Accident Details
Probable Cause and Findings
The pilot's loss of airplane control due to spatial disorientation during an instrument approach in instrument meteorological conditions, and the flight instructor's delayed remedial action. Contributing to the accident was the flight instructor's impairment from the use of prescription pain medication.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn December 8, 2017, about 1115 eastern standard time, a Beech C90, N19LW, was destroyed when it impacted the waters of Lake Harney, near Geneva, Florida. The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were fatally injured. The airplane was registered to Planemarketing LLC, Vero Beach, Florida, and was being operated by L3 Airline Academy as a Title 14 Code of Federal Regulations Part 91 instructional flight. Instrument meteorological conditions existed in the area and an instrument flight rules flight plan was filed for the flight, which originated from Orlando Sanford International Airport (SFB), Sanford, Florida, about 0753.
The chief flight instructor at L3 Airline Academy reported that the accident flight was the students' (commercial pilots) first flight in the Beech C90 as part of their High-Performance Aircraft course. He stated that, during the course, the flight instructor would be seated in the left seat, and the two pilots receiving instruction would take turns in the right seat during the flight. The chief flight instructor stated that the accident flight initially flew to Baldwin County Airport (MLJ), Milledgeville, Georgia, before returning to Sanford, most likely due to weather in the area.
Review of air traffic control and radar information provided by the Federal Aviation Administration (FAA) revealed that the flight returned to SFB and conducted a practice instrument approach to runway 9. After completing the instrument approach, the pilot contacted the Central Florida Terminal Radar Approach Control facility at 1603:22, advising that the flight was flying runway heading at 800 ft mean sea level (msl). Shortly thereafter, the controller verified radar contact with the airplane and asked if they wanted to conduct an ILS approach to runway 9 left (9L), to which the pilot responded, "affirm, two of 'em please." At 1603:45, the controller instructed the pilot to turn left to a heading of 030° for vectors to the ILS for runway 9L, and climb to 3,000 ft. The pilot repeated the instructions.
Between 1604 and 1607, the controller advised the pilot of a runway change at SFB and informed him that the next approach would be an ILS approach to runway 27 right (27R). The controller vectored the airplane north, then east. At 1607:21, the pilot requested "extended vectors." The controller asked the pilot to repeat the request and instructed them to fly a heading of 120°. At 1607:37, the pilot asked for "one minute to set up" and repeated the instruction to fly the 120° heading. The controller then instructed the pilot to fly a heading of 140°, which the pilot acknowledged. Radar data showed a right turn to a southeasterly course while the airplane maintained an altitude of 3,000 ft msl.
At 1608:19, the controller broadcasted updated weather information at SFB, which included a cloud ceiling broken at 800 ft above ground level (agl) and overcast at 1,600 ft agl. At 1609:22, the pilot advised the controller that they were ready to continue the approach, and the controller instructed the flight to descend to 1,600 ft. The pilot acknowledged, and radar data depicted the airplane beginning a descent.
At 1610:08, the controller instructed the pilot to turn right to a heading of 180°, which the pilot confirmed. At 1611:26, the controller issued the pilot a right turn to a heading of 240°, stated that the airplane was 5 miles from the UTIMY intersection, instructed him to remain at 1,600 ft until established on the localizer, and subsequently cleared the airplane for the ILS runway 27R approach. The pilot acknowledged, and radar data showed that the airplane remained level at 1,600 ft and initiated a right turn to a southwesterly course at 1611:38.
At 1612:37, the controller told the pilot that he would appreciate any cloud base reports on final, to which the pilot responded, "ok, wilco." Radar data showed that the airplane remained at 1,600 ft until 1612:12, then climbed to 1,700 ft briefly before descending back to 1,600 ft. At 1613:07, the airplane had turned to a westerly heading, descended to 1,400 ft, and continued a descent through 1,100 ft while initiating a left turn to a southerly heading. Shortly thereafter, the controller issued the airplane two low altitude alerts, about 10 seconds apart, and instructed the pilot to "maintain 1,600 immediately" until established on the approach. Radar data showed that, during this time, the airplane continued its descent, reaching 300 ft before climbing back to 800 ft, as it continued on a southeasterly heading. At 1613:31, the pilot stated, "yeah I am sir, I am, I am." No further radio communication was received from the airplane. The last three radar targets recorded at 1613:37, 1613:41, and 1613:46 showed the airplane at 1,300, 1,700, and 1,400 ft msl, respectively, in the vicinity of the accident site. (Figure 1)
Figure 1: Final portion of recorded radar data
A witness located on a boat near the north end of Lake Harney reported hearing a low-flying airplane approach his position. The witness stated that he could not see the airplane initially due to low clouds and light ground fog; however, he then saw the airplane below the cloud ceiling at 250 to 300 ft above ground level, then it climbed rapidly. The witness further stated that he was looking in the general direction of the engine noise when he saw the airplane dive vertically into the lake south of his location. PERSONNEL INFORMATIONFlight Instructor
The instructor, age 56, held an airline transport pilot certificate with an airplane multi-engine land rating, with commercial privileges for airplane single-engine land. He held a flight instructor certificate with airplane single- and multi-engine and instrument airplane ratings. The pilot's most recent FAA third-class airman medical certificate was issued on August 19, 2017, with a limitation for corrective lenses. On the application for that medical certificate, he reported 4,500 total hours of flight experience. Flight school personnel reported that, at the time of the accident, the instructor had accumulated 4,800 total hours of flight experience, of which 357 hours were in the accident airplane make/model, 233 hours were in the previous 90 days, 62 hours were in the previous 30 days, and 6 hours were in the previous 24 hours.
Representatives of the flight school reported that the instructor provided training in their flight instructor and high-performance courses. The instructor was also a company check pilot for their single- and multi-engine courses. In addition, the instructor was approved to provide end-of-course exams, which included the issuance of a pilot certificate or rating for that respective course.
Pilot Receiving Instruction
The pilot receiving instruction, age 23, held a commercial pilot certificate with airplane single-engine land, multi-engine land, and instrument airplane ratings. His most recent second-class FAA airman medical certificate was issued on December 8, 2016, with a limitation for corrective lenses. Flight school personnel reported that, at the time of the accident, he had accumulated 243 total hours of flight experience, of which 44 hours were in the previous 90 days. In addition, he had accumulated 8 hours of actual instrument experience and 49 hours of simulated instrument experience. AIRCRAFT INFORMATIONThe seven-seat, low-wing, retractable-gear, twin-engine airplane, serial number (S/N) LJ-991, was manufactured in 1981. It was powered by two Pratt & Whitney Canada PT6A-21 engines, each rated at 550 shaft horsepower, which each drove a Hartzell adjustable pitch propeller.
Review of the airframe and engine maintenance logbooks revealed that the most recent phase inspection was completed on October 13, 2017, at a total time and Hobbs time of 10,571.2 hours, left and right engine total time of 10,571.2 hours, 6,568.1 hours since overhaul, and 1,205.4 hours since hot section inspection. The reported Hobbs time at the time the airplane was dispatched for the accident flight was 10,648.9 hours. METEOROLOGICAL INFORMATIONRecorded data at 1053 from the SFB automated weather observation station, located about 10 miles west of the accident site, included wind from 170° at 8 knots, 10 statute miles visibility, a broken cloud layer at 800 ft, an overcast cloud layer at 1,600 ft, temperature 21°C, dew point 18°C, and an altimeter setting of 29.89 inches of mercury.
The National Weather Service (NWS) Weather Forecast Office, located in Melbourne, Florida, issued the SFB Terminal Aerodrome Forecast at 0627, which was valid for a 24-hour period beginning at 0700. The forecast from 0700 to 1100 was for wind from 030° at 3 knots, visibility better than 6 miles, scattered clouds at 800 ft agl, overcast at 1,500 ft. From 1100 to 1300, wind was predicted to be from 190° at 5 knots, visibility better than 6 miles, ceiling broken at 1,500 ft agl. AIRMET Sierra for IFR conditions was current at the time of the accident for most of central Florida, including the area of the accident site.
For further meteorological information, see the weather study in the public docket for this investigation. AIRPORT INFORMATIONThe seven-seat, low-wing, retractable-gear, twin-engine airplane, serial number (S/N) LJ-991, was manufactured in 1981. It was powered by two Pratt & Whitney Canada PT6A-21 engines, each rated at 550 shaft horsepower, which each drove a Hartzell adjustable pitch propeller.
Review of the airframe and engine maintenance logbooks revealed that the most recent phase inspection was completed on October 13, 2017, at a total time and Hobbs time of 10,571.2 hours, left and right engine total time of 10,571.2 hours, 6,568.1 hours since overhaul, and 1,205.4 hours since hot section inspection. The reported Hobbs time at the time the airplane was dispatched for the accident flight was 10,648.9 hours. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted the water...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR18FA045