Accident Details
Probable Cause and Findings
The student pilot's loss of control due to spatial disorientation following an encounter with instrument meteorological conditions shortly after takeoff. Contributing to the accident was the failure of both the pilot and the flight school to ensure that the pilot had received the proper endorsements for the flight and the pilot’s self-imposed pressure to complete the flight in order to remain in the flight program.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn March 5, 2019, at 0703 eastern standard time, a Piper PA-28-161, N556PU, was substantially damaged when it was involved in an accident near Fellsmere, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 solo instructional flight.
The student pilot had been training at the FlightSafety International Inc. (FSI) FlightSafety Academy (FSA) in Vero Beach, Florida; the accident flight was her second solo cross-country flight. The Vero Beach Regional Airport (VRB) control tower was not open at the time of departure, and there were no recorded radio transmissions documenting the pilot's departure.
The airplane was first observed on radar shortly after it departed runway 30L at 0657:23. At that time it was at a groundspeed of 106 knots, and an altitude of 525 ft mean sea level (msl). For about the next 1 minute 30 seconds, the airplane flew on a westerly heading and descended to 325 ft msl and reduced groundspeed to 83 knots.
The airplane then made a right turn toward the northwest before making a left turn back to the southwest. The airplane slowed to a groundspeed of 70 knots and the altitude varied between 425 ft and 300 ft msl before it made a right turn to the north about 0700:36. At that time, the airplane was at a groundspeed of 79 knots, a heading of 336°, and an altitude of 625 ft msl.
Over the next 2 minutes 30 seconds, the airplane made a series of climbing and descending turns with varying groundspeeds and headings, before it entered a steep right turn at 0703:05. At that time, the airplane was at groundspeed of 93 knots, a heading of 242°, and an altitude of 725 ft msl.
Over the next 34 seconds, the airplane continued to turn right before the data ended at 0703:39. At that time, the airplane was at a groundspeed of 117 knots, a heading of 153°, and an altitude of 550 ft msl. The airplane impacted terrain about 1/4-mile south of the last radar return in heavily wooded farmland about 7.3 miles northwest of VRB.
PERSONNEL INFORMATIONThe pilot's planned route on the day of the accident was VRB to Palm Beach County Glades Airport (PHK), Pahokee, Florida, to Okeechobee County Airport (OBE), Okeechobee, Florida, to VRB. According to her logbook, she had completed this same route numerous times with a flight instructor and once as a solo cross-country flight.
A review of text messages provided by the instructor and the pilot's previous instructor revealed that the pilot's initial flight instructor at FSA would not endorse her for solo flight and recommended that she be removed from the flight program. FSA subsequently assigned her a new instructor, who stated that the pilot "was fine" and endorsed her for a solo cross-country flight. This instructor then left FSA, and the pilot was assigned to her current flight instructor.
The pilot's current flight instructor stated that she had only flown with the pilot twice before the accident, both of which were dual cross-country flights. The instructor described the pilot as a "remedial student" who had expressed concern that she would be released from the flight program due to her high flight time. The pilot knew that she needed to complete the solo cross-country flights to remain in the training program.
A review of the pilot's training records, and lesson plans revealed that she started her private pilot training in March 2018 and logged her first training flight on June 11, 2018. She was scheduled to have completed the private pilot course by March 1, 2019. A review of her lesson plans revealed that she had 34 unsatisfactory lessons and 36 satisfactory lessons.
METEOROLOGICAL INFORMATIONFrom the time the student pilot arrived at VRB to the time she departed and the airplane impacted terrain, the weather had deteriorated from visual flight rules to instrument flight rules conditions. Sunrise was at 0642.
The 0553 weather reported at VRB included wind from 230° at 4 knots, 10 miles visibility, light rain, scattered clouds at 2,700 ft above ground level (agl), broken clouds at 10,000 ft agl, temperature 18°C, dewpoint 17° C, with an altimeter setting of 30.00 inches of mercury (inHg).
At 0653, the wind was 270° at 7 knots, 8 miles visibility, light rain, ceiling broken at 500 ft agl, overcast clouds at 1,900 ft agl, temperature 19°C, dewpoint 18°C, and an altimeter setting of 30.03 inHg.
At 0703, the wind was 250° at 8 knots, visibility 6 miles, light rain and mist, ceiling overcast at 400 ft agl, temperature 19° C, dewpoint 18° C, and an altimeter setting of 30.03 in Hg.
Similar conditions were reported 13 miles south of the accident site at Treasure Coast International Airport (FPR), Fort Pierce, Florida, which reported at 0715 wind from 270° at 7 knots, 2 1/2 miles visibility in mist, ceiling overcast at 300 ft agl, temperature 19°C, dew point 18°C, altimeter 30.04 inHg.
A review of the terminal aerodrome forecast (TAF) for VRB on the morning of the accident revealed it was issued at 0044 and was amended at 0632, about 25 minutes before the pilot's departure. The 0044 forecast expected variable winds of 3 knots, visibility unrestricted at 6 miles or more, with broken clouds at 1,500 ft agl between 0300 and 0900. The 0632 forecast reported no change in the forecast through 0900.
The TAF was amended after the accident at 0741 and expected a temporary period of instrument flight rules (IFR) conditions between 0700 and 0900 with visibility of 2 miles in mist with a ceiling overcast at 300 ft.
The National Weather Service issued AIRMET Sierra at 0345, which was current until 1000, for IFR conditions over Florida and the coastal waters, which included the accident site, for ceiling below 1,000 ft agl and visibilities below 3 miles in mist.
FSA required students to obtain their own weather briefings as part of the preflight planning process. The school had a separate room where students could call Leidos Flight Service (LFS) to obtain weather briefings and file flight plans. There were also computers available to obtain weather information and file flight plans electronically. According to the flight school, the computers used to obtain weather information do not require a student to sign in, so there was no record available to determine if the pilot used one of the school's computers to obtain weather information before the accident flight.
According to LFS, neither they nor any of the other vendors that use the LFS database, provided the student pilot any services (weather briefing, flight plan filing) before the accident flight.
A review of FSA's Aviation Safety Action Program (ASAP) dispatch occurrence forms submitted by the four other FSA pilots who flew on the morning of the accident revealed that two of the pilots specifically stated that they had checked the METAR and TAF before they departed and weather was VFR. However, it was still dark out and they could not see the cloud bases. Both pilots departed between 0630 and 0650 and entered the clouds on takeoff between 400 and 700 ft agl. Both pilots were able to climb above the clouds and divert to another airport. Another pilot, who did not specifically say that he checked weather that morning, said that the sky was "dim and gray" and he departed at 0645. After takeoff, he entered the clouds at 600 ft agl, but was able to climb and divert to another airport. The fourth pilot was the first on the flight line that morning and said that the ceiling and visibility were good, and he departed at 0610. The pilot flew east and noted that the cloud layers were not good for practicing maneuvers, so he returned to VRB. He said that the ceiling height was dropping quickly, but he was able to maintain visual contact with the airport and land.
WRECKAGE AND IMPACT INFORMATIONThe airplane’s initial impact point was an approximate 30-ft-tall tree; the wreckage path continued about 460 ft through trees and the airplane came to rest on its right side on a magnetic heading of about 115°. All major components of the airplane were located at the accident site and there was no post-impact fire.
The airplane's right wing, left wing, section of left stabilator, baggage door, nose gear fork, left main gear, engine cowling, pilot's seat, and a section of the outboard seat rail were found along the wreckage path. The main wreckage included the propeller, engine, fuselage, empennage, vertical stabilizer, rudder, and right stabilator.
The left wing separated from the airframe at the wing root and exhibited extensive leading-edge impact damage. The fuel tank was breached. The aileron and flap remained partially attached to the wing. The aileron cables remained attached at the bell crank and exhibited broomstraw fractures.
The right wing separated at the wing root and was fractured into two sections. The outboard section of wing sustained extensive impact damage. The inboard section (fuel tank) was breached. The flap and aileron remained attached to their respective hinges. The aileron cables were attached to the bell crank and the ends exhibited broomstraw fractures.
The wing flap handle was in the 10° flaps-extended position; the flap torque tube was dislodged from its supporting structure.
Measurement of the stabilator trim jackscrew corresponded to a slight nose-down position.
The vertical stabilizer sustained some impact damage. The rudder remained partially attached. The stabilator remained attached to the fuselage. The right side of the stabilator exhibited leading edge damage and the stabilator was deformed aft. The leading edge of the left side of the stabilator was separated from the assembly and displayed impact damage.
Flight control continuity was established from all flight control surfaces to the cockpit. Any breaks in the system exhibited broomstraw fracturing consistent with overstress.
The cockpit area sustained impact damage. The throttle was in the idle position and the mixture was in the full lean positio...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA19FA116