NTSB Factual Report

HISTORY OF FLIGHT

On June 9, 1999, about 2054 eastern daylight time, a Piper PA-28R-200, N56192, registered to Major Strategies, Inc., dba Dolphin Holiday Flying Club, was lost from radar and radio contact approximately 2.2 nautical miles north of the Cape Canaveral Air Force Station Skid Strip, Cape Canaveral Air Station, Florida. Instrument meteorological conditions (IMC) prevailed in the area and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the private-rated pilot, the sole occupant, was fatally injured. The flight originated about 1903, from the Fort Lauderdale Executive Airport, Fort Lauderdale, Florida.

Before taxiing to takeoff, the pilot advised the controller that he received Automatic Terminal Information Service (ATIS) information "Echo", which indicated a thunderstorm distant southwest moving north, and hazardous weather information for south Florida and coastal waters available on HIWAS, Flight Watch, or Flight Service frequencies. The pilot received taxi clearance, requested flight following to the Sanford Airport, and received takeoff clearance. After takeoff at 1904:18, the local controller broadcast on the tower frequency, "attention all aircraft hazardous weather information for florida and coastal waters available through in flight advisory hiwas or flight service convective activity in the area." At 1905:53, the pilot requested a frequency change with the local controller. Air traffic control communications were transferred to Miami Approach Control then to West Palm Beach Approach Control where radar services were terminated and frequency change was approved.

There was no record that the pilot contacted the Witham Field Air Traffic Control Tower, the St. Lucie County International Air Traffic Control Tower, the Vero Beach Municipal Air Traffic Control Tower, the Melbourne International Air Traffic Control Tower, the Space Coast Regional Air Traffic Control Tower, or the Jacksonville Air Route Traffic Control Center.

The pilot radioed Orlando Approach Control and was advised to stand by two times. At 1946:14, the Orlando Approach controller advised the pilot to squawk 0322 and to maintain visual flight rules (VFR) outside of class "B" airspace. The pilot responded at 2046:22, with, "and ah I would like flight following in the storms and I also got diverted and I am now over the shoreline ah right now ah approximately abeam sanford is there any way you can get me in there with a special ifr clearance." Air traffic control communications were transferred to Daytona Beach Approach Control.

At 2048:10, the pilot contacted initially contacted Daytona Beach Approach Control and after acknowledgment by the controller, advised that, "...I got diverted in the storms and uh lost my flight following." The controller asked the pilot to ident. At 2049:08, the controller advised the pilot that the flight was radar identified and, "...fly heading of 290 degrees to the sanford airport maintain vfr the altimeter at melbourne is two niner niner seven." At 2049:27, the pilot acknowledged the transmission from the controller by repeating the heading. At 2051:52, the controller advised the pilot that while flying around, he violated restricted area 2932, class "D" airspace at Melbourne, and that he was going to provide a phone number to the pilot to call after he landed. The pilot responded at 2052:06 with, "ah sorry sir I'm in a major storm right now uh can I change altitude." The controller advised the pilot that he could descend to 5,000 feet or did he want to ascend. The pilot then questioned the controller if ascending would be clearer, and the pilot advised the controller that ascending, "...would be better." The controller advised the pilot to maintain VFR to climb as requested and to advise when able to copy the phone number to call. The controller again questioned the pilot if he was able to copy a phone number and the pilot responded at 2053:21 with "negative sir I'm in a major storm right now (unintelligible) just holding things straight." The controller advised the pilot that "alright if you need to you can turn northbound that will take you ah looks like further away from the weather." The pilot acknowledged with "ah roger sir we'll try." At 2054:14, the controller stated, "five six one niner two your over head restricted area twenty nine thirty two it's in use below five thousand feet suggest you fly eastbound if you need to descend anymore." This transmission was not acknowledged by the pilot.

Review of the Jacksonville Air Route Traffic Control Center (ARTCC) National Track Analysis Program (NTAP) revealed that between 2051:48, to 2054:00, indicates a nearly 540-degree turn to the left. Two primary radar returns were recorded in the immediate vicinity of the secondary radar returns and both occurred during the approximate 540-degree left turn. The first primary radar return occurred at 2053:13, at 28 degrees 30 minutes 33 seconds North Latitude and 080 degrees 33 minutes 07 seconds West Longitude. The second primary radar return occurred at 2053:37, at 28 degrees 31 minutes 04 seconds North Latitude and 080 degrees 33 minutes 48 seconds West Longitude. The radar data also indicates that from 2053:48, to 2054:00, the altitude decreased from 6,400 to 5,400 feet. The airplane was lost from the Jacksonville ARTCC radar at 2054:00, at 28 degrees 30 minutes 19 seconds North Latitude and 080 degrees 34 minutes 07 seconds West Longitude. Review of the radar data from Orlando Approach Control revealed that from 2049:31, and 2050:49, revealed that the heading changed from 196 degrees to 313 degrees. The last radar return with the discrete transponder code and altitude reported was at 2054:08, when the airplane was at 3,700 feet. Radar data from the Jacksonville Air Route Traffic Control Center and Orlando Approach Control are attachments to this report.

According to a controller on duty on the night of the accident at the Shuttle Landing Facility, he observed an aircraft intrude into Restricted airspace R-2932, fly to nearby airports, then re-enter Restricted airspace R-2932. He also noted a thunderstorm just west of the Indian River moving east. He observed that the airplane made a left turn and lost the airplane from radar when the airplane was at 5,400 feet. Another controller notified security and the fire department at Kennedy Space Center about the possible downed airplane.

A search for the airplane was performed by the U.S. Coast Guard, the Civil Air Patrol, aircraft from the 301'st Rescue Squadron Air Force Reserve located at Patrick Air Force Base, and a HC-130 type airplane from Moody Air Force Base. Pieces believed to be from the airplane were spotted first about 1330 hours on June 11, 1999, in an open field; the main wreckage was located approximately 40 minutes later.

PERSONNEL INFORMATION

According to FAA records, the pilot was not instrument rated. Review of his pilot logbook which begin with an entry dated October 7, 1997, to the last logged entry dated May 30, 1999, with no flight time carried forward, revealed he recorded a total of 13.1 hours of simulated instrument instruction. He also logged a 1.4 hour flight as pilot-in-command in actual instrument conditions, a flight that took place on July 3, 1998. The remarks section for that flight indicates "x country/smoke/storms fuel stop pick up *[unreadable]-*[unreadable]." The logbook also indicates that he had logged a total of 11 instrument instructional flights after receiving his private pilot certificate.

AIRCRAFT INFORMATION

On the day of the accident about 1730 hours, the airplane was flown on a maintenance test flight which lasted approximately 15 minutes; following replacement of the landing gear hydraulic pump. According to the pilot who performed the flight, the landing gear and all other systems functioned properly during the flight. According to the airplane hour meter, the airplane had been operated for 2.0 hours since the accident pilot rented the airplane. The airplane was not equipped with weather radar.

METEOROLOGICAL INFORMATION

There was no record of the pilot obtaining a preflight weather briefing with the Miami, St. Petersburg, Gainesville, Macon, Anderson, Anniston, Raleigh, Nashville, or McKeller Automated Flight Service Stations. Additionally, the pilot did not have access to either of the DUAT vendors to obtain a preflight weather briefing. There also was no record of the pilot obtaining any in-flight weather briefing.

The flight track of the airplane obtained from the Orlando ASR-9 radar, was correlated with weather radar images which begin at 2058:32, or approximately 4 minutes after the last radar contact from the aircraft. The 1.4 degree elevation scan completed at 2059:13, which best depicts the conditions observed at the last known flight altitude of the aircraft, indicate the maximum reflectivity observed along the flight track is 33 dBZ. This would result in light to moderate intensity. There were no recorded pilot reports in the central Florida area between 1700 to 2300 local.

The end of civil twilight was calculated to be 2052, which was approximately 2 minutes before the airplane was lost from the Jacksonville ARTCC radar, for the last known position and altitude of the airplane. The Meteorology Factual Report is an attachment to this report.

COMMUNICATIONS

Transcriptions of communications with the Fort Lauderdale Executive Airport Air Traffic Control Tower (ATCT), West Palm Beach Approach Control, Orlando Approach Control, and Daytona Beach Approach Control are attachments to this report.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed on Cape Canaveral Air Station in a wooded area near Launch Complex 20 (See photographs 1-3). The main wreckage consisting of the fuselage with engine and propeller attached, sections of both wings, and two sections of the left horizontal stabilator, was located as determined by a portable GPS to be located at 28 degrees 30.793 minutes North Latitude and 080 degrees 33.588 minutes West Longitude. The right side of the horizontal stabilator and sections of both wings were noted to be separated. The separated segments of the left and right wings and the separated segment of the right horizontal stabilator were located in close proximity at 28 degrees 30.463 minutes North Latitude and 080 degrees 33.658 minutes West Longitude. That location when plotted was determined to be located 197 degrees and .3 nautical mile from the main wreckage location. The wreckage and the separated components were recovered for further examination.

Examination of the airplane revealed that the landing gear and flaps were retracted. One of the propeller blades was fractured; the separated blade was found beneath the engine. The right horizontal stabilizer separated approximately 9 inches outboard of the skin joint. The left and right wing segments separated approximately 7 feet 10 inches and 8 feet 6 inches outboard of the attach point, respectively. Examination of the main spar for the right horizontal stabilator revealed evidence that it was displaced down and aft. Examination of the main spar of the left wing revealed evidence that it failed up and aft at the manufacturer splice location. The aft spar of the left wing exhibited evidence of overload failure 5.5 inches inboard of the manufacturer splice location. A compression wrinkle was noted on the upper surface of the aft spar cap approximately 9 inches outboard of the fracture location (See Photo 6). Examination of the main and aft spars of the right wing revealed they were displaced up and aft; the main spar web exhibited a compression wrinkle and was fractured approximately 1 foot outboard of the manufacturer splice location. A compression wrinkle was noted on the upper spar cap of the aft spar approximately 4 inches outboard of the manufacturer splice location (See Photo 7). Examination of the fracture surfaces of the separated segments of the left and right wings, and the right horizontal stabilator revealed no evidence of preexisting cracks. The vertical stabilizer and rudder were attached to the airframe. Flight control continuity was confirmed for pitch, roll, and yaw. The rotor and rotor housing from the directional gyro was also retained for further examination (See tests and research section of this report).

Examination of the engine revealed impact damage to both magnetos, the engine-driven fuel pump, propeller governor, and the front section of the crankcase. Impact damage was also noted to the vacuum pump (See photo 9), the coupling was still connected to the external spline which were not failed (See Photo 10). The vacuum pump, left magneto, and propeller governor were retained for further examination (See tests and research section of this report); the right magneto was destroyed which precluded testing. Disassembly of the engine revealed crankshaft, camshaft, valve and gear train continuity; there was no evidence of lack of lubrication.

Examination of the propeller revealed that the No. 2 propeller blade was in place, the No. 1 propeller blade was fractured inside the propeller hub. Examination of the No. 1 propeller blade revealed chordwise scratches with a slight forward bend; the leading edge was twisted towards low pitch (See Photo 13). The No. 2 propeller blade exhibited chordwise scratches and a gouge on the blade face near the propeller hub. There was no evidence of preexisting cracks in the fracture surface of the No. 1 propeller blade.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed by Paulino O. Vasallo, M.D., District Medical Examiner, Brevard County. The cause of death was listed as multiple blunt force injuries.

Toxicological testing of specimens of the pilot was performed by the FAA Accident and Research Laboratory (CAMI) and the Wuesthoff Reference Laboratory. No blood specimen was submitted to either the FAA or Wuesthoff Reference Laboratory for testing due to the unsuitable condition. The results of analysis by CAMI was for positive in the bile for cocaine and benzoylecgonine which is an inactive metabolite of cocaine. The liver was found to contain cocaine and benzoylecgonine. Cocaine and benzoylecgonine were detected in lung. Propoxyphehe which is a narcotic painkiller often referred to by the trade name Darvon, and norpropoxyphene which is a metabolite of propoxyphene, were detected in bile. Norpropoxyphene was detected in the liver and lung. The results was positive for Volatiles; the sample was putrefied. Toxicological analysis by Wuesthoff Laboratory of bile specimens of the pilot was positive for Cocaine Metabolite, Propoxyphene, caffeine, and norpropoxyphene.

A wallet that contained the pilot's identification was found in a back pocket of the pants worn by him. Located inside the wallet was a small plastic bag that contained a white substance. Additionally, a wallet that contained identification belonging to the pilot's brother was found in the possession of the pilot. That wallet also had a small plastic bag that contained a residue of a white substance. Both substances were tested by the Florida Department of Law Enforcement Crime Laboratory and determined to be cocaine.

TESTS AND RESEARCH

Impact damage to the propeller governor precluded bench testing. Examination of the propeller governor revealed no evidence of preimpact failure or malfunction.

Examination of the rotor from the directional gyro revealed evidence of deep circumferential scoring near the buckets (See Photo 14). Slight circumferential scoring was noted on the rotor from the attitude indicator. Examination of the Emergency Locator Transmitter (ELT) revealed impact damage which precluded operation (See Photo 15).

Examination of the vacuum pump revealed impact damage to the rear cover. Disassembly of the vacuum pump revealed that the rotor was fractured; the rotor vanes were not failed. No evidence of preimpact failure or malfunction was noted. A copy of the report is an attachment to this

NTSB Probable Cause

The pilot's VFR flight into Instrument meteorological conditions and his subsequent failure to maintain control of the aircraft resulting in overload and separation of both wings. Contributing factors were the pilot's failure to obtain a preflight and in-flight weather briefing, thunderstorm and dark night conditions, and the pilot's lack of instrument certification.