Loss of control in flight: Piper PA-28-236 Dakota, N8438B, fatal accident occurred on April 1, 2024, near Muncie-Delaware County Airport (MIE/KMIE), Muncie, Indiana

• Location: Muncie, Indiana
• Accident Number: CEN24LA144
• Date & Time: April 1, 2024, 10:27 Local
• Registration: N8438B
• Aircraft: Piper PA28
• Aircraft Damage: Destroyed
• Defining Event: Loss of control in flight
• Injuries: 1 Fatal, 2 Serious
• Flight Conducted Under: Part 91: General aviation - Personal

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194014/pdf

https://data.ntsb.gov/Docket?ProjectID=194014

On April 1, 2024, about 1027 eastern daylight time, a Piper PA-28-236 airplane, N8438B, was destroyed when it was involved in an accident near Muncie, Indiana. The pilot sustained fatal injuries and two pedestrians on the ground sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The instrument-rated pilot was repositioning the airplane to a maintenance facility for a pitot-static test required to complete instrument flight rules (IFR) certification. The pilot initially filed a visual flight rules (VFR) flight plan but later filed an IFR flight plan instead. The airplane departed and proceeded toward the destination airport.

The destination airport local control (LC) controller advised the departure radar east (DRE) controller that the destination airport was instrument meteorological conditions (IMC) and the RNAV runway 14 approach was in use. The DRE controller then instructed the pilot to advise when he had the updated weather information for the destination airport and advised him to expect the RNAV runway 14 approach. The pilot responded that he had the updated weather information, and he acknowledged the RNAV runway 14 approach was in use.

As the pilot approached the airport, the LC controller cleared the pilot to land on runway 14. According to air traffic control (ATC) surveillance data, the airplane tracked west of the final approach course. The pilot advised that he needed to perform a 360° turn and reported the field in sight, which the LC controller acknowledged. The LC controller then coordinated with the DRE controller and advised that the pilot was performing a 360° turn to realign with the approach.

The DRE controller then asked the LC controller if the pilot was going to return to the approach. The LC controller stated that the pilot was doing a “quick 360.” The DRE controller advised the LC controller that he was going to vector an uninvolved airplane that had been following the accident airplane and would re-sequence it for the approach. The DRE controller asked the LC controller to let him know when the accident airplane landed, and the LC controller acknowledged.

The LC controller advised the pilot that there was another airplane inbound for the approach behind him and instructed the pilot to advise when he was reestablished on final approach. The pilot acknowledged and stated he would report reestablished. The pilot then completed two clockwise 360° turns and, midway through a third turn, ATC surveillance data stopped approximately 0.8 nautical miles (nm) southwest of the runway 14 threshold.

Two pedestrians who were walking together on a public walking trail sustained serious injuries when the airplane impacted wooded terrain. During the impact sequence, the wings and the empennage separated from the fuselage and the airplane was destroyed.

Examination of the airframe, engine, and propeller found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The flaps were found at the fully extended position. The pitch trim was found in the full nose-down position. The airplane had not had an altimeter test, a pitot static test, or a transponder test performed within the 24 months before the accident, as required for operation under IFR in controlled airspace.

A review of the pilot's logbook showed that he had not met the required instrument experience requirements within the preceding 6 months. There was no record of the pilot obtaining an instrument proficiency check within the preceding 12 months. The owner of the maintenance facility the pilot was departing from reported that the pilot experienced difficulties operating and understanding the onboard navigation system, but that he knew of no issues with the systems.

The pilot's toxicology testing identified diphenhydramine. The quantity of the pilot's specimen was not sufficient for quantitative testing. The specimen tested was also drawn at the same time as the pilot was receiving a large amount of donated blood products. Therefore, whether the diphenhydramine detected resulted from the pilot's use or from transfused blood products could not be determined, and its contribution to the accident could not be established.

During the post-accident evaluation, the pilot was found to have an intracranial vascular abnormality, or cavernous malformation. Cavernous malformations are common vascular brain lesions in adults. These lesions are increasingly identified due to more frequent use of brain imaging. Without symptoms such as seizures or headaches, the risk of serious effects is low. In this case, the pilot reportedly had no symptoms and was unaware of the lesion's presence. It is unlikely that the cavernous malformation contributed to the accident.

Neither post-accident drug nor alcohol testing were ordered nor conducted with the LC controller.

Based on the available evidence, the pilot, who was not instrument current, initiated an IFR flight in an airplane that was not in compliance with required IFR equipment and inspection requirements. During the instrument approach, the pilot likely did not properly configure the onboard navigation system, resulting in the airplane tracking off course.

When the pilot initiated a 360° turn during the instrument approach, the LC controller did not issue missed approach instructions in accordance with the tower's standard operating procedures. Had the appropriate missed approach instructions been provided by the LC controller, the airplane likely would have been resequenced for another approach, rather than continuing the 360° turns.

The presence of known IMC at the destination airport at the time of the accident was conducive to the development of spatial disorientation, and the airplane's flight track is consistent with the known effects of spatial disorientation. The pilot's 360° turns may have been appropriate in visual meteorological conditions (VMC); however, in IMC, they likely resulted in spatial disorientation and a subsequent loss of control.

- Probable Cause: The pilot's spatial disorientation and subsequent loss of control while maneuvering outside established instrument approach procedures in instrument meteorological conditions, which resulted in an impact with terrain. Contributing to the accident was the local control controller's failure to issue appropriate missed approach instructions due to inadequate procedural knowledge.

Loss of engine power (partial): Cessna 402B Utiliner, N4167G, fatal accident occurred on July 11, 2024, near Aeropuerto Internacional Rafael Hernández (BQN/TJBQ), Aguadilla, Puerto Rico

• Location: Aguadilla, Puerto Rico 
• Accident Number: ERA24FA301 
• Date & Time: July 11, 2024, 09:23 Local 
• Registration: N4167G
• Aircraft: Cessna 402B 
• Aircraft Damage: Destroyed 
• Defining Event: Loss of engine power (partial) 
• Injuries: 1 Fatal, 1 Minor 
• Flight Conducted Under: Part 91: General aviation - Personal 

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194672/pdf

https://data.ntsb.gov/Docket?ProjectID=194672

On July 11, 2024, about 0923 Atlantic standard time, a Cessna 402B airplane, N4167G, was destroyed when was involved in an accident near the Rafael Hernandez Airport (BQN), Aguadilla, Puerto Rico. The private pilot was fatally injured, and a person on the ground sustained minor injuries. The airplane was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. 

About 3 months before the accident, the twin-engine airplane underwent an annual maintenance inspection during which the mechanic identified numerous discrepancies with both engines and the airframe. The airplane was not subsequently approved for flight and the owner was provided a list of the discrepancies. The purpose of the accident flight was to relocate the airplane to another airport where the pilot planned to have the discrepancies addressed. The mechanic reported that he had advised the pilot that he needed to apply for a ferry permit from the FAA in order to complete the accident flight, but there was no evidence that the pilot had obtained one.

On the day of the accident flight, air traffic control data showed that the pilot departed and climbed the airplane to about 1,500 ft mean sea level (msl). About 2 miles from the departure airport the pilot advised air traffic control of his intent to return to the departure runway due to a vibration of the right engine. The controller immediately cleared the pilot to enter the left downwind for the departure runway. The airplane then turned to the left and began a descent toward the left downwind leg of the traffic pattern. When the airplane was about a mile from the airport, the pilot reported that the airplane had an “engine failure” and that he intended to land on the departure runway, but in the opposite direction. Recorded flight track data showed that the airplane then turned directly toward the approach end of that runway and that during the final 30 seconds of track data, the airplane's altitude and groundspeed decreased rapidly.  Surveillance video captured the final few seconds of flight, and showed the airplane in a steep vertical descent and a right roll. The airplane impacted a residential area into trees, powerlines, and propane fuel tanks. After the impact, the airplane sustained significant postimpact fire damage.  

Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures of the airplane's flight controls. Although the right engine's fuel manifold was damaged by thermal forces, it contained visible corrosion and remains of diaphragm material when opened. Below the fuel screen at the fuel inlet within the manifold was a large quantity of debris and foreign material that was likely present before the accident. Based on the available evidence, it is possible that this contamination resulted in the total loss of engine power to the right engine that was reported by the pilot; however, given the multiple discrepancies that had been documented with the engine prior to the flight, and the extent of the post impact fire damage to the engine, it is possible that the loss of reported loss of engine power may have been due to other unresolved maintenance issues.

The final recorded position showed the airplane about .3 miles the runway threshold at 200 ft msl and 73 kts groundspeed, on a heading of 209°. The Pilot's Operating Handbook for the accident airplane model listed the minimum controllable airspeed as 82 knots indicated airspeed. Considering the wind information provided by air traffic control to the pilot of 090° at 10 knots, gusting to 14 knots, it is likely that the airplane's airspeed likely decreased below its minimum controllable airspeed which resulted in a loss of control from which the pilot was not able to recover.

- Probable Cause: The pilot’s decision to operate the airplane with known maintenance discrepancies, which resulted in a total loss of right engine power. Contributing to the outcome was the pilot’s failure to maintain airspeed while returning to the airport with a single operating engine, which resulted in a loss of airplane control.

Structural icing: Piper PA-32R-301 Saratoga II HP, N9236J, fatal accident occurred on April 12, 2024, near Knoxville, Tennessee

• Location: Knoxville, Tennessee 
• Accident Number: ERA24FA176 
• Date & Time: April 12, 2024, 16:33 Local 
• Registration: N9236J 
• Aircraft: Piper PA-32R-301 
• Aircraft Damage: Destroyed 
• Defining Event: Structural icing 
• Injuries: 1 Fatal 
• Flight Conducted Under: Part 91: General aviation - Personal

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194081/pdf

https://data.ntsb.gov/Docket?ProjectID=194081

On April 12, 2024, about 1633 eastern daylight time, a Piper PA-32R-301, N9236J, was substantially damaged when it was involved in an accident near Knoxville, Tennessee. The commercial pilot was fatally injured. The flight was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight.

The pilot departed on an instrument flight rules cross-country flight. About 15 minutes after departure, shortly after reaching a cruise altitude of 8,000 ft mean sea level (msl), the pilot reported to air traffic control that he was “picking up moisture in the clouds” and asked for a course deviation or a higher altitude. The controller approved course deviations and cleared the pilot to climb to 10,000 ft msl, which the pilot accepted. A performance study of the airplane's ADS-B flight track data showed that the airplane's airspeed decreased during the subsequent climb, and the airplane reached a maximum altitude about 8,500 ft msl and a minimum airspeed around 80 knots (kts) before it rapidly rolled left and lost altitude at a rate of about 1,300 ft per minute, consistent with an aerodynamic stall. The airplane briefly leveled off before entering a descending right turn, reaching a descent rate of 6,000 ft per minute. The descending turn continued until flight track data was lost at an altitude about 5,750 ft msl. At this time, the airplane's calculated calibrated airspeed was about 210 kts; the airplane's published never-exceed speed (Vne) was 197 kts indicated airspeed.

A witness on the ground near the accident site observed the airplane “twirling” as it descended below the clouds and also observed debris falling from the sky. The wreckage was distributed over a distance of more than 10,000 ft, consistent with an in-flight breakup. Postaccident examination of the airplane and engine revealed no evidence of a mechanical failure that would have precluded normal operation. Control cable separations and airframe structural fractures all exhibited characteristics consistent with overload failure. The airplane was not equipped with anti- or de-icing equipment and was not certified for flight into known icing conditions.

Review of weather information for the area indicated cloud bases around 4,500 to 5,000 ft with tops around 18,500 ft. The freezing level was around 5,500 ft, with supercooled large droplets (SLD) likely between 6,000 and 8,000 ft. The pilot filed his instrument flight plan for the accident flight with a flight planning application that generated a route briefing. The briefing contained weather information for the route of flight, including the forecast for moderate icing conditions; however, information regarding the potential SLD conditions would have been contained in supplemental icing information not provided in the standard briefing. Whether the pilot accessed supplemental icing information before the flight could not be determined.  

Flight track information indicated that the airplane likely entered instrument meteorological and icing conditions shortly after takeoff, and that the airframe and flight control surfaces began to accumulate ice rapidly, as the time between the pilot's request for a higher altitude and the loss of flight track data was about 2 minutes. The airplane then likely encountered an aerodynamic stall while flying at an airspeed of 80 kts (15 kts faster than its maximum published stall speed). This was consistent with the effects of increased drag and stall speed due to ice accretion. It is likely that the pilot lost control of the airplane following the initial aerodynamic stall and was unable to recover. During the subsequent descending turn, the airplane exceeded its structural limitations, resulting in an in-flight breakup.

The pilot held an instrument rating; however, review of available logbook information indicated limited recent instrument experience, with two instrument approaches and one holding procedure conducted during an instructional flight about 7 months before the accident. Whether the pilot's loss of airplane control was the result of his inability to control the airplane due to ice accretion, a lack of proficiency in instrument flight, or a combination of those factors, could not be determined.

Although the pilot's awareness of the potential for SLD could not be determined, the route briefing generated at the time he filed the flight plan provided adequate information to alert him to the potential for icing conditions along his intended route of flight. Nevertheless, the pilot chose to depart and continue into an area with a known potential for icing conditions in the airplane that was not equipped to do so.

- Probable Cause: The pilot's decision to depart into an area of instrument meteorological and icing conditions, which resulted in loss of airplane control and a subsequent in-flight breakup.