Lake Park, GA, USA
N840DS
DIAMOND AIRCRAFT IND INC DA 40
Before departing at night for his destination airport, the noninstrument-rated pilot received a weather briefing, which advised of marginal visual flight rules (MVFR) conditions. The briefing also included an airmen's meteorological information advisory for developing instrument flight rules conditions due to low ceilings and mist. Shortly after takeoff, the pilot contacted a radar approach controller for visual flight rules flight-following services, and he was advised to squawk a beacon code, but, before the approach controller was able to identify the airplane on the radar, the pilot radioed, "I'm in trouble." Shortly after, both radar and radio contact were lost. Review of radar data indicated that the airplane's climb rate was steady until the airplane reached an altitude of about 2,100 ft msl. The airplane then began descending rapidly while turning right until it impacted terrain. Examination of the wreckage did not reveal any evidence of preimpact failures or malfunctions of the engine or primary flight controls. However, examination of the elevator trim system revealed that the elevator trim cable was disconnected from the trim control wheel in the cockpit and that it had pulled out of a swaged rod end (bolt), which displayed a longitudinal crack on the outer surface of the swage. Examination of the fracture surface revealed that the fracture occurred due to overstress. The examinations were not able to determine if the cable pulled out of the fitting during the accident sequence or if it was a pre-existing condition. Regardless, review of the elevator pitch control system revealed that, even if the elevator trim cable had disconnected in flight, it should not have led to an uncontrollable situation due to its redundant design. At the time of the accident, both the sun and the moon were more than 15 degrees below the horizon. Further, warm, moist southerly wind ahead of an approaching cold front was producing variable clouds, and a band of low stratiform clouds with their tops near 4,000 ft existed over the area. Operating in MVFR conditions increases a pilot's workload and stress level because navigation becomes more difficult and reduces the margin of safety. As a result of the increased workload and stress level and the pilot's minimal simulated instrument time (about 7 hours); his minimal night experience (about 3 hours); the dark, night MVFR conditions; restricted visibility, including a lack of ambient light; and the sustained right turn and descent, it is likely the pilot experienced spatial disorientation and subsequently lost control of the airplane.
HISTORY OF FLIGHTOn December 10, 2012, at approximately 1950 eastern standard time, a Diamond Aircraft Industries DA 40; N840DS, was substantially damaged when it impacted trees and terrain after a loss of control during climb, after departure from Valdosta Regional Airport (VLD), Valdosta, Georgia. The certificated private pilot was fatally injured. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 business flight, destined for Jesup-Wayne County Airport (JES), Jesup, Georgia. According to the VLD Air Traffic Control Tower (ATCT) supervisor, at approximately 1935, the pilot radioed VLD ATCT and advised that he was ready to taxi for departure. The pilot was then issued current weather and taxi instructions to the active runway. The pilot then advised the controller that he would be departing to the east to JES. At 1939, the pilot advised ATCT that he was ready for departure and was issued current wind information and was cleared for takeoff. At 1942, the pilot was advised to squawk a beacon code of "1200" and that he could receive visual flight rules (VFR) advisory service with Moody Air Force Base Radar Approach Control (RAPCON) on frequency 126.6. The pilot then advised that he was changing to frequency 126.6 for advisory services. According to the RAPCON supervisor, after the pilot contacted the RAPCON for VFR flight following the pilot was advised to squawk a beacon code of "5576" but, at 1950, before the airplane was radar identified by the RAPCON, the pilot radioed "I'm in trouble." Moments later, both radar and radio contact was lost. At 1953, downed airplane procedures were initiated and a search for the airplane by federal, state, and local authorities was initiated. PERSONNEL INFORMATIONAccording to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on October 15, 2012. He had accrued approximately 208 total hours of flight experience, 123 hours of which was in the DA 40. Further review of the pilot's flight records revealed that of his 208 total hours of flight experience he had accrued approximately 3 hours of night time and approximately 7 hours of simulated instrument time. He did not possess an instrument rating and no record of any actual instrument time being logged was discovered. AIRCRAFT INFORMATIONThe accident airplane was a low wing, T-tailed, single engine monoplane, manufactured primarily of fiberglass reinforced plastic (FRP). The ailerons, elevator and wing flaps were operated through control rods, while the rudder was controlled by cable. The wing flaps were electrically operated. Elevator forces could be balanced by a trim tab on the elevator, which was operated by a Bowden cable. It was powered by a 180 horsepower, air-cooled, four-cylinder, horizontally-opposed, fuel injected, direct-drive engine, driving a 3-bladed constant speed propeller. It was capable of flying in instrument meteorological conditions and was equipped with an electronic flight information system (EFIS) that integrated flight, engine, communication, navigation, and surveillance instrumentation systems to allow a pilot to operate the airplane without visual reference. The system consisted of a Primary Flight Display (PFD), Multi-Function Display (MFD), audio panel, Air Data Computer, Attitude and Heading Reference System, engine sensors, a processing unit, and integrated avionics containing Very High Frequency (VHF) communications, VHF navigation, and GPS (Global Positioning System). The primary function of the PFD was to provide attitude, heading, air data, navigation, and alerting information to the pilot. The PFD could also be used for flight planning. The primary function of the MFD was to provide engine information, mapping, terrain information, and flight planning. The audio panel was used for selection of radios for transmitting and listening, intercom functions, and marker beacon functions. In the event of a malfunction of the EFIS system's PFD or MFD, mounted directly above them were a set of standby analog instruments which consisted of an attitude indicator, airspeed indicator, altimeter, and magnetic compass. According to FAA and maintenance records, the airplane was manufactured in 2007. The airplane's most recent annual inspection was completed on April 27, 2012. At the time of the inspection, the airplane had accrued 203.1 total hours of operation. METEOROLOGICAL INFORMATIONMeteorological information for this investigation was derived from numerous sources. Surface Analysis Chart The National Weather Service (NWS) Surface Analysis Chart for 1900 depicted a deep low pressure system at 995-hectopascals and associated occluded front impacting the northeastern United States with a cold front extending southward across northwestern Georgia and eastern Alabama into the Florida Panhandle, and then into the Gulf of Mexico. The station models ahead of the front over Florida and southern Georgia indicated warm-moist light southerly winds ahead of the front with broken to overcast clouds and scattered rain showers. Soundings The NWS Tallahassee 1900 sounding indicated a moist low level environment with the lifted condensation level (LCL) at 967 feet above ground level (agl), with the sounding relative humidity greater than 80 percent from the surface to 5,000 feet, with the sounding being conditionally unstable with a Lifted Index of 0.2 even with a low level temperature inversion. The freezing level was identified at 14,240 feet. The sounding wind profile indicated a surface winds from the south at 5 knots which veered to the west above the surface and increased in speed. The mean 0 to 6 kilometer (18,000 feet) wind was from 240° at 41 knots. The wind at 2,000 feet was from 220° at 14 knots. Radar Imagery The NWS regional radar mosaic for 1945 depicted several scattered areas of rain showers over Georgia and northern Florida to the southwest and east of the accident site. The Moody Air Force Base WSR-88D radar composite reflectivity image for 1947 depicted very light intensity echoes associated with biological targets and ground clutter associated with a developing nocturnal inversion over the area and no meteorological echoes. No significant weather echoes were identified within 50 miles of the accident site. Satellite Imagery The Geostationary Operational Environmental Satellite (GOES-13) infrared image at 1945 depicted a layer of low stratus clouds over Valdosta area with a radiative cloud top temperature of 289° Kelvin or 15.84° C, which corresponded to cloud tops near 4,000 feet. A large area of enhanced clouds was identified to the south extending from the Gulf of Mexico across northern and central Florida associated with cumulonimbus clouds or thunderstorms. No cumulonimbus clouds were identified in the vicinity of the accident site. Recorded Weather The recorded weather at VLD, at 1953, approximately 3 minutes after the accident included: wind variable at 4 knots, visibility 10 miles, broken clouds at 1,400 feet, temperature 22 degrees C, dew point 19 degrees C, and an altimeter setting of 29.84 inches of mercury. Weather Depiction Chart The NWS Weather Depiction Chart for 2000 depicted an extensive area of Marginal Visual Flight Rules (MVFR) conditions along the front across Alabama and western and northern Georgia, as well as a small portion of southern Georgia and northern Florida. MVFR conditions were depicted over the Valdosta area. Destination Weather Conditions at the planned destination of JES located approximately 85 miles east-northeast of Valdosta indicated light southerly wind, with visibility unrestricted, and high scattered clouds, with lightning detected in the distant south at the time of the accident. Other airports in the immediate vicinity of the destination were reporting scattered to broken clouds at 400 feet agl. during the period. Airman's Meteorological Information Advisory The NWS had issued an Airman's Meteorological Information Advisory (AIRMET) update at 1545. AIRMET Sierra update 3 issued at 1545 EST warned of ceilings below 1,000 feet and visibilities less than 3 miles in mist and fog developing after 1900 through 2100, and continuing through 0400 on December 11, 2012 across northern and southern Georgia. This advisory extended over the departure, the destination, and the accident site. Astronomical Conditions United States Naval Observatory data indicated that sunset occurred at Valdosta at 1732, with the end of civil twilight at 1759. At the time of the accident, both the Sun and the Moon were more than 15 degrees below the horizon. AIRPORT INFORMATIONThe accident airplane was a low wing, T-tailed, single engine monoplane, manufactured primarily of fiberglass reinforced plastic (FRP). The ailerons, elevator and wing flaps were operated through control rods, while the rudder was controlled by cable. The wing flaps were electrically operated. Elevator forces could be balanced by a trim tab on the elevator, which was operated by a Bowden cable. It was powered by a 180 horsepower, air-cooled, four-cylinder, horizontally-opposed, fuel injected, direct-drive engine, driving a 3-bladed constant speed propeller. It was capable of flying in instrument meteorological conditions and was equipped with an electronic flight information system (EFIS) that integrated flight, engine, communication, navigation, and surveillance instrumentation systems to allow a pilot to operate the airplane without visual reference. The system consisted of a Primary Flight Display (PFD), Multi-Function Display (MFD), audio panel, Air Data Computer, Attitude and Heading Reference System, engine sensors, a processing unit, and integrated avionics containing Very High Frequency (VHF) communications, VHF navigation, and GPS (Global Positioning System). The primary function of the PFD was to provide attitude, heading, air data, navigation, and alerting information to the pilot. The PFD could also be used for flight planning. The primary function of the MFD was to provide engine information, mapping, terrain information, and flight planning. The audio panel was used for selection of radios for transmitting and listening, intercom functions, and marker beacon functions. In the event of a malfunction of the EFIS system's PFD or MFD, mounted directly above them were a set of standby analog instruments which consisted of an attitude indicator, airspeed indicator, altimeter, and magnetic compass. According to FAA and maintenance records, the airplane was manufactured in 2007. The airplane's most recent annual inspection was completed on April 27, 2012. At the time of the inspection, the airplane had accrued 203.1 total hours of operation. WRECKAGE AND IMPACT INFORMATIONExamination of the Accident Site On December 11, 2012, at 1115, the wreckage of the airplane was discovered by the crew of Georgia State Patrol helicopter in a heavily wooded area, approximately 7 miles from VLD. Examination of the accident site revealed that the airplane initially made contact with an approximately 56 foot high pine tree before striking two smaller trees and then the ground about 50 feet further on, from the initial impact point with the tree. The impact angle was measured at an approximate 45-degree nose down angle. The airplane came to rest on a 107 degree magnetic heading in a depression on the forest floor, at an approximate elevation of 200 feet above mean sea level (msl). Examination of the Wreckage Examination of the wreckage revealed that the airplane was heavily fragmented. Further examination revealed however, that all major components of the airplane were present and control continuity was able to be established for all of the primary flight controls, and for the wing flaps. Continuity for the elevator trim system could not however be confirmed, as it was discovered that the Bowden cable was disconnected from the trim control wheel in the cockpit. Examination of the Bowden cable revealed that it had pulled out of a swaged rod end which displayed a crack on the outer surface of the swage which ran along its longitudinal axis. Further examination of the crack revealed, that the exposed fractured surfaces were not the same color as the rest of swaged rod end but instead, displayed a brown discoloration on the fracture surfaces. Further examination of the cable end revealed that it also displayed evidence of a powdery looking brown discoloration. Examination of the Propeller and Engine Examination of the propeller and engine did not reveal any evidence of any preimpact failures or malfunctions. The engine was separated from the airframe and found lying inverted about 10 feet forward of the main wreckage. The oil sump and both crankcase halves were impact fractured. The propeller and crankshaft flange were separated from the remainder of the crankshaft just aft of the crankcase nose. Cylinders No.1, No. 2, and No. 4, were impact damaged, and wood fibers were observed to be embedded in the cooling fins of cylinder No. 2. The propeller was discovered separated from the engine near the main wreckage. The spinner was fragmented. The propeller had remained attached the crankshaft flange but, the flange had separated from the engine and was found near the remains of the airplane's fuselage. One of its composite blades was broken off flush with the propeller blade cuff ,with the other two propeller blades broken off and splintered, about 7 inches outboard of their cuffs. The crankshaft exhibited a radial fracture with a 45-degree shear lip just aft of where the propeller flange had separated which was indicative of crankshaft rotation during impact. Drive train continuity was established from the back of the engine forward to the fracture just aft of the crankcase nose, and from the fracture to the propeller hub. The fuel injector servo was impact separated from the engine. The mixture and throttle controls were separated at the servo control arms. Wood fibers consistent with those of the trees impacted by the aircraft were embedded in the servo air inlet opening. The fuel inlet hose was separated from the servo. The fuel inlet screen was absent of debris. The servo regulator section was disassembled and no damage to the internal parts was noted. Liquid with an odor consistent with aviation gasoline was noted in the fuel injector servo and in the fuel flow divider. The engine driven fuel pump was impact separated from the engine and fragmented. The fuel flow divider was partially separated from the engine. The flow divider was disassembled and no internal damage noted. The No. 2 and No. 4 fuel injector nozzles were fractured. No obstruction was noted in any of the nozzles. The oil sump was fractured. Oil however, was observed in the engine. The oil filter was crushed. No debris was noted in the oil suction screen or the propeller governor screen. The oil cooler and oil cooler hoses were impact damaged. The magnetos were impact separated from the engine. The spark plugs were medium gray in color. ADDITIONAL INFORMATIONSpatial Disorientation According to Advisory Circular (AC) 60-4A titled, "Pilot's Spatial Disorientation," surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights overwater, at night, in sparsely populated areas, and in low-visibility conditions. According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with fl
The noninstrument-rated pilot’s improper decision to depart in dark, night marginal visual flight rules conditions, which resulted in his spatial disorientation and subsequent loss of airplane control.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
