DIAMOND AIRCRAFT IND INC DA 40

Full Narrative

HISTORY OF FLIGHTOn March 5, 2023, at 2125 eastern standard time, a Diamond DA-40, N804ER, was substantially damaged when it was involved in an accident near Palm Beach County Park Airport (LNA), West Palm Beach, Florida. The commercial pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14?Code of Federal Regulations Part 91 personal flight.
According to FAA ADS-B and air traffic control information, after takeoff from Williston Municipal Airport (X60), Williston, Florida, the flight proceeded in a south-southeasterly direction to about 14 nautical miles north-northwest of Southwest Florida International Airport (RSW), Fort Myers, Florida, then proceeded east towards LNA.
According to audio from Palm Beach International Airport (PBI) air traffic control tower correlated with ADS-B data, at 2100:43, when the flight was about 279° and 48 nautical miles from LNA, one of the pilots established contact with the facility and advised that they were at 2,500 ft mean sea level (msl). The controller advised the flight to maintain visual flight rules at or above 2,600 ft msl, which the pilot acknowledged. The flight continued toward LNA, then at 2119:47, when the flight was about 7 nautical miles west of LNA, one of the pilots advised the controller that the airport was in sight. Radar services were terminated, and the flight proceeded toward runway 10 at LNA for a straight-in visual approach, while the right-seat occupant made radio calls on the CTAF.
Two witnesses, one of whom was a private pilot and the other a student pilot, reported that they knew both pilots onboard the accident airplane and had exchanged text messages with the right-seat pilot that they were waiting on the ramp at LNA for the airplane to arrive. The witnesses’ location abeam the runway was about 2,313 ft down and 513 ft south of runway 10. The private pilot witness reported seeing the airplane on a 10-mile final approach for runway 10 and he planned to film the airplane’s arrival on short final. He reported that, at the intersection of runways 10/28 and 4/22, which was located about 800 ft from the approach end of runway 10, the airplane started to go around. He reported that it descended no lower than 20 to 30 ft above ground level (agl) and did not touch down. He then began to capture video the flight and reported that the engine was “constantly smooth” as the airplane flew over runway 10. He noted that the airplane climbed no higher than between 200 ft and 250 ft agl, then when at or just past the departure end of the runway, the airplane banked to the right, stalled, and rolled inverted.
The student pilot witness reported that, when the airplane was at the departure end of runway 10, it made a “sudden 45° right bank,” which was not expected. He noted the airplane banked right, the nose leveled off, then entered a right bank of 60°. When the nose of the airplane was pointed toward them, the right wing stalled. He also stated that it did not sound like the engine was producing full power, but that the engine “appeared fine” the whole time, adding that the engine sounded “ok” during the turn to behind the hangars, then it went silent.
There was no radio call on the CTAF announcing the go-around.
A postaccident fire was extinguished by first responders from a nearby fire station. PERSONNEL INFORMATIONLeft-Seat Pilot
The left seat pilot held a private pilot certificate with a rating for airplane single-engine land. His logbook began with an entry dated September 12, 2007, to the last entry dated February 4, 2023, and indicated that his most recent flight review was on July 19, 2022. He logged a total of 4.4 hours night flight time all as dual received, with his last logged night flight on March 7, 2011.
Right-Seat Pilot
The right-seat pilot held a commercial pilot certificate with ratings for airplane single-engine land and sea, and a flight instructor certificate with ratings for airplane single-engine and instrument airplane.
A review of the right-seat pilot’s logbook revealed that his most recent flight review was on October 26, 2022, when he added an instrument rating to his flight instructor certificate. After his medical had expired, he logged 4 separate flights as pilot-in-command; the remarks section of those flights listed names consistent with instruction given. His last logged night flight as a flight instructor and pilot-in-command was on January 4, 2023, in a Diamond DA-40. The entire portion of the 1.2-hour-long flight was logged as night.
According to the right-seat pilot’s medical records, his last aviation medical examination was on February 15, 2022. At that time, he reported, in part, obstructive sleep apnea with use of a continuous positive airway pressure (CPAP) machine, which was found in the wreckage. He was issued a first-class medical certificate with a time limitation (not valid for any class after February 28, 2023). According to medical records from the Veteran’s Affairs Medical Center (VAMC), he was evaluated by his VAMC sleep physician on February 14, 2023. According to the sleep physician’s documentation, the pilot’s CPAP record from February 14, 2022 to February 13, 2023, was reviewed and the pilot had been adherent to his prescribed CPAP therapy. The reviewed CPAP records show the pilot used the machine an average time on the days used of 7 hours 57 minutes, and usage on 99% of the days during the time period reviewed. There was no record that he obtained another FAA-issued medical after February 28, 2023. AIRCRAFT INFORMATIONAs part of the airplane’s last annual inspection on February 24, 2023, the throttle cable was adjusted and secured. The airplane was approved for return to service.
According to the operator’s chief pilot, the recently leased airplane was being flown to their facility at LNA. Since taking possession of the airplane on the day of the accident at Henderson City-County Airport (EHR), Henderson, Kentucky, the airplane was flown to Harris County Airport (PIM), Pine Mountain, Georgia, then to Williston Municipal Airport (X60), Williston, Florida, arriving there about 1840. The chief pilot indicated that the fuel tanks were topped off at X60.
Metering of fuel delivered to the engine was performed by a servo fuel injector, which was controlled from the cockpit at an engine control assembly in the center console that held the throttle and mixture control levers. The throttle control lever in the cockpit sets the position of the throttle control lever at the fuel servo and the two ends are mechanically connected by a Bowden cable. The engine-compartment end of the throttle control cable has a cable eye, or rod end, that attaches to the throttle control lever at the fuel servo. The throttle control cable attach hardware in the engine compartment was equipped with a spring that attached to the hardware securing the throttle cable to the throttle lever at the fuel servo and also to a spring anchor bracket attached to the fuel servo. The spring was designed and part of the initial type certification so that if the throttle control separated at the engine fuel metering device, the tension spring was intended to move the throttle control to full power.
Two mini iPads, two cellular phones, and an Apple Series 6 watch were recovered from the wreckage and submitted to the NTSB Vehicle Recorder Division for download; however, the extent of damage precluded obtaining any data. AIRPORT INFORMATIONAs part of the airplane’s last annual inspection on February 24, 2023, the throttle cable was adjusted and secured. The airplane was approved for return to service.
According to the operator’s chief pilot, the recently leased airplane was being flown to their facility at LNA. Since taking possession of the airplane on the day of the accident at Henderson City-County Airport (EHR), Henderson, Kentucky, the airplane was flown to Harris County Airport (PIM), Pine Mountain, Georgia, then to Williston Municipal Airport (X60), Williston, Florida, arriving there about 1840. The chief pilot indicated that the fuel tanks were topped off at X60.
Metering of fuel delivered to the engine was performed by a servo fuel injector, which was controlled from the cockpit at an engine control assembly in the center console that held the throttle and mixture control levers. The throttle control lever in the cockpit sets the position of the throttle control lever at the fuel servo and the two ends are mechanically connected by a Bowden cable. The engine-compartment end of the throttle control cable has a cable eye, or rod end, that attaches to the throttle control lever at the fuel servo. The throttle control cable attach hardware in the engine compartment was equipped with a spring that attached to the hardware securing the throttle cable to the throttle lever at the fuel servo and also to a spring anchor bracket attached to the fuel servo. The spring was designed and part of the initial type certification so that if the throttle control separated at the engine fuel metering device, the tension spring was intended to move the throttle control to full power.
Two mini iPads, two cellular phones, and an Apple Series 6 watch were recovered from the wreckage and submitted to the NTSB Vehicle Recorder Division for download; however, the extent of damage precluded obtaining any data. WRECKAGE AND IMPACT INFORMATIONThe airplane crashed on airport property about 1,030 ft and 191° from the departure end of runway 10.
Examination of the accident site revealed a ground scar consistent with impact with the left wing, indicating that the airplane was on a magnetic heading of 228°. The airplane came to rest upright leaning on its right side on a magnetic heading of 221°. The left wing was fragmented, while the right wing remained intact but impact damaged. About 6 gallons of fuel were drained from the right wing fuel tank. The aft empennage was displaced to the left. All major components of the airplane either remained attached or were found in close proximity to the main wreckage.
Examination of the elevator, aileron, and rudder flight controls revealed no evidence of preimpact failure or malfunction. Examination of the flap actuator revealed a position consistent with the wing flaps being retracted.
The propeller was separated from the engine and was partially buried in earth immediately adjacent to the resting position of the engine.
Examination of the engine revealed that the crankshaft flange was fractured but remained connected to the propeller flange. Rotation of the crankshaft using a splined tool inserted at one of the accessory drives revealed crankshaft, camshaft, and valvetrain continuity. Thumb suction and compression were noted in each cylinder. Borescope inspection of each cylinder revealed no anomalies. Examination of the oil lubricating, air induction, exhaust, and ignition systems revealed no evidence of preimpact failure or malfunction.
Inspection of the engine fuel metering system revealed that the No. 2 cylinder fuel injector line was separated from the injector nozzle, but the line was in close proximity to the nozzle. According to the NTSB Materials Laboratory factual report, about 3/4 of the circumference of the thread peaks of the fuel injector nozzle exhibited smearing deformation, while a portion of the threads of the fuel injector line were fractured with sliding deformation. All other lines remained tightly secured to their respective nozzles. The servo fuel injector (fuel servo) remained attached to the oil sump and air plenum and the mixture control cable remained attached to the mixture control lever, which was impact damaged; however, the throttle control cable was not attached to the throttle control lever. The end of the throttle cable that would have attached to a rod end exhibited bending overload. A bolt that secured the rod end located on the end of the throttle control to the throttle control lever was in place at the lever, but a nut was not affixed to the bolt, and the nut and rod end were not located. The flow divider was free of contaminants and the diaphragm was intact. Examination of the fuel servo inlet screen revealed it was clean; a slight amount of fuel consistent with 100 low lead drained from the inlet when the fuel line was removed.
Examination of the propeller revealed that both blades remained secured in the propeller hub. One blade exhibited a slight aft bend about 10° and leading edge twisting toward low pitch. The blade tip was curled aft about 90° beginning 3 inches from the tip, the leading edge of the blade was polished from about 1/3 span out to the tip, and a section of blade was missing at the tip on the trailing edge. The second blade exhibited scratches on the cambered side of the blade and a heavy gouge on the blade’s aft face about 5.5 inches from the hub. MEDICAL AND PATHOLOGICAL INFORMATIONPostmortem examinations of both pilots were performed by the District 15 Medical Examiner’s Office, West Palm Beach, Florida. The cause of death for both was specified to be total body blunt trauma, and there was no significant natural disease found of the right-seat pilot.
Forensic toxicology testing was performed on specimens of both pilots by the FAA Forensic Sciences Laboratory and Axis Forensic Toxicology (AFT). The toxicology report for the left-seat pilot by the FAA indicated that Carboxy-delta-9-THC was detected in urine at 3.6 ng/mL. Carboxy-delta-9-THC was not detected in cavity blood. Delta-8-THC was detected in cavity blood and urine at low levels. Carboxy-delta-8-THC was detected in cavity blood at 1 ng/mL and in urine at 48 ng/mL. Losartan was detected in urine and was not detected in cavity blood. Testing by AFT confirmed caffeine was presumptively detected in heart blood while Carboxy-THC was detected in urine.
Carboxy-delta-9-THC is a non-psychoactive metabolite of delta-9-THC, which was not detected in this case. Delta-9-THC is the primary psychoactive chemical in cannabis, including marijuana, hashish, and other cannabis products. The specific psychoactive effects of delta-9-THC vary depending on the user, user history of use, dose consumed, and route of consumption. Effects of delta-9-THC consumption may impair motor coordination, decrease reaction time, impair decision making and problem solving, distort perceptions of reality, and decrease vigilance. Delta-9-THC is a federally controlled substance, and the FAA considers it unsuitable for flying, regardless of state cannabis laws. Delta-8-THC is a psychoactive compound typically chemically manufactured from cannabidiol (CBD), a chemical in the cannabis plant. It has similar psychoactive effects as delta-9-THC such as cognitive impairment including decreased processing speed of information, distorted perception, visual disturbances and decreased attention and response time. Delta-8-THC containing products are often marketed simply as “hemp” or “CBD” products, which consumers may not associate with potential psychoactive effects. Delta-8-THC is available in a variety of over-the-counter products for oral consumption, smoking, and inhalation and vary widely in potency of delta-8-THC and content of delta-9-THC. Delta-8 THC products have not been evaluated or approved by the US Food and Drug Administration for safe use in any context.
Caffeine is a central nervous system stimulant that is commonly ingested, including in coffee, tea, soft drinks, and chocolate, and is also an ingredient in certain anti-drowsiness medications and headache medications. Losartan is a prescription medication commonly used to treat high blood pressure. Caffeine and losartan are not generally considered impairing.
FAA toxicology testing of the right-seat pilot’s submitted specimens identified ibuprofen in urine, but it was not detected in cavity blood. The test results by AFT were positive for caffeine in cavity blood.
Ibuprofen is a non-prescription medication commonly used to treat mild to moderate pain and fever; caffeine and ibuprofen are not generally considered impairing. TESTS AND RESEARCHNTSB analysis of two videos taken by the ground witnesses to determine engine rpm was performed for 5 points, which included 3 during the low pass portion and the remaining 2 during the right banked turn. The engine rpm at the first 3 points was 2,389, 2,389 and 2,377, respectively, while the engine rpm at the final two points were 2,330 and 2,282, respectively. Throughout the videos, the propeller speed sound was smooth and consistent with normal engine operation.