Pilot Debrief

STEINMAN MARK E LANCAIR 320 near Atlantic Ocean, AO — 2021-02-24

Final reportERA21LA141
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Date
2021-02-24
Location
Atlantic Ocean, AO, USA
Aircraft
STEINMAN MARK E LANCAIR 320
Registration
N670BS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The airplane’s impact with water for reasons that could not be determined.

NTSB narrative

The pilot was operating a cross-country flight in visual flight rules (VFR) weather conditions. About 10 miles from the destination airport, the pilot contacted the air traffic control tower and reported the airplane’s location and altitude and his intention to land. The controller advised the pilot to report entering a left downwind for the active runway, which the pilot acknowledged. No further communications were received from the pilot or, nor were any made by the controller. Shortly after the pilot’s last transmission, the airplane made a gradual turn to the right and then back to the left, and the airplane then continued on a constant heading with a gradual descent. About 4 minutes later, the airplane passed the destination airport, which the controller did not notice, and the airplane continued in a gradual descent until tracking data ended. At that time, the airplane was over the Atlantic Ocean about 16 miles southeast of the destination airport. Family members reported the airplane overdue 2 days later, after which the Federal Aviation Administration (FAA) issued an alert notification. Search and rescue operations, which were coordinated by the US Coast Guard, ensued. The airplane and pilot were not located despite a 3.5-day search. Search and rescue operations might have been initiated sooner if the controller at the destination airport had followed the track of the airplane as it transitioned through the controlled airspace. If the controller had followed the airplane’s track, he would likely have attempted to contact the pilot and initiated procedures for search and rescue operations after losing contact with the airplane over the ocean. Further, the pilot had not filed a VFR flight plan, which is the primary tool the FAA uses to initiate search and rescue operations for an overdue airplane operating under VFR. Such flight plans are not required by the FAA. However, for those VFR flight plans that are filed, the FAA will initiate action if the flight plan is not closed or the airplane is not confirmed to have successfully landed beginning 30 minutes after the estimated time of arrival indicated on the flight plan. Because the airplane could not be examined and no pilot autopsy or toxicology could be performed, the investigation was unable to determine the events that led to the airplane’s impact with water.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have ensured valid medical certification before flying.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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