NTSB Factual Report

HISTORY OF FLIGHT

On March 20, 1994, about 2032 eastern standard time, a Piper PA-28R-200, N55999, registered to Aries Enterprise Inc., Wilmington, Delaware, operated by Sunshine Flying Club, St. Petersburg, Florida, crashed into Sarasota Bay, Sarasota, Florida, while maneuvering on a 14 CFR Part 91 personal flight. The airplane was destroyed. Instrument meteorological conditions prevailed, and an instrument flight plan was filed. The airline transport pilot-in-command (PIC), private pilot copilot, private pilot passenger, and one other passenger was fatally injured. The accident flight originated from Daytona Beach, Florida, about 1 hour 25 minutes before the accident.

Review of transcripts on file at Gainesville Flight Service Station (GNVPF3) revealed the pilot-in-command of N55999 called GNVPF3 at 2335:41 (1935:41 EST), and filed an instrument flight plan to Sarasota, Florida. The PIC was briefed on the weather at Sarasota, Florida, by an air traffic control specialist at 2337:25 (1937:25 EST). The weather was, "indefinite ceiling one hundred obscured visibility one half fog forecast for Sarasota ceiling one hundred sky obscured visibility one half fog occasionally ceiling of four hundred overcast visibility three in fog and that's valid through seven A-M in the morning." The PIC asked for and received the weather for Tampa, Florida. The PIC did not list an alternate airport, and the briefing was completed at 2339:14 (1939:14 EST).

Transcripts of recorded communication between Tampa Approach Control, and N55999 revealed that N55999 was cleared for an ILS approach to runway 32 at the Sarasota/Bradenton International airport at 0125:44 (2025:44 EST). N55999 acknowledged the clearance at 0125:53 (2025:53 EST) stating triple niner. All other communication was unintelligible. Tampa Approach instructed Cherokee triple niner to contact Sarasota tower on frequency one two zero point one at 0126:57 (2026:57 EST). The acknowledgement was unintelligible. N55999 attempted to contact Sarasota tower at 0126:35 (2026:35 EST). Voice communication from N55999 remained unintelligible. N55999 was instructed to ident on the transponder, N55999 complied with the instruction and was cleared to land on runway 32. N55999 replied by keying the airplane microphone.

The airplane was observed by Sarasota tower local controller on radar making a missed approach to the left prior to reaching the missed approach point. The pilot did not fly the published missed approach. The pilot was issued alternate IFR missed approach instructions to fly heading 220, maintain 1,600 feet by the local controller. The pilot acknowledged the ATC alternate IFR missed approach procedures by clicking the microphone. The procedures issued by the ATC controller comply with IFR departure procedures contained in the Letter of Agreement between Tampa Approach Control and Sarasota ATCT. The pilot did not comply with the alternate IFR missed approach instructions. Additional attempts by the local controller to establish communication with N55999 were uneventful.

Review of the Continuous Data Recording (CDR), and the data plot generated by Tampa ATC tower reveals N55999 was 100 feet below altitude, and right of the final approach course when the airplane was abeam the locator outer marker at 0126:57 (2026:57 EST). The airplane was established on the localizer course at 0127:20 (2027:20 EST), and continued to "s" turn through the final approach course to the right, left, right, and left before initiating a missed approach at 400 feet msl at 0129:06 (2029:06 EST), about .93 tenths of a mile before reaching the published missed approach point. The airplane continued the left turn to a heading of 317 degrees and descended to 200 feet msl at 0129:43 (2029:43 EST) before turning back to the right and climbing to 600 feet msl at 0130:57 (2030:57 EST). The airplane made another left turn, followed by a right turn. The last recorded radar hit was at 0131:48 (2031:48 EST). The airplane was at 700 feet msl on a heading of 047 degrees.

A witness stated he walked outside a restaurant at the marina plaza located on Sarasota Bay and heard an airplane fly overhead to the west. The witness could not see the airplane. The weather at the time was ceiling less than 200 feet agl, visibility 1/2 mile and fog. The airplane appeared to circle to the north and returned back towards the marina from the southeast. The witness observed the airplane descending through the fog in a 45-degree nose-down attitude, in a right turn estimated about 65 to 75 degrees. The navigation lights were on and the landing gear was up. The airplane disappeared from view behind a building. The engine rpm was heard to increase followed by an impact, and a subsequent explosion.

PERSONNEL INFORMATION

Review of the pilot-in-command's, Joseph F. Carlin Jr., pilot master logbook revealed his last recorded flight in the PA-28R before the accident was on March 27, 1988. The PIC's total time recorded as logged in the PA-28R was 8.3 hours, of which 1.1 hours was actual instruments. The PIC's last recorded instrument flight in instrument flight conditions was on August 22, 1993. The PIC's last recorded hooded flight was on January 14, 1988, and his last recorded night flight was on July 10, 1993. There was no recorded entry in the PIC's logbook indicating the PIC had made three takeoffs and landings at night as the sole manipulator of the flight controls within the preceding 90 days. (For additional information pertaining to the PIC see NTSB Form 6120.4).

The Federal Aviation Administration records, Oklahoma City, Oklahoma, revealed the copilot, Carsten Quandt, was issued a private pilot airman certificate, with ratings for airplane single engine land on March 12, 1991, on the basis of his German certificate number 9856-NWDU. The copilot held a first-class medical certificate issued on March 5, 1991. The copilot passed the instrument pilot written exam on April 1, 1992, and the flight check on April 9, 1992. He recorded on the airman certificate and or rating application dated April 9, 1992, that he held a third-class medical certificate issued on March 5, 1991. A record of diligent search by the Department of Transportation revealed the FAA had no record of a medical certification for Carsten Quandt. The copilot's logbooks were not located.

AIRCRAFT INFORMATION

Review of airframe maintenance records revealed the static pressure system test was recorded as logged on September 16, 1993. (For additional information pertaining to aircraft information see NTSB Form 612.1/2 and NTSB Form 6120.4).

METEOROLOGICAL INFORMATION

Instrument meteorological conditions prevailed at the time of accident. Witnesses who observed the accident stated the ceiling was between 50 to 200 feet, and the visibility was between 50 feet to 1/2 mile with fog. Official sunset was at 1842 hours with the end of twilight at 1905 hours. (For additional weather information, see NTSB Form 6120.4).

WRECKAGE AND IMPACT INFORMATION

The wreckage of N55999 was located in Sarasota Bay underneath slip 2, "E" dock at the Marina Jack Plaza, Sarasota, Florida. Examination of the crash site revealed the right wing of the airplane collided with the mast of two sailboats while descending in a right turn. The airplane continued forward and collided with the boat dock, collapsing about 8 feet of the dock, and separated the "T" end of the dock from the dock. The propeller separated from the propeller flange. Torsional twisting and "s" bending was present on both propeller blades. The left wing separated at the wing root and was bent up outboard the left fuel tank. The right wing separated at the wing root. Semicircular crushing was present along the leading edge of the right wing adjacent to the right main landing gear bay, and the outboard section of the right wing separated extending to the wing tip. The left and right fuel tanks were ruptured. The fuel selector valve was not recovered. The cabin area was compressed aft to the baggage compartment. The airplane came to rest on a heading of 280 degrees magnetic.

Examination of the airframe, flight controls, engine assembly, and accessories revealed no evidence to indicate a precrash mechanical failure or malfunction.

Visual inspection of the turn and slip indicator, attitude gyro, and the directional gyro after disassembly revealed the rotor in the turn and slip indicator was found in the normal position in the housing. The gyro rotors in the attitude gyro and the directional gyro were found in their normal position in the housing.

Visual inspection of the alternator after disassembly revealed one negative diode was disconnected. All diodes were functionally checked with an ohm meter. Continuity of the rotor and all three stater wires was confirmed with an ohm meter.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examination of the pilot-in-command, Joseph F. Carlin Jr., was conducted by Dr. James C. Wilson, Associate Medical Examiner, District 12, Sarasota, Florida, on March 21, 1994. The cause of death was multiple severe blunt traumatic injuries. Injuries sustained during the crash sequence were consistent with an individual on the flight controls at the time of impact. Postmortem toxicology studies of specimens from the pilot-in-command was performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs. Quinine was detected in the urine ,and (9.900 ug/ml) of salicylate was detected in the urine.

Postmortem examination of the copilot, Carsten Quandt, was conducted by Dr. James C. Wilson, Associate Medical Examiner, District 12, Sarasota, Florida, on March 21, 1994. The cause of death was multiple severe blunt traumatic injuries. Postmortem toxicology studies of specimens from the copilot was performed by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs.

TEST AND RESEARCH

Light bulbs from the instrument panel for the landing gear, auto-ext-off, external panel lights, and left navigation light were forwarded to the NTSB Materials Laboratory Division for analysis. Examination of the light bulbs for the landing gear, and the auto-ext-off revealed the lamps were intact, and contained no evidence of stretched filaments. Examination of the 17 external panel lights revealed 13 panel lights contained filaments that were intact and severely stretched. The glass bulbs were broken on the remaining four lamps due to postimpact damage. Magnified examination of the left navigation light filament revealed particles of fused glass between the coils. (For additional information see NTSB Physical Science Technician's Factual Report).

Advisory Circular 60-4 states in part, "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon or other visual reference exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight supported by other senses, allow the pilot to maintain orientation. However during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. Spatial disorientation to a pilot means simply the inability to tell which way is "up."...Lack of natural horizon or such reference is common on over water flights, at night...or in low visibility conditions."

A flight check of ILS runway 32 at the Sarasota/Bradenton International Airport, Sarasota, Florida, was requested and conducted by the FAA Atlanta Flight Inspection Field Office on March 21, 1994, with no deficiencies noted.

ADDITIONAL INFORMATION

The airplane wreckage was released to Mr. Joe W. Jones, Florida Air Marine Adjusters Inc., Riverview, Florida, on March 22, 1994. Components retained for further testing were released to Mr. Al E. Sharpe, Aviation Consultant Services, Wimauma, Florida, on June 26, 1994. The aircraft logbooks were released to Mr. Robert Ennes, Manager, Sunshine Flying Club, St. Petersburg, Florida, on April 1, 1994.

NTSB Probable Cause

Failure of the pilot(s) to maintain control of the airplane due to spatial disorientation. Factors related to the accident were: A malfunction that resulted in a loss of normal radio transmission, and the pilot(s) lack of recent experience in this make and model of airplane.