History of Flight
On March 5, 2023, at 2125 eastern standard time, a Diamond DA-40, N804ER, was substantially damaged 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 flight was a Title 14 Code of Federal Regulations Part 91 personal flight. According to FAA ADS-B and air traffic control data, after takeoff from Williston Municipal Airport (X60), the flight proceeded south-southeast to about 14 nautical miles north-northwest of Southwest Florida International Airport (RSW), then east toward LNA. At 2100:43, the flight contacted Palm Beach International Airport (PBI) ATC at 2,500 ft msl, and was advised to maintain VFR at or above 2,600 ft msl. At 2119:47, about 7 nautical miles west of LNA, the pilot reported the airport in sight. Radar services were terminated and the flight proceeded for a straight-in visual approach to runway 10. Two witnesses, a private pilot and a student pilot, reported seeing the airplane on final. The private pilot reported that at the intersection of runways 10/28 and 4/22, the airplane initiated a go-around, descending no lower than 20-30 ft agl without touching down. He observed the engine was “constantly smooth” as the airplane flew over runway 10. The airplane climbed to between 200 and 250 ft agl, then at or past the departure end, it banked right, stalled, and rolled inverted. The student pilot reported a sudden 45° right bank, then a 60° bank, and the right wing stalled. The engine sounded not at full power but “appeared fine” and then went silent. There was no CTAF call announcing the go-around. A postaccident fire was extinguished by first responders.
Personnel Information
The left-seat pilot held a private pilot certificate with a rating for airplane single-engine land. His logbook, from September 12, 2007, to February 4, 2023, indicated a flight review on July 19, 2022. He logged 4.4 hours night flight time, all as dual received, with the last night flight on March 7, 2011. 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. His logbook showed a flight review on October 26, 2022. After his medical expired, he logged four flights as pilot-in-command; remarks indicated instruction given. His last logged night flight as flight instructor and pilot-in-command was on January 4, 2023, in a Diamond DA-40. His last aviation medical examination was on February 15, 2022, with a first-class medical certificate valid until February 28, 2023. He reported obstructive sleep apnea and used a CPAP machine, which was found in the wreckage. Medical records from the Veterans Affairs Medical Center indicated adherence to CPAP therapy.
Aircraft Information
The airplane’s last annual inspection on February 24, 2023, included adjustment and securing of the throttle cable. According to the operator’s chief pilot, the recently leased airplane was flown from Henderson City-County Airport (EHR) to Harris County Airport (PIM) to Williston Municipal Airport (X60), arriving about 1840, where fuel was topped off. The throttle control cable, when separated, is designed with a spring to move to full power. Two mini iPads, two cellular phones, and an Apple Series 6 watch were recovered but damaged beyond data retrieval.
Wreckage and Impact
The airplane crashed on airport property about 1,030 ft and 191° from the departure end of runway 10. A ground scar indicated left wing impact on a magnetic heading of 228°. The airplane came to rest upright leaning on its right side on heading 221°. The left wing was fragmented; the right wing remained intact but impact damaged. About 6 gallons of fuel drained from the right wing fuel tank. The aft empennage was displaced to the left. All major components remained attached or were found nearby. Flight control examinations revealed no preimpact failure or malfunction. The flap actuator indicated flaps retracted. The propeller separated from the engine and was partially buried. Engine examination revealed crankshaft, camshaft, and valvetrain continuity; thumb suction and compression in each cylinder; no anomalies in oil, induction, exhaust, or ignition systems. The No. 2 cylinder fuel injector line was separated with smearing deformation. The throttle control cable was not attached to the throttle control lever; the bolt securing the rod end was in place but the nut and rod end were missing. The spring was intact.
Medical and Pathological Information
Postmortem examinations of both pilots determined the cause of death as total body blunt trauma. No significant natural disease was found in the right-seat pilot. Toxicology testing on the left-seat pilot detected Carboxy-delta-9-THC in urine at 3.6 ng/mL, Delta-8-THC in cavity blood and urine, and Carboxy-delta-8-THC in cavity blood at 1 ng/mL and urine at 48 ng/mL. Losartan was in urine; caffeine in heart blood. The right-seat pilot tested positive for ibuprofen in urine and caffeine in cavity blood. Caffeine and losartan are not generally considered impairing; ibuprofen is not generally considered impairing.
Tests and Research
NTSB analysis of two witness videos estimated engine rpm at five points: 2,389, 2,389, 2,377 during the low pass, and 2,330 and 2,282 during the right banked turn. Propeller speed sound was smooth throughout.