ERA23FA181

The pilot’s decision to initiate a visual flight rules flight into dark night conditions, which resulted in spatial disorientation during the initial climb and subsequent steep banking descent into water.

After flying into a coastal airport and having dinner, the instrument-rated commercial pilot conducted a night visual flight rules (VFR) departure over an oceanic basin. Witnesses reported seeing the airplane take off; shortly after takeoff, the airplane entered a right turn before it descended into the water. ADS-B track data indicated that the airplane took off and climbed on the runway heading to an altitude of about 300 ft as it maintained a ground speed of about 103 knots. The airplane then began to turn to the right and began to descend. The last data depicted the airplane at 100 ft, with a ground speed of about 136 knots and a vertical descent rate of 3,008 feet per minute. At the time of departure, dark night conditions prevailed, the winds were calm, and there was 10 miles of visibility with clear skies. Astronomical data indicated that, although the moon was full and moonrise had occurred, the moon was low on the eastern horizon, behind and to the left of the airplane, and there would not have been any visible horizon over the water. Examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures with the airplane or instruments. The airplane was equipped with an autopilot with an attitude recovery function; however, the autopilot was limited to operations over 500 ft above ground level which was about 200 ft higher than the airplane’s peak altitude. The autopilot On/Off switch was found in the Off position. Due to the pilot’s heart disease, the pilot was at an increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack. However, there was no forensic evidence that such an event occurred. Ethanol was detected in the pilot’s cavity blood at a very low level and was not detected in vitreous fluid. Some or all of the detected ethanol may have been from postmortem production. It is unlikely that ethanol effects contributed to the accident. The pilot had diabetes and the postmortem vitreous level of glucose was elevated, as was the hemoglobin A1c (HbA1c). The pilot’s elevated HbA1c was consistent with uncontrolled diabetes over the previous several months. Short-term effects of high blood sugar may include decreased cognitive performance, including slower informational processing speed and decreased executive function and attention. Chronic high blood glucose levels can lead to vision complications and an increased risk of cardiovascular disease. Whether the pilot’s uncontrolled diabetes caused such symptoms or contributed to the accident could not be determined. Based upon track, meteorological, and astronomical data, the pilot initiated a VFR flight into known dark night conditions, without a visible horizon, which would have prevented reliable control of the airplane using only external visual cues. The turning and rapidly descending flight track were consistent with a pilot who was experiencing spatial disorientation, which resulted in a loss of control in flight and an impact with water. The pilot’s instrument and night currency could not be determined.

A review of the 2135 recorded weather at VNC, recorded about 2 minutes before the accident, indicated that the winds were calm, visibility was 10 miles, and skies were clear. Astronomical data indicated that the moon was full the night of the accident and moonrise had occurred about 2 hours 4 minutes before the accident; however, around the time of the accident the moon was at an altitude of 25° and at an azimuth of 109.68°, which would have been low on the eastern horizon, behind and to the left of the airplane. According to FAA records, the pilot’s most recent FAA second-class medical certificate was issued on June 3, 2016. On June 17, 2021, the pilot received certification under the FAA BasicMed program. No pilot logbooks were recovered or provided. A review of flight time information from an aviation insurance policy that began on May 15, 2022 (about 11 months before the accident) indicated that the pilot had accrued about 1,566 total hours of flight time, of which 250 hours were in tailwheel-equipped airplanes, 225 hours were in retractable gear airplanes, 15.9 hours were in multi-engine airplanes, and 15 hours were in the accident airplane make and model. Further review indicated the pilot had flown 15 hours in the last 12 months, but it did not indicate how many hours of night flight, or actual and simulated instrument time, the pilot had accrued. No maintenance logbooks were recovered or provided. A review of historical business records (an aircraft status report, and copies of previous maintenance logbook entries) obtained from a maintenance and repair organization indicated that the airplane's most recent annual inspection was completed on September 15, 2022. At the time of the inspection, the airplane had accrued 5307.3 total hours of operation and the engine had accrued 134.5 hours since major overhaul. Medical Case Review According to the FAA medical case review, the 64-year-old pilot’s last aviation medical examination was June 3, 2016. At that time, he reported having type II diabetes and high cholesterol. He reported taking simvastatin, a prescription medication commonly used to treat high cholesterol; saxagliptin and metformin, prescription oral medications commonly used to help control blood sugar in type II diabetes; and aspirin, an over-the-counter anti-inflammatory medication commonly used to treat pain and fever and decrease cardiovascular risk. At the time of the examination, the pilot’s hemoglobin A1c (HbA1c) was 7.8%. The Aviation Medical Examiner (AME) issued him a second-class medical certificate via AME-Assisted Special Issuance (AASI), with the limitation that the medical certificate was not valid for any class after June 30, 2017. The medical certificate was no longer valid at the time of the accident. The pilot completed a BasicMed course and had reported completing a BasicMed Comprehensive Medical Examination Checklist (CMEC), most recently in June 2021. According to the FAA medical case review, the pilot received a Letter of Eligibility in 2004 for diet-controlled diabetes mellitus. In 2011, the pilot received an Authorization for Special Issuance for second-class medical certification for diabetes treated with oral medication; he was granted another authorization in 2015. Autopsy Report The State of Florida District Twelve Medical Examiner’s Office performed the pilot’s autopsy. According to the pilot’s autopsy report, the cause of death was blunt impact injuries, and his manner of death was accident. Examination of his coronary arteries revealed 50%-60% stenosis of the four major coronary arteries and/or their distal branches from atherosclerotic plaque. The aorta was found to have multiple areas of complex atherosclerotic plaque without an aneurysm. Examination of the brain, lungs and remainder of the heart identified no other significant natural disease. Toxicological Testing At the request of the District Twelve Medical Examiner’s Office, the University of Florida Forensic Toxicology Laboratory performed toxicological testing of the pilot’s cavity blood and bile. According to the autopsy report, no tested-for substances were detected. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem cavity blood and vitreous fluid of the pilot. Ethanol was detected in cavity blood at 0.013 g/dL, and ethanol was not detected in vitreous fluid. Glucose was detected in vitreous fluid at 162 mg/dL and the HbA1c was 12.1% in cavity blood. Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury and can cause an affected toxicological specimen to test positive for ethanol while another specimen from the same person tests negative. Local emergency services and Sea Tow Venice (a local Sea Tow franchise that provided boat towing services) recovered most of the wreckage from the floor of the Gulf of America, at a depth of about 23 ft. The wreckage was then moved to a secure facility for examination. Postaccident examination of the wreckage identified all major airplane components and control surfaces except for the right wing, right aileron, right flap, sections of the main fuselage, and parts of the fuel system. The fuselage had been destroyed by impact; the top portion of the cabin and right wing were not recovered. The left wing was impact separated. The empennage was also impact separated approximately 12 ft from the rear of the airplane. The two rear seats and one seat back that were recovered were impact separated. The rudder pedal cables remained attached to the rudder bar and had separated at the rear cabin separation area. The left rudder cable had separated at the turnbuckle. The right rudder cable displayed evidence of tensile overload. Both stabilator control cables were attached to the T-bar and were separated at the rear cabin area. The rear stabilator control cable displayed evidence of tensile overload, and the forward stabilator control cable was separated at the turnbuckle. The aileron control chain was separated from its sprockets. Both cables remained attached to the aileron control chain and were separated in the main cabin area. The separation areas displayed evidence of tensile overload. Examination of the vacuum-powered attitude indicator revealed that the gyro was in place, would rotate, and displayed evidence of rotational scoring. Examination of the electric turn and bank indicator also revealed that the gyro had remained in place and rotational scoring was evident. Flight control continuity was established from all primary flight control surfaces (except the right aileron, which was not recovered) to the control column and rudder pedals except for impact and recovery related separations. The left wing was separated from the fuselage and exhibited outboard leading-edge damage. The flap remained in place and the aileron inboard section remained attached to the inboard hinge. Aileron continuity was established from the inboard aileron section to the wing root. Both cables separations at the wing root displayed evidence of tensile overload. The pitot mast was field tested with low pressure air and was free from blockage. The inboard fuel tank finger screen was free from blockage. The vertical stabilizer and rudder remained attached to the empennage, and rudder continuity was established from the rudder to the empennage separation area. The right rudder cable separation displayed evidence of tensile overload, an