total time at the time of the accident was approximately 681 hours.

The airplane owner reported that he last flew the airplane on October 22nd and 23rd, 2004, on flights from Sarasota, Florida, to Gulfport, Mississippi (Gulfport), then returned to Sarasota, Florida. He did not experience any problems with the airplane or its systems, and the autopilot system was working perfectly but he did not know if the accident pilot was proficient in using the autopilot system. He performed a full coupled ILS approach into Gulfport, and did not experience any problems. He also reported the airplane was scheduled for an annual inspection on November 8, 2004.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at the Key West International Airport at 1940, or approximately 13 minutes after the accident indicates that the wind was from 090 degrees at 5 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dewpoint were 27 and 21 degrees Celsius, respectively, and the altimeter setting was 30.00 inHg.

United States Naval Observatory data for November 4, 2004, indicates that the sunset was at 1745, and the end of civil twilight occurred at 1809.

COMMUNICATIONS

The pilot was last in contact with the Naval Air Station Air Traffic Control Facility; there was no reported communication difficulty.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed into the Straits of Florida. Floating wreckage located immediately by the U.S. Coast Guard was retained for further examination. The main wreckage was located on December 8, 2004, or 34 days later, at 24 degrees 29.065 minutes North latitude and 081 degrees 46.849 minutes West longitude, which was approximately .55 nautical mile and 278 degrees from the last recorded radar target. All debris found at the site was located within approximately 100 feet of the main wreckage.

The NTSB first examined the wreckage following recovery. The examination revealed that the fuselage and both wings were fragmented. The main spars of the wings were connected at the center section of the aircraft, and both were fractured approximately 2 feet outboard of the center section. The right wing upper spar cap was rotated forward, while the left-wing upper spar cap bent down and slightly forward. The vertical stabilizer remained secured to the empennage, and the rudder remained connected by the trim cable. The pitch, counterweight was separated but located. Examination of the fracture surface revealed 45-degree shear lips. The horizontal stabilator was comprised of three major sections; all major structure was accounted for. Both attachment fittings were fractured, with no evidence of preimpact failure or malfunction. The stabilator trim tab actuator measured 1.936 inches extended, or approximately 3 threads exposed. The airplane manufacturer indicates that with three full threads exposed, the pitch trim jackscrew is in the full nose up position. The stabilator push/pull tubes exhibited multiple fractures; no evidence of preimpact failure or malfunction was noted. The full span of both ailerons were accounted for. The aileron push/pull tubes were fractured in several locations; no evidence of preimpact failure or malfunction was noted. The outboard push/pull tube for the right aileron was not identified. Examination of the rudder push/pull tubes revealed not all sections were located. No evidence of preimpact failure or malfunction was noted on any of the fracture surfaces. The left main landing gear was not located, and the nose and right main landing gears were separated. The left main landing gear actuator was extended 2.75 inches, while the right main landing gear actuator was extended 5.25 inches. No evidence of fire or heat damage was noted to any recovered wreckage.

Examination of the wreckage located and initially retained by the U.S. Coast Guard consisting of a 22 cubic foot oxygen tank, seat cushions, and miscellaneous items revealed no evidence of fire or heat damage.

Examination of the cockpit revealed the landing gear selector was in the down position, the flap indicator depicted 1/2 flaps extended, and the turn coordinator indicated a right bank greater than standard rate. The airspeed indicator was indicating 206 knots (Vne limitation is 186 knots). The backup attitude indicator installed on the co-pilot's side of the instrument panel indicated a right bank of approximately 65 degrees, and although the airplane silhouette was not in position, the indicator was depicting a nose-low attitude greater than 20 degrees. The oil temperature was in the green arc, and the oil pressure was in the upper end of the green arc. The left and right fuel quantity gauges indicated zero, and the tachometer was indicating approximately 2,700 rpm, or greater than maximum red line. The fuel selector was positioned to the right tank. The attitude indicator and altimeter were retained for further examination.

Examination of the engine by a representative of the engine manufacturer with NTSB oversight revealed the propeller remained attached to the engine, but the crankshaft was bent and partially separated approximately 1.5 inches aft of the crankshaft flange. The single-drive dual magneto (magneto), servo fuel injector, and vacuum pump were separated from the engine but recovered. Partial disassembly of the engine revealed crankshaft, camshaft, and valve train continuity. Impact and salt water corrosion to the magnetos, ignition harness, servo fuel injector (fuel servo), flow divider, fuel injector lines and nozzles precluded bench testing. Examination of the fuel servo revealed the mixture and throttle shafts were bent. The fuel servo inlet screen was partially covered with the white colored substance. Disassembly of the fuel servo revealed the fuel and air diaphragms were not cut or torn, and the fuel diaphragm stem was not fractured. Examination of the flow divider revealed the diaphragm was not torn, and a residual liquid consistent with 100 Low Lead was observed inside the unit during disassembly. The diaphragm section of the engine-driven fuel pump was separated from the drive section of the engine, and the top cover of the pump was corroded away. The top diaphragm was ruptured and the bottom diaphragm was not torn. Examination of the magneto revealed internal corrosion and the points of the right magneto were broken. Examination of the spark plugs revealed all exhibited normal wear. The engine-driven vacuum pump was separated; the drive coupling was not recovered. A section of the vacuum pump attachment flange remained secured to the accessory case of the engine. Disassembly of the engine-driven vacuum pump revealed the rotor and rotor vanes were not fractured. Examination of the standby vacuum pump revealed the mounting bracket was bent, and the drive coupling was separated. Disassembly of the standby vacuum pump revealed the rotor and rotor vanes were not fractured.

Examination of the propeller revealed both propeller blades remained secured inside the propeller hub, but both blades were free to rotate inside the propeller hub. The No. 1 propeller blade exhibited a smooth radius forward bend beginning approximately 16 inches inboard from the blade tip. The No. 2 propeller blade was bent aft and the leading edge was twisted towards low pitch. The leading edge was damaged near the blade tip.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination and toxicological analysis of specimens of the pilot were not performed due to insufficient specimens. Relatives of the pilot reported that he did not smoke, and was generally in good health. Additionally, there had been no family history of either a heart attack or stroke.

A postmortem examination of the passenger was preformed by the District 16 Medical Examiner's Office. The cause of death was listed as multiple blunt force injuries.

The FAA Toxicology and Accident Research Laboratory (CAMI), located in Oklahoma City, Oklahoma, performed toxicological analysis of specimens of the passenger. Ethanol was detected in the liver specimen (25 mg/dL), and in the muscle specimen (33 mg/dL), respectively. Additionally, acetaldehyde was also detected in the liver specimen (65 mg/dL), and in the muscle specimen (17 mg/dL), respectively. The result was negative for tested drugs, and testing for carbon monoxide and cyanide was not performed.

TESTS AND RESEARCH

At approximately 1930, an individual in a boat advised the U.S. Coast Guard (Coast Guard) Key West Sec

NTSB Probable Cause

The pilot's failure to maintain aircraft control as a result of spatial disorientation. A related factor was the dark, night conditions.