N804ER

HISTORY OF FLIGHTOn March 5, 2023, at 2125 eastern standard time, a Diamond DA-40, N804ER, was substantially damaged when it was involved in an accident near Palm Beach County Park Airport (LNA), West Palm Beach, Florida. The commercial pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14?Code of Federal Regulations Part 91 personal flight.

According to FAA ADS-B and air traffic control information, after takeoff from Williston Municipal Airport (X60), Williston, Florida, the flight proceeded in a south-southeasterly direction to about 14 nautical miles north-northwest of Southwest Florida International Airport (RSW), Fort Myers, Florida, then proceeded east towards LNA.

According to audio from Palm Beach International Airport (PBI) air traffic control tower correlated with ADS-B data, at 2100:43, when the flight was about 279° and 48 nautical miles from LNA, one of the pilots established contact with the facility and advised that they were at 2,500 ft mean sea level (msl). The controller advised the flight to maintain visual flight rules at or above 2,600 ft msl, which the pilot acknowledged. The flight continued toward LNA, then at 2119:47, when the flight was about 7 nautical miles west of LNA, one of the pilots advised the controller that the airport was in sight. Radar services were terminated, and the flight proceeded toward runway 10 at LNA for a straight-in visual approach, while the right-seat occupant made radio calls on the CTAF.

Two witnesses, one of whom was a private pilot and the other a student pilot, reported that they knew both pilots onboard the accident airplane and had exchanged text messages with the right-seat pilot that they were waiting on the ramp at LNA for the airplane to arrive. The witnesses’ location abeam the runway was about 2,313 ft down and 513 ft south of runway 10. The private pilot witness reported seeing the airplane on a 10-mile final approach for runway 10 and he planned to film the airplane’s arrival on short final. He reported that, at the intersection of runways 10/28 and 4/22, which was located about 800 ft from the approach end of runway 10, the airplane started to go around. He reported that it descended no lower than 20 to 30 ft above ground level (agl) and did not touch down. He then began to capture video the flight and reported that the engine was “constantly smooth” as the airplane flew over runway 10. He noted that the airplane climbed no higher than between 200 ft and 250 ft agl, then when at or just past the departure end of the runway, the airplane banked to the right, stalled, and rolled inverted.

The student pilot witness reported that, when the airplane was at the departure end of runway 10, it made a “sudden 45° right bank,” which was not expected. He noted the airplane banked right, the nose leveled off, then entered a right bank of 60°. When the nose of the airplane was pointed toward them, the right wing stalled. He also stated that it did not sound like the engine was producing full power, but that the engine “appeared fine” the whole time, adding that the engine sounded “ok” during the turn to behind the hangars, then it went silent.

There was no radio call on the CTAF announcing the go-around.

A postaccident fire was extinguished by first responders from a nearby fire station. PERSONNEL INFORMATIONLeft-Seat Pilot

The left seat pilot held a private pilot certificate with a rating for airplane single-engine land. His logbook began with an entry dated September 12, 2007, to the last entry dated February 4, 2023, and indicated that his most recent flight review was on July 19, 2022. He logged a total of 4.4 hours night flight time all as dual received, with his last logged night flight on March 7, 2011.

Right-Seat Pilot

The right-seat pilot held a commercial pilot certificate with ratings for airplane single-engine land and sea, and a flight instructor certificate with ratings for airplane single-engine and instrument airplane.

A review of the right-seat pilot’s logbook revealed that his most recent flight review was on October 26, 2022, when he added an instrument rating to his flight instructor certificate. After his medical had expired, he logged 4 separate flights as pilot-in-command; the remarks section of those flights listed names consistent with instruction given. His last logged night flight as a flight instructor and pilot-in-command was on January 4, 2023, in a Diamond DA-40. The entire portion of the 1.2-hour-long flight was logged as night.

According to the right-seat pilot’s medical records, his last aviation medical examination was on February 15, 2022. At that time, he reported, in part, obstructive sleep apnea with use of a continuous positive airway pressure (CPAP) machine, which was found in the wreckage. He was issued a first-class medical certificate with a time limitation (not valid for any class after February 28, 2023). According to medical records from the Veteran’s Affairs Medical Center (VAMC), he was evaluated by his VAMC sleep physician on February 14, 2023. According to the sleep physician’s documentation, the pilot’s CPAP record from February 14, 2022 to February 13, 2023, was reviewed and the pilot had been adherent to his prescribed CPAP therapy. The reviewed CPAP records show the pilot used the machine an average time on the days used of 7 hours 57 minutes, and usage on 99% of the days during the time period reviewed. There was no record that he obtained another FAA-issued medical after February 28, 2023. AIRCRAFT INFORMATIONAs part of the airplane’s last annual inspection on February 24, 2023, the throttle cable was adjusted and secured. The airplane was approved for return to service.

According to the operator’s chief pilot, the recently leased airplane was being flown to their facility at LNA. Since taking possession of the airplane on the day of the accident at Henderson City-County Airport (EHR), Henderson, Kentucky, the airplane was flown to Harris County Airport (PIM), Pine Mountain, Georgia, then to Williston Municipal Airport (X60), Williston, Florida, arriving there about 1840. The chief pilot indicated that the fuel tanks were topped off at X60.

Metering of fuel delivered to the engine was performed by a servo fuel injector, which was controlled from the cockpit at an engine control assembly in the center console that held the throttle and mixture control levers. The throttle control lever in the cockpit sets the position of the throttle control lever at the fuel servo and the two ends are mechanically connected by a Bowden cable. The engine-compartment end of the throttle control cable has a cable eye, or rod end, that attaches to the throttle control lever at the fuel servo. The throttle control cable attach hardware in the engine compartment was equipped with a spring that attached to the hardware securing the throttle cable to the throttle lever at the fuel servo and also to a spring anchor bracket attached to the fuel servo. The spring was designed and part of the initial type certification so that if the throttle control separated at the engine fuel metering device, the tension spring was intended to move the throttle control to full power.

Two mini iPads, two cellular phones, and an Apple Series 6 watch were recovered from the wreckage and submitted to the NTSB Vehicle Recorder Division for download; however, the extent of damage precluded obtaining any data. AIRPORT INFORMATIONAs part of the airplane’s last annual inspection on February 24, 2023, the throttle cable was adjusted and secured. The airplane was approved for return to service.

According to the operator’s chief pilot, the recently leased airplane was being flown to their facility at LNA. Since taking possession of the airplane on the day of the accident at Henderson City-County Airport (EHR), Henderson, Kentucky, the airplane was flown to Harris County Airport (PIM), Pine Mountain, Georgia, then to Williston Municipal Airport (X60), Williston, Florida, arriving there about 1840. The chief pilot indicated that the fuel tanks were topped off at X60.

Metering of fuel delivered to the engine was performed by a servo fuel injector, which was controlled from the cockpit at an engine control assembly in the center console that held the throttle and mixture control levers. The throttle control lever in the cockpit sets the position of the throttle control lever at the fuel servo and the two ends are mechanically connected by a Bowden cable. The engine-compartment end of the throttle control cable has a cable eye, or rod end, that attaches to the throttle control lever at the fuel servo. The throttle control cable attach hardware in the engine compartment was equipped with a spring that attached to the hardware securing the throttle cable to the throttle lever at the fuel servo and also to a spring anchor bracket attached to the fuel servo. The spring was designed and part of the initial type certification so that if the throttle control separated at the engine fuel metering device, the tension spring was intended to move the throttle control to full power.

Two mini iPads, two cellular phones, and an Apple Series 6 watch were recovered from the wreckage and submitted to the NTSB Vehicle Recorder Division for download; however, the extent of damage precluded obtaining any data. WRECKAGE AND IMPACT INFORMATIONThe airplane crashed on airport property about 1,030 ft and 191° from the departure end of runway 10.

Examination of the accident site revealed a ground scar consistent with impact with the left wing, indicating that the airplane was on a magnetic heading of 228°. The airplane came to rest upright leaning on its right side on a magnetic heading of 221°. The left wing was fragmented, while the right wing remained intact but impact damaged. About 6 gallons of fuel were drained from the right wing fuel tank. The aft empennage was displaced to the left. All major components of the airplane either rema...