NTSB Factual Report

HISTORY OF THE FLIGHT

On February 7, 2014, about 1930 eastern standard time, a Piper PA-28-161, N2571U, was destroyed when it impacted the Atlantic Ocean off the coast of Stuart, Florida. The private pilot was fatally injured. Night instrument meteorological conditions (IMC) prevailed and no flight plan was filed for the flight, which originated from The Florida Keys Marathon Airport (MTH), Marathon, Florida, about 1730, and was destined for Vero Beach Municipal Airport (VRB), Vero Beach, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

According to the airplane's owner/operator, the pilot had rented the airplane for the period of one week, while he visited the United States from Europe. On the day of the accident, the pilot had flown the airplane from VRB to MTH. Review of fueling receipts from MTH showed that the pilot serviced the airplane with 16 gallons of 100LL aviation fuel at 1717, prior to departing for VRB.

According to radar and voice communication information provided by the Federal Aviation Administration, after departing from MTH, the pilot contacted air traffic control (ATC) about 1734, and requested visual flight rules flight following services, with a stated destination of VRB. The flight was subsequently radar identified and flew north, following the eastern Florida coastline. About 1 hour later, the pilot was approved to transition through the airspace of Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida, at an altitude of 500 feet or below. After transitioning through the airspace, ATC asked the pilot if he preferred to remain at his current altitude, or climb back up to his previous altitude, to which the pilot responded that he would remain "low."

About 1852, the pilot requested and was approved to transition through the airspace of Palm Beach International Airport (PBI), West Palm Beach, Florida at an altitude below 500 feet. At that time, the flight was about 12 nautical miles southeast of the airport. At 1853, ATC advised another airplane operating on the same radio frequency that IMC prevailed at Witham Field (SUA), Stuart, Florida, and that the flight subsequently requested an instrument flight rules clearance and an instrument approach to the airport. About one minute after that flight requested an instrument flight rules clearance, the accident pilot contacted ATC and requested, "approach, do you have a sense of the weather at Vero Beach, last I checked it was fine, but that was a while ago in Marathon and I couldn't check it since."

The controller initially provided the 1753 weather conditions at VRB – ¬¬with the caveat that they were an hour old¬¬¬ – which included an overcast ceiling at 800 feet and 10 statute miles visibility. At 1859, the controller provided the pilot with the 1853 weather observation at VRB, which included an overcast ceiling at 600 feet and 10 statute miles visibility. The pilot then requested the controller check the weather conditions at St Lucie County International Airport (FPR), Fort Pierce, Florida. The controller advised the pilot that the 1853 weather observation at FPR included scattered clouds at 700 feet, an overcast ceiling at 1,000 feet, and 10 statute miles visibility. The pilot responded, "alright, I guess I'm gonna have to divert to Fort Pierce in that case."

About 1901, the pilot checked with another PBI approach controller, and advised that he was flying at an altitude of 450 feet. About six minutes later, the pilot asked the controller if he could momentarily leave the radio frequency to check the weather conditions at SUA. When he checked back in with the controller, the controller asked the pilot, "what's your request, Stuart is IFR [instrument flight rules]?" The pilot responded, "…I'm already diverting to Fort Pierce because of the conditions at Vero Beach." At 1909, when the flight was about 20 nautical miles southeast of SUA, the controller asked the pilot if he planned to circumnavigate the airspace of the airport to maintain visual flight rules (VFR), to which the pilot responded in the affirmative. The controller also instructed the pilot to advise him if he need to change altitude in order to maintain VFR.

At 1914, when the flight was about 15 nautical miles southeast of SUA, the controller asked the pilot, "how does the weather look?" The pilot responded, "…the ceiling is pretty low, but otherwise it's ok." Shortly thereafter, the controller terminated radar services and issued the pilot a frequency change to the SUA air traffic control tower. The SUA tower controller subsequently advised the pilot to return to the PBI approach control frequency.

About 1916, the pilot again contacted PBI approach control, and the controller advised the pilot to circumnavigate the airspace surrounding SUA, and if possible to climb to 2,000 feet. The pilot responded that he would circumnavigate the airspace, but that, "I'll try and climb a little bit, but I don't think I'll get to 2,000." The controller then asked the pilot how the ceiling looked to his northeast, to which the pilot responded, "Looks a little bit better, looks to be improving." The controller then asked the pilot if he would like to transition through the SUA airspace about 2 to 3 miles offshore at an altitude of 1,000 feet. The pilot responded, "I think I'm going to be here for the time being, 'cause I can't get a real handle on the ceiling." The controller responded by asking the pilot what altitude he was able to maintain, to which the pilot responded 700 feet. The controller then advised the pilot to proceed northbound along the shoreline.

The PBI approach control radar continued to track the flight until about 1922. The airplane's last known position was recorded at 1922:47, about 4 nautical miles east of SUA, at a pressure altitude of 400 feet. The PBI approach controller next tried to contact the pilot at 1924, but his radio call was not answered. He then requested another flight relay a request to the accident pilot to contact the Miami Air Route Traffic Control Center (ARTCC). The pilot subsequently contacted the Miami Center controller at 1926, and advised the controller that he was about 15 miles from his destination of FPR, at an altitude of 450 feet. The controller questioned if the pilot intended to remain at that altitude, to which the pilot responded affirmative. The controller then stated, "roger, I will not be able to provide flight following at that altitude. I can't even give you vectors. [The] minimum safe altitude in the vicinity of Vero Beach is 1,600." The pilot acknowledged the controller at 1927:49. No further transmissions were received from the pilot.

The aircraft owner subsequently contacted Miami ARTCC about 2247 and reported the flight missing. Miami ARTCC issued an alert notice for the flight on February 8 at 1639. On February 9, a backpack containing the pilot's rental car keys and an identification document was given to the Martin County Sheriff's Office. The backpack had been discovered on the beach, about 3.5 nautical miles northeast of SUA on February 8, about 0730.

AIRCRAFT INFORMATION

According to FAA registration and airworthiness records, the accident airplane was manufactured in 1979. In May 2003, the airplane was modified with the installation of several components manufactured by Knots 2U, Ltd., which included wing root fairings and aileron, flap, and stabilator gap seals. No additional information regarding the airplane's airworthiness or maintenance history was available.

The airplane's owner/operator was the proprietor of a business that rented airplanes and accommodations to pilots from around the world. Typically pilots would stay in an apartment located adjacent to his home, located on a residential airpark. Depending on the type of flying the pilots intended to do during their visit, they would complete a "check flight" with the operator for day VFR, night VFR, or IFR operations. The accident pilot completed a check flight for VFR day operation, and the owner/operator expressed that he thought he had a verbal understanding with the pilot that he would not operate the airplane at night or in IMC.

PERSONNEL INFORMATION

The pilot held a FAA private pilot certificate with a rating for airplane single engine land. He did not hold an instrument rating. The pilot's certificate was issued on the basis of his United Kingdom pilot's license. According to the pilot's United Kingdom (UK) Civil Aviation Authority record, he held a private pilot license for airplanes [PPL(A)] with single engine piston land rating, which was issued in September 2010. He subsequently received a night qualification in December 2012.

The pilot's personal flight logs were not recovered. On his application for a US private pilot certificate, dated July 16, 2012, the pilot stated that he had accumulated 68 total hours of flight experience, with 1.28 hours of flight experience at night. The Air Accidents Investigation Branch of the UK also provided aircraft rental and flight instruction records for flying the pilot had done in the recent past. According to those records, the pilot had flown 6.5 total hours between November 2013 and January 18, 2014. All of the hours were logged as dual instruction, and none of the hours were flown at night. No other flight log information was recovered, and the pilot's total flight experience at the time of the accident could not be determined.

METEOROLOGICAL INFORMATION

The National Weather Service area forecast issued at 1345, and valid at the time of the accident, covering the northern two-thirds of Florida, predicted an overcast ceiling at 1,000 feet with cloud tops of 12,000 feet, and 5 statute miles visibility in light rain and mist. The prediction for the southern third of Florida included scattered clouds at 4,000 feet through 2200. After that time, a broken ceiling at 1,000 feet with cloud tops at 4,000 feet, and visibilities of 3 statute miles in mist were forecast to prevail.

There were no AIRMETs valid for the area surrounding the flight's last known position. An AIRMET for instrument meteorological conditions issued at 1545 warned of IMC north of SUA, with an outlook forecast extending the expected area of IMC south of SUA after 2200.

The Terminal Aerodrome Forecast (TAF) for VRB, issued at 1227, generally described that VMC would prevail with a broken ceiling at 1,500 feet through 0100 the following morning, at which time the ceiling was expected to fall to 800 feet. The subsequent VRB TAF, issued at 1834, forecast scattered clouds at 800 feet, overcast clouds at 1,500 feet through 0800 the following day, with a temporary period of 400-foot overcast ceilings and visibilities of 3 statute miles in mist between 0400 and 0800 (the following day).

Shortly before the pilot's departure from MTH, the current reported weather conditions at VRB (issued at 1653) included scattered clouds at 1,000 feet, a broken ceiling at 1,400 feet, and 10 statute miles visibility. A special observation was issued at 1730, reporting an overcast ceiling at 800 feet. The 1853 weather observation reported an overcast ceiling at 600 feet and 10 statute miles visibility.

The 1853 weather conditions reported at FPR included scattered clouds at 700 feet and a broken ceiling at 1,000 feet. A special observation was issued at 1900 advising of an overcast ceiling at 700 feet. The 1953 weather observation reported an overcast ceiling at 600 feet.

The weather conditions reported at SUA at 1747 included a broken ceiling at 700 feet and 7 statute miles visibility. Those conditions persisted beyond 1847, and the 2015 weather observation advised of an overcast ceiling at 500 feet with 10 statute miles visibility.

The weather conditions reported at PBI at 1843 included a broken ceiling at 4,100 feet and 10 statute miles visibility. The reported ceiling at PBI remained above 4,500 feet until 0110 the following day, when a broken ceiling at 300 feet was reported.

According to the U.S. Naval Observatory, the sun set at 1807 and the end of civil twilight occurred at 1831. Moonrise occurred at 1231, and the moon set at 0207 the following day.

WRECKAGE AND IMPACT INFORMATION

In the days and weeks following the accident, law enforcement agencies located in Martin and St. Lucie counties collected wreckage and personal effects correlated to be from the accident airplane as they washed onshore or were recovered at sea. The wreckage included a portion of one wing that included the fuel filler port and fuel filler placard. The wing piece was about 2 feet long and displayed significant impact related damage. A portion of wreckage was also recovered, which by manufacturer and part number stamps, was correlated to be a supplemental type certificated flap gap seal known to have been installed on the accident airplane. Other identifiable small parts included a portion of one seat track, a trim control cable, and the engine oil filler tube.

MEDICAL AND PATHOLOGICAL INFORMATION

About 4 weeks after the accident, a bone fragment was discovered on a beach in the vicinity of the airplane's last known position, and provided to the Martin County Sheriff's Department. Subsequent DNA-based testing revealed it to be a positive match with the pilot. No additional remains were recovered; therefore, toxicological testing was not performed.

ADDITIONAL INFORMATION

FAA Advisory Circular 61-134

In April 2003, the FAA published Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness. The circular stated in part:

"Operating in marginal VFR /IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC. As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR [instrument flight rules] applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT [controlled flight into terrain] accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough."

The circular concluded with several recommendations to avoid CFIT-type accidents which in part included:

"(1) Noninstrument rated VFR pilots should not attempt to fly in IMC.

(2) Know and fly above minimum published safe altitudes. VFR: Fly a minimum of 1,000 feet above the highest terrain in your immediate operating area in nonmountainous areas. Fly a minimum of 2,000 feet in mountainous areas."

According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of

NTSB Probable Cause

The noninstrument-rated pilot’s continued flight into dark night, instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation and subsequent impact with water.