ERA19LA012

The instructor's decision to conduct and continue a visual flight rules flight into instrument meteorological conditions with a known flight instrument anomaly, which resulted in spatial disorientation, causing a loss of airplane control and subsequent in-flight breakup. Contributing to the accident were the instructor's lack of recent instrument flight experience and degraded airplane control and decision-making due to hypoxia.

The flight instructor picked up the private pilot and passenger for a cross-country flight. The instructor requested visual flight rules (VFR) flight following services from air traffic control (ATC) and indicated a planned climb to 8,500 ft mean sea level (msl); however, the airplane continued to climb past that altitude. During the climb, the instructor indicated to the ATC controller, in separate transmissions, that he was climbing to reach "VFR on-top," that he was experiencing problems with an "unreliable" attitude indicator, and that the airplane was "in and out of IMC [instrument meteorological conditions]." Based on weather sounding and satellite imagery, it is likely that the airplane was operating in IMC above 4,100 ft. About 20 minutes after the airplane departed, the controller declared an emergency on behalf of the pilot and provided multiple radar vectors for the airplane to return to visual meteorological conditions (VMC); however, the airplane's radar track showed that the airplane continued climbing to 19,400 ft msl before it entered a series of figure-eight turns followed by a steep, turning descent. A witness stated that the airplane sounded "as if it were a stunt plane doing spins (pitch changing)" and then heard a "pop" and saw large pieces of the airplane descending from the overcast sky. Examination of the recovered portions of the airplane revealed no evidence of preimpact mechanical anomalies and a wreckage distribution consistent with an in-flight breakup. Both the instructor and the private pilot had low levels of ethanol in cavity blood but none in vitreous (instructor) or urine (private pilot). The absence of ethanol in the second specimen indicates it is likely the ethanol was not from ingestion and therefore it did not contribute to the accident circumstances. The private pilot also had evidence of use of morphine, an impairing opioid. However, the decision-making on this flight, including the route and response to weather conditions, was most likely performed by the instructor. Therefore, it is unlikely that effects from low levels of morphine in the private pilot contributed to the accident circumstances. The instructor demonstrated several lapses in judgment associated with conducting the flight. Specifically, the instructor did not appear to recognize the significance of widespread ceilings along his route of flight and planned a cruise altitude that took him into instrument conditions. The instructor likely did not carry supplemental oxygen onboard the nonpressurized airplane and continued to climb the airplane to altitudes that required the use of oxygen; without oxygen he risked becoming susceptible to the effects of hypoxia. Further, another pilot who had flown the accident airplane before the accident flight stated that the airplane had a known problem with the directional gyro, yet the instructor flew the airplane in instrument conditions; based on the instructor's failure to follow the controllers' directional instructions, it is likely the directional gyro was still not working. Lastly, review of the instructor's logbook and an interview with another flight instructor indicated that the instructor was likely not instrument current, so his ability to safely maneuver the airplane in the clouds that were prevalent during the flight would have been negatively impacted by the broken gyro and his lack of currency. In summary, the instructor's decision to continue the flight in instrument conditions with a known flight instrument anomaly greatly increased his workload and likely resulted in his eventual loss of airplane control due to spatial disorientation. The rapidly descending turn (graveyard spiral) depicted on radar and the in-flight breakup due to overstress during the ensuing uncontrolled descent were consistent with the known effects of spatial disorientation. Further, the airplane had been operating above 16,000 ft msl for more than 10 minutes at the time of the upset; there was no evidence that the airplane was equipped with supplemental oxygen. Therefore, the instructor was operating the airplane above altitudes in which supplemental oxygen is required, and without it, his performance and decision-making would have likely been degraded to some extent due to hypoxia. The flight's erratic flight track away from the intended destination and the instructor's inability to successfully maneuver the airplane in response to ATC instructions that he acknowledged are consistent with the effects of hypoxia.

The northeast section of the National Weather Service (NWS) Surface Analysis Chart for 1100 depicted a low-pressure system off the New York Long Island coast with a cold front extending southwest to another low off the North Carolina coast. The station models in the area depicted a west-to-northwest wind of about 10 knots, overcast cloud cover with multiple stations reporting light continuous rain, and temperature dew point spreads of 2º F or less. The NWS Storm Prediction Center (SPC) constant pressure chart for 500 hPa for 0800 depicted the conditions at 18,000 ft msl as an upper-level trough of low pressure extending south from Canada, across western New York and Pennsylvania, and into West Virginia. This upper-level disturbance was referenced in NWS advisories as the principle reason for clouds and precipitation that were expected over the region during the period. The ceiling at DXR, the departure airport, at the time of departure was broken at 4,100 ft above ground level (agl) and overcast at 4,900 ft agl. A High Resolution Rapid Refresh (HRRR) sounding for 1100 supported multiple layers of clouds from the lifted condensation level of 1,157 ft msl through 18,700 ft msl, where the relative humidity exceeded 90%. Satellite imagery depicted an extensive area of clouds obscuring the accident site, consistent with nimbostratus-type clouds that supported light-to-moderate rain. The infrared radiative cloud top temperature over the accident site was -22.16°C, which corresponded to cloud tops near 21,000 ft msl based on the HRRR sounding. Pilot reports in the area of the accident flight indicated cloud tops to 23,000 ft msl with no mention of multiple layers. Pilots reported instrument conditions and light rime to mixed-type ice. The instructor did not file a flight plan, and there was no record of him having obtained a weather briefing from Leidos Flight Services or ForeFlight before departure. Flight Instructor The instructor held a flight instructor certificate with ratings for airplane single- and multi- engine, and instrument airplane. He also held an airline transport pilot certificate with a rating for airplane single-engine land, with commercial privileges for airplane multi-engine land and single-engine sea, and a mechanic certificate with ratings for airframe and powerplant. He owned and operated Oxford Flight Training in Oxford, Connecticut. His most recent FAA third-class medical certificate was issued July 18, 2018, at which time he reported 4,000 total hours of flight experience. Review of the instructor's logbook showed that his most recent instrument proficiency check flight was on December 16, 2016. No logbook entries after that date included simulated or actual instrument flight time. Examination of FAA airman records revealed that his pilot and instructor certificates were revoked in 2011 for falsifying logbook entries and that his mechanic certificate was suspended in 2011 for the "careless and reckless" operation of an airplane in an unairworthy condition. A flight instructor at Oxford Flight Training stated that he did not believe that the accident instructor was instrument current at the time of the accident. He stated that the instructor was "always about getting VFR-on-top" because he did not like being vectored around New York by ATC. Several other pilots who had flown with the accident instructor stated that they had requested special VFR clearances when flying with the instructor. One pilot reported multiple flights during which the instructor disregarded required cloud clearances and instrument-approach minima. Private Pilot The private pilot held a private pilot certificate with a rating for airplane single- engine land. His most recent FAA third-class medical certificate was issued August 27, 1986, and he reported no flight experience at that time. Flight Instructor The Chief Medical Examiner of the Suffolk County, New York, Office of the Medical Examiner, Hauppauge, New York, performed an autopsy of the flight instructor on October 14, 2018. The autopsy report indicated that the instructor died as a result of multiple blunt force injuries. The FAA's Forensic Sciences Laboratory performed toxicological testing. Fluid and tissue specimens were tested and 13 mg/dL of ethanol were identified in cavity blood, but no ethanol was identified in liver tissue. In addition, an unspecified level of Rosuvastatin was identified in the liver, and Metoprolol was identified in the liver and cavity blood. According to the FAA Forensic Toxicology Drug Information, Rosuvastatin is a prescription medication used to reduce blood cholesterol and triglycerides levels. Metoprolol is a blood pressure medication that also can be used to control the rate of fast arrhythmias like atrial fibrillation. Neither are considered impairing. Ethanol may be produced in body tissues by microbial activity after death. Private Pilot The Chief Medical Examiner of the Suffolk County, New York, Office of the Medical Examiner, Hauppauge, New York, performed an autopsy of the Private Pilot on October 15, 2018. The autopsy report indicated that the cause of death was multiple blunt force injuries. The FAA's Forensic Sciences Laboratory performed toxicological testing. Fluid and tissue specimens were tested and 10 mg/dL of ethanol was identified in cavity blood. In addition, 0.01 (µg/mL, ug/g) Morphine was identified in cavity blood and 0.137 µg/mL Morphine was identified in urine. According to the FAA Forensic Toxicology Drug Information, morphine is a prescription medication used to relieve moderate to severe pain and can also be an active metabolite of codeine. This medication has the potential to impair mental or physical ability required for the performance of potentially hazardous tasks, such as flying, driving, operating heavy machinery. The airplane was registered to the flight instructor in June 2018. Review of maintenance records showed that when the most recent annual inspection was completed by the flight instructor on September 10, 2018, the left engine had accrued 2,337.8 hours of flight time and the right engine had accrued 1,097.5 hours of flight time. The maintenance record included the statement, "replaced right vacuum pump with overhauled." Other maintenance records showed that the left engine vacuum pump was replaced on May 21, 2012; however, examination of the left engine vacuum pump revealed that the half of the data plate with the model number and serial number was missing, thus the logbook information could not be confirmed. A flight instructor at Oxford Flight Training stated that, in August 2018, several weeks before the accident, one of the accident airplane's vacuum pumps had been not working. In addition, he said that it was necessary to reset the directional gyroscope every 10 minutes by flying straight and level and resetting it to match the magnetic compass. He stated that the accident instructor was aware of this issue and would "just compensate for it." Between the annual inspection and the accident flight, there were no maintenance entries associated with the right vacuum pump. On October 13, 2018, at 1058 eastern daylight time, a Piper PA-34-200T, N593MS, was destroyed when it was involved in an accident near Westhampton Beach, New York. The flight instructor, a private pilot and a passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The flight instructor departed Waterbury Oxford Airport (OXC), Oxford, Connecticut, and landed at Danbury Municipal Airport (DXR), Danbury, Connecticut, to pick up the private pilot and passenger for the flight to Charleston Executive Airport (JZI), Charleston, South Carolina. Text messages from the flight instructor to another student indicated that the instructor planned to fly back alone after dropping off the private pilot and the passenger. Radar and