Pilot Debrief

CIRRUS DESIGN CORP SR22 near Kewanee, IL — 2015-08-30

Final reportCEN15FA388
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Date
2015-08-30
Location
Kewanee, IL, USA
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N765CD
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot's loss of control due to spatial disorientation shortly after takeoff into low instrument meteorological conditions.

NTSB narrative

The instrument-rated private pilot and two passengers departed on an instrument flight rules flight plan in low instrument meteorological conditions (IMC), including fog and cloud ceilings at 200 ft above ground level. Before takeoff, the pilot announced on the airport's common traffic advisory frequency that the airplane was departing runway 19; however, the airplane departed runway 27. Radar data indicated that the airplane made 3 nearly 360° left turns in close succession just before ground impact. The airplane's altitude during the turns varied between 1,200 ft and 1,800 ft msl. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation, and data retrieved from onboard engine monitoring equipment indicated that the engine was operating normally throughout the flight. Conditions conducive to the development of spatial disorientation existed at the time of the accident, including restricted visibility, entry into IMC, and maneuvering for an assigned course after takeoff. It could not be determined whether the pilot recognized his error in departing from the incorrect runway, but it is possible that this error presented the pilot with an operational distraction about the time the airplane was entering IMC, and could have precipitated the pilot's spatial disorientation. Additionally, the pilot had reported to the airplane's co-owner the day before the accident that the airplane's autopilot was inoperative and that he did not plan to use it. Thus, the pilot did not have the autopilot available to help manage his workload during the flight. The radar depiction of the accident flight path was consistent with the known effects of spatial disorientation, and it is likely that the pilot became disoriented shortly after entering IMC after takeoff.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have delayed takeoff due to fog and low visibility conditions.

NTSB coding

Evidence available

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

Docket documents17

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