Pilot Debrief

PIPER PA-28-161 near Boynton Beach, FL — 2021-01-25

Final reportERA21LA111
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Date
2021-01-25
Location
Boynton Beach, FL, USA
Airport
LNA
Aircraft
PIPER PA-28-161
Registration
N266ND
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot’s controlled flight into the ocean at night due to his unrecognized spatial disorientation. Contributing to the accident was the pilot’s distraction with the tuning of his transponder while maneuvering over an area with reduced visual references.

Contributing factors

Contributing to the accident was the pilot’s distraction with the tuning of his transponder while maneuvering over an area with reduced visual references.

NTSB narrative

While in cruise flight about 1,000 ft on a southbound heading over land in night visual meteorological conditions, the pilot requested flight following services and routing to the north “along the shoreline.” Air traffic control approved the request, issued the altimeter setting, and instructed the pilot to proceed offshore and “follow the shoreline northbound at or below 500 feet.” The pilot acknowledged the instructions and repeated the altimeter setting as the airplane began a descending left turn to the east. The target identified as the accident airplane continued an eastbound descent on a heading about perpendicular to the shoreline when the controller assigned the airplane a new transponder code. When the pilot acknowledged the transponder code instructions, the airplane was at 300 ft and descending and displayed a transponder code one digit off that which was assigned. At that time, the airplane was crossing the beach at 225 ft and descending. Once over water, the airplane’s track depicted a shallow, descending left turn. Soon after, radar contact was lost and there were no further communications with the airplane. Onboard video revealed that the descent was initiated by multiple reductions in engine rpm as the airplane turned to the east, consistent with the controller’s instructions to fly offshore and continue north below 500 ft; however, no sounds consistent with an increase in engine rpm to arrest the descent occurred after the airplane began tracking toward the ocean, nor in the final moments of flight as the airplane initiated a turn toward the north well below 500 ft. Given the dark nighttime conditions, the pilot’s lack of instrument experience likely focused his attention outside the aircraft. In a low-wing airplane, cultural/ambient lighting on the ground ahead of the airplane would have provided some cues of both altitude and attitude; however, the availability of those cues would have rapidly decreased as the airplane neared the shoreline. The circumstances of this accident suggest that the pilot over-relied on outside references and did not effectively reference the altimeter. The controller’s instructions to reset the transponder code about the same time the airplane was descending through 500 ft, although routine, likely served as an operational distraction to a pilot with his limited experience. His efforts to reset the transponder likely further diverted his attention away from the altimeter, and the pilot allowed the airplane to descend into the water.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have avoided flying over water without a visible horizon.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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