NTSB Factual Report

HISTORY OF FLIGHT

On December 10, 2012, at approximately 1950 eastern standard time, a Diamond Aircraft Industries DA 40; N840DS, was substantially damaged when it impacted trees and terrain after a loss of control during climb, after departure from Valdosta Regional Airport (VLD), Valdosta, Georgia. The certificated private pilot was fatally injured. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 business flight, destined for Jesup-Wayne County Airport (JES), Jesup, Georgia.

According to the VLD Air Traffic Control Tower (ATCT) supervisor, at approximately 1935, the pilot radioed VLD ATCT and advised that he was ready to taxi for departure. The pilot was then issued current weather and taxi instructions to the active runway. The pilot then advised the controller that he would be departing to the east to JES.

At 1939, the pilot advised ATCT that he was ready for departure and was issued current wind information and was cleared for takeoff.

At 1942, the pilot was advised to squawk a beacon code of "1200" and that he could receive visual flight rules (VFR) advisory service with Moody Air Force Base Radar Approach Control (RAPCON) on frequency 126.6. The pilot then advised that he was changing to frequency 126.6 for advisory services.

According to the RAPCON supervisor, after the pilot contacted the RAPCON for VFR flight following the pilot was advised to squawk a beacon code of "5576" but, at 1950, before the airplane was radar identified by the RAPCON, the pilot radioed "I'm in trouble." Moments later, both radar and radio contact was lost.

At 1953, downed airplane procedures were initiated and a search for the airplane by federal, state, and local authorities was initiated.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with a rating for airplane single-engine land.

His most recent FAA third-class medical certificate was issued on October 15, 2012. He had accrued approximately 208 total hours of flight experience, 123 hours of which was in the DA 40.

Further review of the pilot's flight records revealed that of his 208 total hours of flight experience he had accrued approximately 3 hours of night time and approximately 7 hours of simulated instrument time.

He did not possess an instrument rating and no record of any actual instrument time being logged was discovered.

AIRCRAFT INFORMATION

The accident airplane was a low wing, T-tailed, single engine monoplane, manufactured primarily of fiberglass reinforced plastic (FRP). The ailerons, elevator and wing flaps were operated through control rods, while the rudder was controlled by cable. The wing flaps were electrically operated. Elevator forces could be balanced by a trim tab on the elevator, which was operated by a Bowden cable.

It was powered by a 180 horsepower, air-cooled, four-cylinder, horizontally-opposed, fuel injected, direct-drive engine, driving a 3-bladed constant speed propeller.

It was capable of flying in instrument meteorological conditions and was equipped with an electronic flight information system (EFIS) that integrated flight, engine, communication, navigation, and surveillance instrumentation systems to allow a pilot to operate the airplane without visual reference. The system consisted of a Primary Flight Display (PFD), Multi-Function Display (MFD), audio panel, Air Data Computer, Attitude and Heading Reference System, engine sensors, a processing unit, and integrated avionics containing Very High Frequency (VHF) communications, VHF navigation, and GPS (Global Positioning System).

The primary function of the PFD was to provide attitude, heading, air data, navigation, and alerting information to the pilot. The PFD could also be used for flight planning. The primary function of the MFD was to provide engine information, mapping, terrain information, and flight planning. The audio panel was used for selection of radios for transmitting and listening, intercom functions, and marker beacon functions.

In the event of a malfunction of the EFIS system's PFD or MFD, mounted directly above them were a set of standby analog instruments which consisted of an attitude indicator, airspeed indicator, altimeter, and magnetic compass.

According to FAA and maintenance records, the airplane was manufactured in 2007. The airplane's most recent annual inspection was completed on April 27, 2012. At the time of the inspection, the airplane had accrued 203.1 total hours of operation.

METEOROLOGICAL INFORMATION

Meteorological information for this investigation was derived from numerous sources.

Surface Analysis Chart

The National Weather Service (NWS) Surface Analysis Chart for 1900 depicted a deep low pressure system at 995-hectopascals and associated occluded front impacting the northeastern United States with a cold front extending southward across northwestern Georgia and eastern Alabama into the Florida Panhandle, and then into the Gulf of Mexico. The station models ahead of the front over Florida and southern Georgia indicated warm-moist light southerly winds ahead of the front with broken to overcast clouds and scattered rain showers.

Soundings

The NWS Tallahassee 1900 sounding indicated a moist low level environment with the lifted condensation level (LCL) at 967 feet above ground level (agl), with the sounding relative humidity greater than 80 percent from the surface to 5,000 feet, with the sounding being conditionally unstable with a Lifted Index of 0.2 even with a low level temperature inversion. The freezing level was identified at 14,240 feet. The sounding wind profile indicated a surface winds from the south at 5 knots which veered to the west above the surface and increased in speed. The mean 0 to 6 kilometer (18,000 feet) wind was from 240° at 41 knots. The wind at 2,000 feet was from 220° at 14 knots.

Radar Imagery

The NWS regional radar mosaic for 1945 depicted several scattered areas of rain showers over Georgia and northern Florida to the southwest and east of the accident site.

The Moody Air Force Base WSR-88D radar composite reflectivity image for 1947 depicted very light intensity echoes associated with biological targets and ground clutter associated with a developing nocturnal inversion over the area and no meteorological echoes. No significant weather echoes were identified within 50 miles of the accident site.

Satellite Imagery

The Geostationary Operational Environmental Satellite (GOES-13) infrared image at 1945 depicted a layer of low stratus clouds over Valdosta area with a radiative cloud top temperature of 289° Kelvin or 15.84° C, which corresponded to cloud tops near 4,000 feet. A large area of enhanced clouds was identified to the south extending from the Gulf of Mexico across northern and central Florida associated with cumulonimbus clouds or thunderstorms. No cumulonimbus clouds were identified in the vicinity of the accident site.

Recorded Weather

The recorded weather at VLD, at 1953, approximately 3 minutes after the accident included: wind variable at 4 knots, visibility 10 miles, broken clouds at 1,400 feet, temperature 22 degrees C, dew point 19 degrees C, and an altimeter setting of 29.84 inches of mercury.

Weather Depiction Chart

The NWS Weather Depiction Chart for 2000 depicted an extensive area of Marginal Visual Flight Rules (MVFR) conditions along the front across Alabama and western and northern Georgia, as well as a small portion of southern Georgia and northern Florida. MVFR conditions were depicted over the Valdosta area.

Destination Weather

Conditions at the planned destination of JES located approximately 85 miles east-northeast of Valdosta indicated light southerly wind, with visibility unrestricted, and high scattered clouds, with lightning detected in the distant south at the time of the accident. Other airports in the immediate vicinity of the destination were reporting scattered to broken clouds at 400 feet agl. during the period.

Airman's Meteorological Information Advisory

The NWS had issued an Airman's Meteorological Information Advisory (AIRMET) update at 1545. AIRMET Sierra update 3 issued at 1545 EST warned of ceilings below 1,000 feet and visibilities less than 3 miles in mist and fog developing after 1900 through 2100, and continuing through 0400 on December 11, 2012 across northern and southern Georgia. This advisory extended over the departure, the destination, and the accident site.

Astronomical Conditions

United States Naval Observatory data indicated that sunset occurred at Valdosta at 1732, with the end of civil twilight at 1759. At the time of the accident, both the Sun and the Moon were more than 15 degrees below the horizon.

WRECKAGE AND IMPACT INFORMATION

Examination of the Accident Site

On December 11, 2012, at 1115, the wreckage of the airplane was discovered by the crew of Georgia State Patrol helicopter in a heavily wooded area, approximately 7 miles from VLD.

Examination of the accident site revealed that the airplane initially made contact with an approximately 56 foot high pine tree before striking two smaller trees and then the ground about 50 feet further on, from the initial impact point with the tree. The impact angle was measured at an approximate 45-degree nose down angle. The airplane came to rest on a 107 degree magnetic heading in a depression on the forest floor, at an approximate elevation of 200 feet above mean sea level (msl).

Examination of the Wreckage

Examination of the wreckage revealed that the airplane was heavily fragmented. Further examination revealed however, that all major components of the airplane were present and control continuity was able to be established for all of the primary flight controls, and for the wing flaps.

Continuity for the elevator trim system could not however be confirmed, as it was discovered that the Bowden cable was disconnected from the trim control wheel in the cockpit. Examination of the Bowden cable revealed that it had pulled out of a swaged rod end which displayed a crack on the outer surface of the swage which ran along its longitudinal axis. Further examination of the crack revealed, that the exposed fractured surfaces were not the same color as the rest of swaged rod end but instead, displayed a brown discoloration on the fracture surfaces. Further examination of the cable end revealed that it also displayed evidence of a powdery looking brown discoloration.

Examination of the Propeller and Engine

Examination of the propeller and engine did not reveal any evidence of any preimpact failures or malfunctions.

The engine was separated from the airframe and found lying inverted about 10 feet forward of the main wreckage. The oil sump and both crankcase halves were impact fractured. The propeller and crankshaft flange were separated from the remainder of the crankshaft just aft of the crankcase nose. Cylinders No.1, No. 2, and No. 4, were impact damaged, and wood fibers were observed to be embedded in the cooling fins of cylinder No. 2.

The propeller was discovered separated from the engine near the main wreckage. The spinner was fragmented. The propeller had remained attached the crankshaft flange but, the flange had separated from the engine and was found near the remains of the airplane's fuselage. One of its composite blades was broken off flush with the propeller blade cuff ,with the other two propeller blades broken off and splintered, about 7 inches outboard of their cuffs.

The crankshaft exhibited a radial fracture with a 45-degree shear lip just aft of where the propeller flange had separated which was indicative of crankshaft rotation during impact. Drive train continuity was established from the back of the engine forward to the fracture just aft of the crankcase nose, and from the fracture to the propeller hub.

The fuel injector servo was impact separated from the engine. The mixture and throttle controls were separated at the servo control arms. Wood fibers consistent with those of the trees impacted by the aircraft were embedded in the servo air inlet opening. The fuel inlet hose was separated from the servo. The fuel inlet screen was absent of debris. The servo regulator section was disassembled and no damage to the internal parts was noted. Liquid with an odor consistent with aviation gasoline was noted in the fuel injector servo and in the fuel flow divider. The engine driven fuel pump was impact separated from the engine and fragmented. The fuel flow divider was partially separated from the engine. The flow divider was disassembled and no internal damage noted. The No. 2 and No. 4 fuel injector nozzles were fractured. No obstruction was noted in any of the nozzles.

The oil sump was fractured. Oil however, was observed in the engine. The oil filter was crushed. No debris was noted in the oil suction screen or the propeller governor screen. The oil cooler and oil cooler hoses were impact damaged.

The magnetos were impact separated from the engine. The spark plugs were medium gray in color.

MEDICAL AND PATHOLOGICAL INFORMATION

An Autopsy was performed on the pilot by the Georgia Bureau of Investigation. Cause of death was multiple blunt force trauma.

Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The pilot's specimens were negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs, with the exception of ethanol which was detected in Muscle, and was from a source other than ingestion, and Atorvastatin, which is a member of the drug class known as statins, and is used for lowering blood cholesterol.

The pilot had previously reported his use of Atorvastatin to his FAA airman medical examiner.

TESTS AND RESEARCH

Weather Briefing

Review of the outlook weather briefing requested by the pilot from the Princeton Contracted Flight Service Station (FCFSS) revealed that prior to departure; he had been advised of AIRMET Sierra. Additionally, he had also been advised of the weather conditions that had been reported in the Valdosta area which included scattered clouds at 1,600 feet, broken clouds at 2,200 feet, and broken clouds at 4,300 feet. Furthermore, He was also given the temperature and dew point which at the time were within 4 degrees of each other, and was advised that it was marginal VFR, which is defined by the NWS as a ceiling between 1,000 and 3,000 feet or visibility in the three- to five-mile range.

Radar Data

Review of correlated radar data indicated that at 19:46:13.11, the airplane's climb rate was steady until reaching an altitude of approximately 2,100 feet msl. Approximately 7 seconds later the airplane's altitude dropped to 1,900 feet msl, and the airplane had begun to turn right.

At 19:46:22.927, the airplane was still turning to the right and had descending through 1,700 feet msl. Approximately 5 seconds later, it was still continuing to turn right, and was at 1,400 feet msl.

Further examination of the radar data, indicated that the last radar contact occurred at 19:46:32.507, when the airplane was still at 1,400 feet msl. The average rate of descent up to that point was approximately 3,420 feet per minute.

Comparison of the last radar contact to the location of the accident site, indicated that the last radar contact had occurred when the airplane was approximately 359 yards from its initial impact point with the trees.

Elevator Trim System

The DA 40 elevator trim system included a mechanically operated trim tab. This allowed the pilot to trim the airplane for different speeds and center-of-gravity positions.

The elevator trim system had three main parts:

- The handwheel assembly with trim indicator.

- The Bowden Cable (Elevator Trim Cable) which connected the handwheel to the trim tab.

- The trim tab actuator assembly.

The handwheel assembly on the center console controlled the elevator trim system. The assembly had a metal mounting frame. The frame attached to the rear of the engine control assembly and the top of the control bulkhead. A long bolt through

NTSB Probable Cause

The noninstrument-rated pilot’s improper decision to depart in dark, night marginal visual flight rules conditions, which resulted in his spatial disorientation and subsequent loss of airplane control.