Pilot Debrief

Vans RV9 near Zeeland, MI — 2020-09-19

Final reportCEN20LA399
Sign in to save
Date
2020-09-19
Location
Zeeland, MI, USA
Airport
Z98
Aircraft
Vans RV9
Registration
N94KJ
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain airspeed during a visual approach in dark night conditions, which resulted in an aerodynamic stall and loss of airplane control. Contributing to the accident was the pilot’s lack of recent flight experience at night.

Contributing factors

Contributing to the accident was the pilot’s lack of recent flight experience at night.

NTSB narrative

The pilot departed under visual flight rules (VFR) from a rural airport during dark night, VFR conditions. After climbing toward the destination for about 2 minutes, the pilot turned back to the airport and flew a visual approach. The airplane’s flight track was consistent with a go-around near the runway threshold, likely due to excessive airspeed, followed by a climb toward the downwind leg of the traffic pattern for the opposite runway. On an approximate left base leg, the airplane decelerated to stall speed and entered a right spin that continued until ground impact. The disposition of the wreckage was consistent with a low forward speed indicative of a stalled condition. Two weeks before the accident, the airplane’s attitude heading reference system (AHRS) failed during a daytime flight. The pilot landed uneventfully by referencing the airplane’s backup (unlit) flight instruments located on the instrument panel’s far right side. After troubleshooting the AHRS failure, the pilot made repairs to a circuit card that involved intricate soldering of a capacitor and two diodes. The accident occurred on the second flight after this repair. Examination revealed no engine or flight control anomalies. Fire damage precluded assessment of avionics anomalies. His disease placed him at increased risk of a sudden impairing or incapacitating cardiac event. It is possible that the pilot was experiencing symptoms of a heart-related medical event and that may have been the reason for his attempt to return to the airport. Furthermore, symptoms of such an event might have impaired his performance while maneuvering. However, there is no specific evidence that a such an event occurred and a systems failure involving the AHRS repair provides a reasonable alternate explanation for the pilot’s attempted return. In such a scenario, challenges related to the failure and the dark conditions might explain his loss of control, even without impairment. Thus, whether the pilot’s severe coronary artery disease contributed to the accident could not be determined. The pilot had not flown the accident airplane at night and his most recent night landing was about 5 years before the accident. The pilot’s lack of recent night experience likely contributed to his poor airspeed control during the two attempted approaches and the subsequent loss of aircraft control.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have opted not to fly at night given limited night experience.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

Related mishaps