Aircraft Accident/Incident Report

Vieques, Puerto Rico 00765
Sunday, February 15, 2004 21:00 AST

NTSB Narrative Summary Released at Completion of Accident

While proceeding eastbound at night along the shoreline of an island, the airplane began a rapid spiral descent, and impacted the ground. Despite an extensive search by multiple entities, the airplane remained missing for approximately 4 years; however, when the wreckage was located, there was sufficient evidence to show that the vacuum pump, which powered the attitude indicator and the directional gyro, had failed. Examination of Federal Aviation Administration (FAA) records revealed that the airplane had accrued in excess of 1,224.8 total hours of operation, but no evidence of the vacuum pump ever being overhauled or replaced was discovered. The pilot did not possess an instrument rating, and most likely had not flown at night for approximately 10 years. The airplane was equipped with an autopilot; however, the pilot was reported not to be experienced in its use. Taking into consideration the direction of flight, available weather data, and the lack of ground lights in the area, there would have been no visible horizon forcing the pilot to maintain control of the airplane solely by referencing the flight instruments. It has been well documented that such conditions can result in a myriad of vestibular illusions which can be extremely difficult to overcome. One illusion in particular can cause a pilot to believe the airplane is in level flight, when in reality, it is in a gradual turn. If the airspeed increases, the pilot may experience a postural sensation of a level dive and pull back on the yoke, which tightens the turn. If recovery is not initiated, a steep spiral will develop and continue until the airplane impacts the ground or water. The FAA's Airplane Flying Handbook states that "unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided." FAA Advisory Circular AC 91-75, highlights that pilots tend to rely heavily on the attitude indicator in instrument meteorological conditions, and that vacuum system failures can be a significant cause or contributor to fatal accidents because in most cases the corresponding instruments slowly becomes inaccurate, making the failure difficult to recognize.

NTSB Probable Cause Narrative

The pilot's inadequate preflight and in-flight planning and decision making which resulted in the airplane entering instrument meteorological conditions. Contributing to the accident was the pilot's lack of instrument experience, a vacuum pump failure, and the night lighting conditions.

Event Information

Type of Event Accident
Event Date 2/15/2004
Event Day of the Week Sunday
Time of Event 2100
Event Time Zone Atlantic Standard Time
Event City Vieques
Event State PUERTO RICO
Event Country --
Zipcode of the event site 00765
Event Date Year 2004
Event Date Month 2
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 180907N
Event Location Longitude 0652142W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 2056 Atlantic Standard Time
Direction of event from weather observation facility (degrees) 310
Weather Observation Facility ID TJSJ
Elevation of weather observation facility 9
Distance of event from weather observation facility (units?) 40
Time Zone of the weather observation AST
Lighting Conditions Night
Lowest Ceiling Height 5500
Lowest Non-Ceiling Height 3400
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 23
Dew Point at event time (in degress fahrenheit) 23
Wind Direction (degrees magnetic) 90
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30.11
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 24380
NTSB Notification Source NTSB Comm Center
NTSB Notification Date Apr 16 2008 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Sep 26 2008 6:40PM
User who most recently changed record NTSB\lema
Basic weather conditions Visual Meteorological Cond
FAA District Office San Juan, PR

Aircraft Involved

Aircraft #1

Aircraft Registration Number N1261J
NTSB Number NYC04FA223
Missing Aircraft Indicator Y
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed VFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Aero Commander
Aircraft Model 112
Aircraft Series Identifier --
Aircraft Serial Number 261
Certified Max Gross Weight 2550
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Sep 1 2003 12:00AM
Airframe hours since last inspection --
Airframe Hours 1224.8
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Sheldon H. Prudoff
Aircraft Owner Street Address --
Aircraft Owner City Christiansted
Aircraft Owner State VI
Aircraft Owner Country USA
Aircraft Owner Zipcode 00823
Operator is an individual? Yes
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code TJSJ
Departure City San Juan
Departure State PR
Departure Country USA
Departure Time 2030
Departure Time Zone AST
Destination Same as Local Flt --
Destination Airport Code TISX
Destination City Christiansted
Destination State VI
Destination Country USA
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Sep 24 2008 12:24AM
User who most recently changed record MUZD
Since inspection or accident Last Inspection
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --