Saturday, January 18, 2020

Loss of Control in Flight: Lancair 360 (LNC2), N4ZQ; fatal accident occurred March 31, 2018 in Atlantic Ocean off the coast of Stuart, Florida

View of all recovered pieces of airplane.
Federal Aviation Administration

View of Fuselage and Wing Sections Recovered.
Federal Aviation Administration

View of empennage section and rudder.
Federal Aviation Administration

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Miramar, Florida 

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:

Location: Atlantic Ocean, AO
Accident Number: ERA18LA119
Date & Time: 03/31/2018, 1117 EDT
Registration: N4ZQ
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

On March 31, 2018, about 1120 eastern daylight time, an experimental amateur-built Lancair LNC2, N4ZQ, was destroyed when it impacted the Atlantic Ocean off the coast of Stuart, Florida. The private pilot and the passenger were fatality injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. An instrument rules flight plan was filed, and instrument meteorological conditions (IMC) prevailed at the time of the accident. The flight originated from Stella Maris Airport (MYLS), Long Island, Bahamas, about 0940 and was destined for Treasure Coast International Airport (FPR), Fort Pierce, Florida.

According to Federal Aviation Administration (FAA) air traffic control (ATC) and radar data, a radar target identified as the accident airplane was at 8,000 ft mean sea level (msl) until 1111. At that time, the controller instructed the pilot to descend to 4,000 ft msl. At 1112:37, the controller stated that there were areas of "moderate to heavy precipitation eleven to one o'clock three miles area's one five miles in diameter." The pilot acknowledged with the airplane call sign. At 1113:34, the pilot reported the airplane's altitude as 5,100 ft msl (in response to the controller's query a few seconds earlier) and continued to descend the airplane to 4,000 ft msl along a 305° course. About 1115, the airplane began a left turn, and the controller asked if the pilot was deviating from the airplane's previously established course; the pilot responded at 1115:12, "negative, but we could use 10 degrees left." Two seconds later, the controller responded that the airplane should proceed direct to WADAS waypoint—the initial approach fix for the RNAV (GPS) RWY 32 approach into FPR—and the pilot acknowledged the instruction at 1116:05 (the last transmission from the airplane) and continued the turn. About 1116 the airplane completed a turn of about 90° before maintaining a course along a 210° heading. The airplane continued flying straight until 1117, when radar contact was lost. An Alert Notice (ALNOT) was issued for the airplane; the US Coast Guard located debris from the airplane about 10 miles north of its last radar-observed location.

According to a pilot who was flying another airplane from MYLS to FPR, the accident pilot topped off the airplane with fuel before takeoff. Both pilots planned to fly at an altitude of 8,000 ft msl, and the accident pilot departed about 45 minutes after the pilot of the other airplane. The accident pilot and the other pilot spoke twice during the flights about both airplanes' airspeed and the distance from FPR.

When the other pilot was about 50 miles from a filed waypoint, he noted a buildup of precipitation near the waypoint and requested to divert. He deviated to the south of the weather, and the airplane entered IMC when it was west and south of the waypoint. The airplane remained in IMC until it was descending to land. The airplane broke out of the clouds at an altitude of about 1,500 ft msl, and the pilot performed a visual landing at FPR.

Pilot Information

Certificate: Private
Age: 71, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present:No 
Instructor Rating(s): None
Toxicology Performed:Yes 
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 01/30/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 1325 hours (Total, all aircraft) 

According to FAA airmen records, the accident pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on January 30, 2017. At that time, he reported 1,325 total hours of flight experience, of which 56 hours were accumulated during the previous 6 months. The pilot's logbooks were not available for review. In July 2014, the pilot reported his flight time to the Lancair Owners and Builders Organization (LOBO) as 1,100 total hours of flight experience, including 100 hours of total instrument flight time, 73 hours of which was actual instrument flight time. According to LOBO's records, the pilot's instrument flight time had not changed since he began reporting it to LOBO in 2014.

Aircraft and Owner/Operator Information

Aircraft Make: AMES ANGIER M

Registration: N4ZQ
Model/Series: LNC2 NO SERIES
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: AMES1
Landing Gear Type: Retractable - Tricycle
Seats: 2
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 350 Hours
Engine Manufacturer: Lycoming
Engine Model/Series: IO-360-B-1F
Registered Owner: On file
Rated Power: 180 hp
Operator: On file
Operating Certificate(s) Held: None

According to FAA airworthiness records, the pilot built the airplane in 2012. It was equipped with a Lycoming IO-360-B-1F 180-hp engine. According to LOBO records, the airplane had accumulated about 350 hours of flight time. The airplane's maintenance logbooks were not located.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions

Condition of Light: Day
Observation Facility, Elevation: FPR, 23 ft msl
Distance from Accident Site: 32 Nautical Miles
Observation Time: 1131 EDT
Direction from Accident Site: 288°
Lowest Cloud Condition: Few / 2400 ft agl
Visibility:  10 Miles
Lowest Ceiling: Overcast / 3000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 40°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.16 inches Hg
Temperature/Dew Point: 24°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Stella Maris, FN (MYLS)
Type of Flight Plan Filed: IFR
Destination: FORT PIERCE, FL (FPR)
Type of Clearance: IFR
Departure Time: 0940 EDT
Type of Airspace:

The closest National Weather Service Weather Surveillance Radar–1988, Doppler (WSR-88D) to the accident site was the Melbourne, Florida, radar, which was 65 miles north-northwest of the accident site and 72 miles north-northwest of the last radar target. Reflectivity values between 30 and 45 dBZ were located in the area of the airplane's last radar observed position, between 1115 and 1121; these values corresponded to moderate-to-heavy precipitation (see figure 1). The reflectivity bands were moving from northeast to southwest between 1100 and 1135. There were no lightning strikes near the accident location about the time of the accident.

Figure 1 - Melbourne, Florida, WSR-88D composite reflectivity image at 1121 with the airplane's ATC radar-derived flight track points in pink, the last ATC target point marked with black circle, and the debris location indicated with a red star.

Visible and infrared imagery from the Geostationary Operational Environmental Satellite No. 16 (GOES-16) indicated abundant cloud cover above the accident site at the accident time with the low-level cloud cover moving from northeast to southwest and the mid- and high-level cloud cover moving from southwest to northeast. The lower brightness temperature bands (indicating higher cloud tops) were oriented southwest to northeast and were located around the accident site and in areas across Florida.

A High-Resolution Rapid Refresh model sounding was created for the accident site for 1100 with station elevation at sea level. The sounding indicated the possibility of clouds between 1,500 ft and 4,500 ft.

A search of two official weather briefing sources: Leidos, the Automated Flight Service Station provider for weather briefings, and the Direct User Access Terminal Service (DUATS). The search determined that the accident pilot did not request a weather briefing through Leidos or DUATS before the flight.

A search of archived data from ForeFlight revealed that the accident pilot requested a weather briefing at 0903 on March 30, 2018, the day before the accident. The briefing contained standard weather information that was valid for March 30 at 0900. The only weather data that would also be valid for 0900 on March 31 was the winds aloft forecast. The accident pilot did not request a weather briefing or weather information via ForeFlight on March 31. It is unknown if the accident pilot checked or received additional weather information before or during the accident flight. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal

Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: Unknown
Ground Injuries: N/A
Aircraft Explosion: Unknown
Total Injuries: 2 Fatal
Latitude, Longitude: 27.334167, -79.800833 (est) 

The airplane debris located by the US Coast Guard included separated sections of the vertical stabilizer, rudder, fuselage, and wings. No other parts of the airplane were recovered. 

Medical And Pathological Information

The St. Lucie County Medical Examiner, Fort Pierce, Florida, performed an autopsy of the pilot. The autopsy report indicated that the pilot died as a result of multiple injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified ethanol (10 mg/dl, mg/hg) in the pilot's muscle tissue. No tested drugs were identified in the pilot's muscle tissue.

Additional Information

Airplane Flying Handbook

The handbook provided the following information about an airplane's attitude and spatial disorientation:

The pilot must believe what the flight instruments show about the airplane's attitude regardless of what the natural senses tell. The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately send the attitude changes which occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

FAA Advisory Circular 60-4A, Pilot's Spatial Disorientation

The advisory circular stated the following:

The attitude of an aircraft is generally determined by reference to the natural horizon or other visual reference with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of orientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.'…Surface references and the natural horizon may at times become obscured, although visibility may be above flight rule minimums. Lack of natural horizon or such reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions…. The disoriented pilot may place the aircraft in a dangerous attitude… therefore, the use of flight instruments is essential to maintain proper attitude when encountering any of the elements which may result in spatial disorientation.

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