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NTSB investigation record

ERA19FA112

Completed

Piper Pa25· N145AB

Date
March 1, 2019
Location
Fort Lauderdale, FL
Conditions
VMC
Record
Published January 28, 2021

Primary finding

Probable cause

The pilot’s failure to maintain proper altitude and clearance while maneuvering during a banner tow flight, which resulted in an in-flight collision with a 19-story building in a heavily congested area. Contributing to the accident were the easterly wind conditions, the pilot's total lack of experience in banner tow operations, and his inadvertent flight over a densely populated area with numerous tall buildings nearby.

Investigator assessment

Analysis narrative

The newly-hired banner tow pilot departed on his first banner-tow flight away from the training airport. After completing several circuits the pilot was flying on a southerly heading with an 8 knot easterly wind about 1/4 mile offshore, which was about half the distance he was trained to be offshore. The pilot initiated a right turn descended to 250 ft mean sea level and flew over a heavily congested area with tall buildings nearby. The airplane was seen flying about 250 ft above ground level over a heavily-congested area before it impacted the 16th and 17th floors of a 19-story building while in a right turn. Although witnesses provided varying accounts of how the engine was operating near the end of the flight, a sound spectrum study conducted with video taken of the airplane just before the impact indicated that the engine was operating near its maximum available power at the time of impact. Postaccident examination of the airplane and engine revealed no evidence of preimpact failure or malfunction. The abnormal engine sounds reported by several witnesses were likely attributed to be from the lack of a muffler of the exhaust system. Given the lack of any mechanical malfunctions with the airplane, it was likely that the pilot did not adequately compensate for the wind conditions, which would have pushed the airplane inland during a right turn to reverse course. The operator reported that banner-tow flights were performed between 500 and 700 ft above mean sea level while offshore. At no time, except during takeoff or landing or unless authorized by air traffic control, were pilots expected to fly at altitudes less than 500 ft. According to training records, the pilot had received 17 hours of banner tow flight training, He completed a .6-hour solo banner tow training flight in the airport vicinity 3 days before the accident.

Source record

Factual narrative

The pilot's first evaluation flight with the operator occurred on November 18, 2018. The flight duration was 1.1 hours and covered full stalls, flight at critically low airspeeds, and maximum performance maneuvers. The flight was conducted in a Cessna 305A. He was hired and began his ground training on January 23, 2019. According to the "Banner Tow Pilot Training" form dated February 22, 2019, he received 20 hours of ground training and about 17 hours flight training, which included a 1.5-hour dual/solo banner tow flight. A "Verification Of Training And FAA Observation" form dated February 22, 2019, indicated that he had 1.5 hours banner tow time. He was trained to fly the operator's Cessna 305A and Piper PA-25 airplanes in banner tow operations and was put on the company's FAA Certificate of Waiver on February 28, 2019. The pilot’s logbook showed that he had completed a .6-hour practice solo banner tow flight in the vicinity of the airport on February 26, 2019. The accident flight was the pilot's first solo banner tow flight away from the banner tow box at North Perry Airport (HWO), Hollywood, Florida, where he conducted his training. Coworkers who interacted with the pilot before the flight reported he was excited and enthusiastic about it; one employee described that the pilot displayed an "appropriate level of nervousness." The airplane was equipped with a "Live View GPS Tracker" system. The exhaust system consisted of pipes with no muffler on either side. A postmortem examination of the pilot was performed by the Broward County Medical Examiner's Office. The cause of death was reported to be blunt head trauma." Forensic toxicology was performed on specimens of the pilot by the FAA Forensic Sciences Laboratory. The FAA toxicology report indicated testing for cyanide was not performed and the results were negative for carbon monoxide, volatiles, and tested for drugs. The airplane came to rest on the 2nd floor of an outside pool area that was under construction. The banner was found on the ground about 400 ft east-southeast of the building. The wreckage came to rest on its left side on a magnetic heading of 050°. The left wing exhibited extensive impact damage and was resting beneath the fuselage, while the right wing was elevated and sustained minimal impact damage. A slight amount of oil was noted on the upper surface of the right wing outboard of the lift strut. Both cockpit doors were found near the main wreckage. The fuel cap was separated from the fuel tank but remained attached by its chain. The oil filler cap and rod were separated from the engine but found in the immediate vicinity of the engine. The rod portion of the oil filler cap and rod was bent near the cap. Both wing lift struts, the aileron flight control cables, and the left flap bellcrank were cut to facilitate recovery. There was no evidence of bird remains on either wing, horizontal stabilizer, vertical stabilizer, or in the cockpit area. The engine remained partially attached to the airframe. The engine mount was impact damaged and the engine was displaced about 25° to 30° in a clockwise direction. The propeller was separated from the engine and a piece about 15 inches in length was fractured off. The separated propeller and fractured propeller piece were found in close proximity to the main wreckage. The position of the engine precluded visual examination of the mixture control cable. Flight control continuity was confirmed from each control surface to each cockpit control, except where cut for recovery. The left flap control cable was connected at the handle and bellcrank near the control surface, while the right flap control cable was connected at the flap control handle and at the bellcrank near the control surface, but exhibited tension overload at the wing root. The stall warning system revealed no evidence of pre-impact failure or malfunction. The 75-gallon capacity aluminum fuel tank was bulged and ruptured on the forward end consistent with hydraulic deformation. No fuel remained in the tank. Only drops of fuel, a slight amount of water, and some ferrous and non-ferrous slivers were found inside the strainer bowl. The fuel strainer screen was unobstructed. No obstructions were noted from the fuel tank to the fuel strainer and to the carburetor bowl. The auxiliary fuel pump was electrically tested and could be heard operating; it was not functionally tested. About 2 ounces of blue-colored liquid consistent with 100LL aviation fuel were drained from the auxiliary fuel pump. Examination of the engine following recovery revealed impact damage to the crankshaft flange and to the No. 6 cylinder, which precluded 360° rotation of the crankshaft. Borescope examination of each cylinder revealed no anomalies. Examination of the lubrication, ignition, valve train, air induction, and exhaust systems revealed no evidence of preimpact failure or malfunction. The carburetor was fractured from engine but was suspended by its attached throttle cable and carburetor heat cable. The mixture cable was detached from its attachment hardware, which was still in place. The mixture control lever was near its midrange position when first viewed. The carburetor inlet screen was impact-damaged and a section could not be removed and remained inside the inlet housing. The section of inlet screen that remained was free of obstructions. The carburetor bowl contained about 2 ounces of fuel which tested negative for the presence of water. Propeller blade No. 1 (as marked by the manufacturer) was twisted toward low pitch. Heavy coarse chordwise scratches were noted on the cambered side of the blade. It exhibited a slight aft bend near the hub, and a slight forward bend about 2/3 span. Slight chordwise scratches were noted on the aft side of the blade. The No. 2 propeller blade was fractured about 25.5 inches from the center of the propeller hub. Heavy coarse chordwise scratches were noted on the cambered side of the blade. The blade tip was curled about 270°. Coarse chordwise scratches were also noted on the aft side of the blade near the fracture surface. The leading edge exhibited a gouge near the tip, and a section of blade was missing from the trailing edge. The propeller spinner exhibited signs of rotation. On March 1, 2019, about 1141 eastern standard time, a Piper PA-25-235, N145AB, was destroyed when it was involved in an accident near Fort Lauderdale, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 banner tow flight. The pilot was scheduled to complete a 2-hour flight towing a "medium size" company banner, which was 30 feet high by 90 feet long, near Hollywood Beach, Fort Lauderdale Beach, and north to the Commercial Boulevard Pier, which was the northernmost point of the route. The operator reported that, after taking off, the pilot conducted 5 or 6 practice banner pick-ups, then picked up the accident banner about 1059. Company tracking data and Federal Aviation Administration (FAA) radar data indicated that the flight proceeded due east to the beach, where the pilot performed several circuits near Hollywood Beach. Review of the track data revealed that, at the southern end of the second circuit, the pilot began a right turn to return to a northerly direction but changed to a left turn and then proceeded in a northerly direction. He made several more circuits, then at 1125:00, the pilot initiated a right turn and proceeded north toward Commercial Boulevard Pier. At 1137:23, while over water south of the Commercial Boulevard Pier, the pilot initiated a right turn and flew in a south-southwesterly direction less than 1/2 nautical mile from the beach. At 1140:02, when the flight was south of Oakland Park Boulevard, about 0.4 nautical mile east-southeast from the accident site, flying about 1/4 mile offshore, he initiated a right turn. (The pilot had been taught to fly ½ miles fr

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