Pilot Debrief

EXTRA NG near St. Augustine, FL — 2022-03-02

Final reportERA22FA141
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Date
2022-03-02
Location
St. Augustine, FL, USA
Airport
SGJ
Aircraft
EXTRA NG
Registration
N100NG
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s excessive airspeed during landing, which resulted in a runway excursion and collision with terrain. Contributing to the accident was the loss of engine power for undetermined reasons and contributing to the severity of the accident were the environmental challenges related to the airplane’s location in a marsh, which increased the emergency response time.

Contributing factors

Contributing to the accident was the loss of engine power for undetermined reasons and contributing to the severity of the accident were the environmental challenges related to the airplane’s location in a marsh, which increased the emergency response time.

NTSB narrative

The accident pilot was the lead pilot of a flight of two returning to their home base after a local flight. The pilot reported a loss of engine rpm and the pilot of the second airplane reported the accident airplane was trailing smoke. An emergency was declared, and the airplane was cleared to land. Automatic dependent surveillance-broadcast (ADS-B) data showed the airplane crossed the airport boundary at an altitude of 200 ft with a groundspeed of 165 knots. The recommended speed for a precautionary landing with engine power is 90 knots. The pilot overflew the runway, and the airplane came to rest inverted in a marsh, about 1,500 ft past the end of the runway. The airplane was not visible from shore. First responders used multiple boats and a drone to search for the airplane; however, shallow water and the terrain slowed responders’ progress. A good Samaritan, who first located the airplane, provided assistance to the pilot and guided emergency responders to the airplane. During the time responders searched for and extricated the pilot the tide continued to rise and submerged the pilot before extrication. Downloaded engine data indicated an increase in cylinder head temperature (CHT) in the No. 4 cylinder followed by loss of oil pressure, a drop in exhaust gas temperature (EGT), and a decrease in engine power to 50%. The No. 4 cylinder exhibited low compression and suction during the postaccident examination, which was most likely due to environmental debris from the accident sequence that was found on the valve seat. No other anomalies were found during the examination that would have resulted in the loss of engine power. Review of postaccident medical records, including the autopsy data and toxicology reports, revealed no medical issues that would have contributed to the accident. Although the toxicology detected therapeutic levels of the unapproved antidepressant vilazodone, which is associated with side effects such as dizziness, it is unknown how long the pilot was taking this medication or the severity of her depression. Given the pilot’s actions during the flight, it is unlikely that effects from this medication or the pilot’s depression were factors in this accident. The metabolite of naltrexone, 6-beta-natrexol, was detected but not quantified, suggesting that any effects from the use of naltrexone were likely minimal and not a factor in this accident. ADS-B data revealed the airplane crossed over the runway threshold at a significantly higher airspeed than recommended in the pilot’s operating handbook. It’s likely the pilot’s perceived emergency and urgency to land led to the excessive airspeed on final approach and inability to touchdown on the runway.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have initiated a precautionary landing earlier.

NTSB coding

Evidence available

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

Docket documents17

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