Pilot Debrief

Cessna 210 near Apalachicola, FL — 2018-11-30

Final reportERA19FA059
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Date
2018-11-30
Location
Apalachicola, FL, USA
Airport
AAF
Aircraft
Cessna 210
Registration
N3995Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's controlled flight into terrain as a result of his spatial disorientation during departure in dark nighttime conditions.

NTSB narrative

The private pilot had departed on the second leg of a cross-country flight just after the end of civil twilight. Another pilot approaching the airport from the west reported seeing the airplane as it departed to the east and communicating with the pilot over the radio. Soon afterward, the other pilot observed a fireball. The wreckage was subsequently found in a remote, unlit marsh about 2 miles north of the airport. The pilot did not make any distress calls over the radio. Examination of the wreckage and accident site indicated a high-energy, near-wings-level impact at a shallow descent angle, which was consistent with controlled flight into terrain. The landing gear was down, and the flaps were up. The wreckage examination revealed no evidence of a preaccident mechanical failure or malfunction that would have precluded normal operation of the airframe or engine. The accident occurred at the end of civil twilight, and, because of the cloud cover, no moon would have been visible. The lack of external lighting cues as the pilot took off over an area with no lights would have been conducive to the development of spatial disorientation. The pilot likely experienced a vestibular illusion and/or spatial disorientation and allowed the airplane to descend into the marsh under controlled flight. The pilot's diabetes was well controlled and thus not a factor in this accident. Toxicology testing revealed the pilot's use of venlafaxine, an antidepressant. The cognitive impairment associated with depression could have made the pilot more susceptible to spatial disorientation and less able to recognize the situation and respond quickly. However, given the available evidence, the investigation could not determine whether cognitive impairment related to depression contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have reconsidered departure into dark conditions after sunset.

NTSB coding

Evidence available

  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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