The National Transportation Safety Board (NTSB) has released the final report of the plane that crashed into the Atlantic Ocean in October 2018, killing Guyanese pilot Munidat “Raj” Persaud and two other people.
According to the NTSB’s final investigation reported, the probable cause of the crash was the instructor’s decision to conduct and continue a VFR flight into instrument meteorological conditions with a known flight instrument anomaly, which resulted in spatial disorientation, causing a loss of airplane control and subsequent in-flight breakup.
Contributing to the accident were the instructor’s lack of recent instrument flight experience and degraded airplane control and decision-making due to hypoxia.
The 1978 Piper Seneca (N593MS) plane owned by Raj Persaud who was acting in the capacity of flight instructor on that day, departed Danbury, Connecticut (DXR) and was destined for Charlston South Carolina (JZI). On board with him were private pilot Richard Terbrusch and passenger Jennifer Landrum who were setting out on a cross-country training flight.
The plane departed on a VFR (visual flight rules) flight with a planned climb to 8,500 feet; however, the airplane continued to climb past that altitude.
During the climb, the instructor indicated to Air Traffic Control, in separate transmissions, that he was climbing to reach “VFR on-top,” that he was experiencing problems with an “unreliable” attitude indicator, and that the airplane was “in and out of IMC (instrument meteorological conditions).”
About 20 minutes after the airplane departed, the controller declared an emergency on behalf of the pilot and provided multiple radar vectors for the airplane to return to visual meteorological conditions (VMC); however, the airplane’s radar track showed that the airplane continued climbing to 19,400 ft msl before it entered a series of figure-eight turns followed by a steep, turning descent.
A witness stated that the airplane sounded “as if it were a stunt plane doing spins (pitch changing)” and then heard a “pop” and saw large pieces of the airplane descending from the overcast sky. Examination of the recovered portions of the airplane revealed no evidence of preimpact mechanical anomalies and a wreckage distribution consistent with an in-flight breakup.
According to the report, the instructor demonstrated several lapses in judgment associated with conducting the flight. Specifically, the instructor did not appear to recognize the significance of widespread ceilings along his route of flight and planned a cruise altitude that took him into instrument conditions.
The instructor likely did not carry supplemental oxygen onboard the nonpressurized airplane and continued to climb the airplane to altitudes that required the use of oxygen; without oxygen he risked becoming susceptible to the effects of hypoxia.
Further, another pilot who had flown the accident airplane before the accident flight stated that the airplane had a known problem with the directional gyro, yet the instructor flew the airplane in instrument conditions; based on the instructor’s failure to follow the controllers’ directional instructions, it is likely the directional gyro was still not working.
Lastly, review of the instructor’s logbook and an interview with another flight instructor indicated that the instructor was likely not instrument current, so his ability to safely maneuver the airplane in the clouds that were prevalent during the flight would have been negatively impacted by the broken gyro and his lack of currency.
In summary, the instructor’s decision to continue the flight in instrument conditions with a known flight instrument anomaly greatly increased his workload and likely resulted in his eventual loss of airplane control due to spatial disorientation. The rapidly descending turn (graveyard spiral) depicted on radar and the in-flight breakup due to overstress during the
ensuing uncontrolled descent were consistent with the known effects of spatial disorientation.
The airplane had been operating above 16,000 feet for more than 10 minutes at the time of the upset and there was no evidence that the airplane was equipped with supplemental oxygen. The NTSB surmised that the instructor’s performance and decision-making would have likely been degraded to some extent due to hypoxia.
The plane crashed just off the coast of Long Island, New York.