Sanford - Sanford

The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were conducting an instructional flight in the multi-engine airplane during instrument meteorological conditions. After performing a practice instrument approach, the flight was cleared for a second approach; however, the landing runway changed, and the controller vectored the airplane for an approach to the new runway. The pilot was instructed to turn to a southwesterly heading and maintain 1,600 ft until established on the localizer. Radar information revealed that the airplane turned to a southwesterly heading on a course to intercept the localizer and remained at 1,600 ft for about 1 minute 39 seconds before beginning a descending right turn to 1,400 ft. The descent continued to 1,100 ft; at which time the air traffic control controller issued a low altitude alert. Over the following 10 seconds, the airplane continued to descend at a rate in excess of 4,800 ft per minute (fpm). The controller issued a second low altitude alert to the crew with instructions to climb to 1,600 ft immediately. The pilot responded about 5 seconds later, "yeah I am sir, I am, I am." The airplane then climbed 1,400 ft over 13 seconds, resulting in a climb rate in excess of 6,700 fpm, followed by a descent to 1,400 ft over 5 seconds, resulting in a 1,500-fpm descent before radar contact was lost in the vicinity of the accident site. Radar data following the initial instrument approach indicated that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of autopilot use until the final turn to intercept the localizer course. Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including altitude and course deviations and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe, engines, and propellers revealed no evidence of any preexisting anomalies that would have precludednormal operation. Therefore, it is likely that the pilot receiving instruction was experiencing the effects of spatial disorientation when the accident occurred. Toxicology testing of the flight instructor identified significant amounts of oxycodone as well as its active metabolite, oxymorphone, in liver tissue; oxycodone was also found in muscle. Oxycodone is an opioid pain medication available by prescription that may impair mental and/or physical ability required for the performance of potentially hazardous tasks. The flight instructor's tissue levels of oxycodone suggest that his blood level at the time of the accident was high enough to have had psychoactive effects, and his failure to recognize and mitigate the pilot's spatial disorientation and impending loss of control further suggest that the flight instructor was impaired by the effects of oxycodone. Toxicology testing of all three pilots identified ethanol in body tissues; however, given the varying amounts and distribution, it is likely that the identified ethanol was from postmortem production rather than ingestion.

Flight / Schedule

Sanford - Sanford

Registration

N19LW

MSN

LJ-991

Year of Manufacture

1981

Date

December 8, 2017 at 11:15 AM

Type

CRASH

Flight Type

Training

Flight Phase

Landing (descent or approach)

Crash Site

Lake, Sea, Ocean, River

Crash Location

Lake Harney Florida

Region

North America • United States of America

Coordinates

28.7549°, -81.0615°

Crash Cause

Human factor

Narrative Report

On December 8, 2017 at 11:15 AM, Sanford - Sanford experienced a crash involving Beechcraft 90 King Air, operated by L3 Airline Academy, with the event recorded near Lake Harney Florida.

The flight was categorized as training and the reported phase was landing (descent or approach) at a lake, sea, ocean, river crash site.

3 people were known to be on board, 3 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.

Crew on board: 2, crew fatalities: 2, passengers on board: 1, passenger fatalities: 1, other fatalities: 0.

The listed crash cause is human factor. The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were conducting an instructional flight in the multi-engine airplane during instrument meteorological conditions. After performing a practice instrument approach, the flight was cleared for a second approach; however, the landing runway changed, and the controller vectored the airplane for an approach to the new runway. The pilot was instructed to turn to a southwesterly heading and maintain 1,600 ft until established on the localizer. Radar information revealed that the airplane turned to a southwesterly heading on a course to intercept the localizer and remained at 1,600 ft for about 1 minute 39 seconds before beginning a descending right turn to 1,400 ft. The descent continued to 1,100 ft; at which time the air traffic control controller issued a low altitude alert. Over the following 10 seconds, the airplane continued to descend at a rate in excess of 4,800 ft per minute (fpm). The controller issued a second low altitude alert to the crew with instructions to climb to 1,600 ft immediately. The pilot responded about 5 seconds later, "yeah I am sir, I am, I am." The airplane then climbed 1,400 ft over 13 seconds, resulting in a climb rate in excess of 6,700 fpm, followed by a descent to 1,400 ft over 5 seconds, resulting in a 1,500-fpm descent before radar contact was lost in the vicinity of the accident site. Radar data following the initial instrument approach indicated that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of autopilot use until the final turn to intercept the localizer course. Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including altitude and course deviations and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe, engines, and propellers revealed no evidence of any preexisting anomalies that would have precludednormal operation. Therefore, it is likely that the pilot receiving instruction was experiencing the effects of spatial disorientation when the accident occurred. Toxicology testing of the flight instructor identified significant amounts of oxycodone as well as its active metabolite, oxymorphone, in liver tissue; oxycodone was also found in muscle. Oxycodone is an opioid pain medication available by prescription that may impair mental and/or physical ability required for the performance of potentially hazardous tasks. The flight instructor's tissue levels of oxycodone suggest that his blood level at the time of the accident was high enough to have had psychoactive effects, and his failure to recognize and mitigate the pilot's spatial disorientation and impending loss of control further suggest that the flight instructor was impaired by the effects of oxycodone. Toxicology testing of all three pilots identified ethanol in body tissues; however, given the varying amounts and distribution, it is likely that the identified ethanol was from postmortem production rather than ingestion.

Aircraft reference details include registration N19LW, MSN LJ-991, year of manufacture 1981.

Geospatial coordinates for this crash are approximately 28.7549°, -81.0615°.

Fatalities

Total

3

Crew

2

Passengers

1

Other

0

Crash Summary

The flight instructor, commercial pilot receiving instruction, and commercial pilot-rated passenger were conducting an instructional flight in the multi-engine airplane during instrument meteorological conditions. After performing a practice instrument approach, the flight was cleared for a second approach; however, the landing runway changed, and the controller vectored the airplane for an approach to the new runway. The pilot was instructed to turn to a southwesterly heading and maintain 1,600 ft until established on the localizer. Radar information revealed that the airplane turned to a southwesterly heading on a course to intercept the localizer and remained at 1,600 ft for about 1 minute 39 seconds before beginning a descending right turn to 1,400 ft. The descent continued to 1,100 ft; at which time the air traffic control controller issued a low altitude alert. Over the following 10 seconds, the airplane continued to descend at a rate in excess of 4,800 ft per minute (fpm). The controller issued a second low altitude alert to the crew with instructions to climb to 1,600 ft immediately. The pilot responded about 5 seconds later, "yeah I am sir, I am, I am." The airplane then climbed 1,400 ft over 13 seconds, resulting in a climb rate in excess of 6,700 fpm, followed by a descent to 1,400 ft over 5 seconds, resulting in a 1,500-fpm descent before radar contact was lost in the vicinity of the accident site. Radar data following the initial instrument approach indicated that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of autopilot use until the final turn to intercept the localizer course. Maneuvering the airplane in restricted visibility placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including altitude and course deviations and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe, engines, and propellers revealed no evidence of any preexisting anomalies that would have precludednormal operation. Therefore, it is likely that the pilot receiving instruction was experiencing the effects of spatial disorientation when the accident occurred. Toxicology testing of the flight instructor identified significant amounts of oxycodone as well as its active metabolite, oxymorphone, in liver tissue; oxycodone was also found in muscle. Oxycodone is an opioid pain medication available by prescription that may impair mental and/or physical ability required for the performance of potentially hazardous tasks. The flight instructor's tissue levels of oxycodone suggest that his blood level at the time of the accident was high enough to have had psychoactive effects, and his failure to recognize and mitigate the pilot's spatial disorientation and impending loss of control further suggest that the flight instructor was impaired by the effects of oxycodone. Toxicology testing of all three pilots identified ethanol in body tissues; however, given the varying amounts and distribution, it is likely that the identified ethanol was from postmortem production rather than ingestion.

Cause: Human factor

Occupants & Outcome

Crew On Board

2

Passengers On Board

1

Estimated Survivors

0

Fatality Rate

100.0%

Known people on board: 3

Operational Details

Schedule / Flight

Sanford - Sanford

Flight Type

Training

Flight Phase

Landing (descent or approach)

Crash Site

Lake, Sea, Ocean, River

Region / Country

North America • United States of America

Aircraft Details

Registration

N19LW

MSN

LJ-991

Year of Manufacture

1981