NTSB Factual Report

HISTORY OF FLIGHT

On February 17, 2003, about 0910, eastern standard time, a Piper PA-23-250, N54835, registered to and operated by a private individual, as a Title 14 CFR Part 91 personal flight, crashed into the Atlantic Ocean, about 8 miles east of Miami, Florida. Instrument meteorological conditions prevailed in the area at the time, and a visual flight rules flight plan was filed. The private-rated pilot and three passengers received fatal injuries, and the airplane was destroyed. The flight originated the same day, about 0859.

According to information received from the U.S. Coast Guard, at 1143, they were notified that an airplane with four persons onboard had been reported overdue on a flight from Kendall-Tamiami Executive Airport, Miami, Florida, to South Bimini Airport, in the Bahamas. The U.S. Coast Guard launched search and rescue assets at 1146, and initiated a search for the missing airplane. At 1226, personal items along with light airplane related debris specific to the missing airplane were discovered floating in the vicinity of geographic position 25 degrees 29 minutes north latitude, 079 degrees 58 minutes west longitude, 8 miles east of the Miami Harbor Entrance, Miami, Florida. In addition, the bodies of the pilot and three passengers were also recovered by the U.S. Coast Guard, and there was an estimated 500 foot long and 200 foot wide oil sheen in the area.

Radar data related to the accident airplane was obtained from the Miami International Airport (MIA) Air Traffic Control Tower Airport Surveillance Radar System model 9 (ASR-9) radar site. The radar targets were extracted from the MIA Automated Radar Terminal System (ARTS) 111A continuous data recording (CDR) system. The radar targets attributable to N54835 began at 0859:47. Between 0859:47 and 0906:00 radar data showed that the airplane's altitude-encrypted transponder indicated a continuous climb to 4,500 feet. The airplane's ground speed varied between 124 to 144 knots. The data further showed that the airplane remained at 4,500 feet for approximately 45 seconds and at 0906:37 began a slow descent. The descent continued until the airplane was lost from radar, approximately 4 minutes later. Its ground speed during this interval varied between 147 and 190 knots. Radar data from the aircraft's last minute of flight showed a right turn during descent from a magnetic heading of 129 degrees to 170 degrees and from an altitude of 2,500 feet MSL to 300 feet MSL. The last radar return was observed at 0910:51, in a location consistent with where debris had been found by rescue assets.

PERSONNEL INFORMATION

According to information obtained from the FAA, the pilot of the PA-23-250 held a private pilot certificate with airplane single-engine land and airplane multiengine land ratings, issued on February 21, 1971. No records could be found that would indicate that the pilot posessed an FAA instrument rating. He also held an FAA third class medical certificate, issued on August 1, 2001, with had the stated limitation "Holder shall wear corrective lenses while exercising the priveleges of this airman certificate". At the time of his application for the medical certificate he reported having accumulated over 4,000 hours of total flight experience.

AIRCRAFT INFORMATION

Light airplane-related debris was found floating in the Atlantic Ocean by U.S. Coast Guard search and rescue assets. The debris included portions of the seat/seat cushions, life jackets, a distress float bag containing an Emergency Position Indicating Radiobeacon, and a landing gear wheel etc. The main airplane wreckage and the two engines were not recovered.

N54835 is a 1975 Piper PA-23-250 Aztec, serial number 27-7554. The airplane log books were never obtained by the NTSB. The airplane was equipped with two Lycoming TI0-540 SER, 310 horsepower engines.

METEOROLOGICAL INFORMATION

The pilot of N54835 had received weather information from the Miami Automated International Flight Service Station (MIA-AIFSS) on five separate occasions before departing Tamiami. During each conversation, he inquired into the expected weather along the route from the Kendall-Tamiami Executive Airport to the South Bimini Airport.

The pilot's first communication with MIA-AIFSS took place at 1451, on February 16, 2003, at which time the pilot requested an outlook briefing for his intended route of flight. The weather briefer informed the pilot that rain showers and thunderstorms were predicted to precede the frontal system across the southern tip of Florida and move out past Nassau, Bahamas, later in the afternoon. The pilot told the briefer that based upon the outlook he did not plan on going, but would call back to see if the conditions had improved.

The pilot's last communication with MIA-AIFSS prior to departure occurred at 0825, on the day of the accident. During this conversation, the pilot noted that he had initially filed a VFR flight plan, and had intended to depart at 0815. The briefer then told the pilot that there was weather activity beginning near Key Largo, Florida, and extending to the southwest, but that presently there was nothing significant along his route from Tamiami, to Bimini. The briefer further added that the "Key Largo system" was moving slowly to the northeast. According to the radar data valid at the time of this briefing, the path from Tamiami to Bimini were mostly free of precipitation. A half hour passed between the end of this brief and the time that N54835 took off, during which time radar data showed that the system had progressed to the northeast.

The closest weather station to the accident location was at the Miami International Airport (MIA), Miami, Florida. The MIA 0856, surface weather observation was, wind from 190 degrees at 3 knots, visibility 10 statute miles, scattered clouds at 10,000 feet AGL, broken layer at 25,000 feet AGL, temperature 73 degrees F, dew point temperature 66 degrees F, altimeter setting 30.04 inHg. Miami, Florida, is located 25 miles north west of the accident site at 314 degrees.

The Miami terminal aerodrome forecast predicted 2,000 foot ceilings around the time of the accident. No in-flight advisories had been issued for the time and location of the accident, but advisories were issued for locations to the north of the accident site.

The Tamiami 0853, surface weather observation was, wind from 180 degrees at 5 knots, visibility 10 statute miles, few clouds at 1,500 feet AGL, overcast at 8,000 feet AGL, temperature 72 degrees F, dew point temperature 70 degrees F, altimeter setting 30.03 inHg. Tamiami, Florida is located 34 miles northwest of the accident site and was the departure airport of the accident flight.

The Area Forecast that was valid at the time of the accident was issued on February 17, 2003, at 0445, and was valid until 1800. The outlook for this area was conducive to flight under visual flight rules. According to the forecast, the southern portion of Florida could expect scattered to broken skies at 1,500 feet, broken layer at 11,000 feet, and tops at 25,000 feet. Light rain showers would be widely scattered along the east coast and by 0900, a scattered to broken sky cover at 2,000 feet and broken at 5,000 feet could be expected. The outlook for the Atlantic coastal waters of southern Florida was visual flight rules with scattered light rain showers and isolated light thunderstorms in the area.

Two pilot reports also noted the existence of low clouds and overcast skies within 2 hours of the accident. A report from Fort Lauderdale, Florida, approximately 1 hour and 45 minutes after the accident stated that IMC conditions were sporadically encountered during climbout and up to 27,000 feet. There were no reports of turbulence in the area.

Upper air data was examined in order to determine whether an environment existed that could produce and sustain a convective weather system. Data from the Miami 1200Z, upper air sounding showed a 1.59 inch precipitable water value. Winds were out of the west-southwest, and wind speeds were between 20 and 25 knots from 1,000 to 10,000 feet. Upper air data indicated that the freezing level was near 14,000 feet. Data from the sounding was used to determine air saturation and dewpoint temperature spread. Air temperature at the surface at the time of the accident was 67 degrees F and the dew point temperature was 65 degrees F.

See the NTSB Meteorology Group Chairman's Factual Report.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot of N54835 was performed by a pathologist with the District 11 Medical Examiner's Office, Miami, Florida, on February 19, 2003. The cause of death was attributed to multiple blunt traumatic injuries. No findings which could be considered causal to the accident were reported.

A toxicological examination was performed by the District 11 Medical Examiner's Office for the presence of ethanol, benzoylecgonine, opiates, benzodiazepines, barbiturates, and basic drugs. Ethanol was found to be present in the bile and liver at .02% and .03%.

The FAA Toxicology Laboratory, Oklahoma City, Oklahoma, conducted toxicology studies on specimens from the pilot. The specimens were tested for the presence of volatiles and drugs. Ethanol was found to be present the liver and muscles, with levels ranging from 13 (mg/dl, mg/hg) to 16 (mg/dl, mg/hg). Acetaldehyde was found to be present in the liver.

NTSB Probable Cause

The non instrument-rated pilot-in-command's improper inflight planning/decision, and continued VFR flight into instrument meteorological conditions, which resulted in a loss of control during descent, and impact with water.