Pilot Debrief

CESSNA 172P near Kekaha, HI — 2022-03-21

Final reportANC22LA025
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Date
2022-03-21
Location
Kekaha, HI, USA
Aircraft
CESSNA 172P
Registration
N98763
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s improper decision to continue the visual-flight-rules flight into low visibility conditions, which resulted in controlled flight into terrain.

NTSB narrative

The airplane departed on a visual-flight-rules flight to conduct a routine hurricane/tsunami warning mission. The standard flight route was to fly inland, passing a radar dome before turning west toward the coast. The airplane was then to fly offshore, following the coastline around the island. Automatic Dependent Surveillance–Broadcast (ADS–B) data showed the airplane never made the turn to the coast and it continued over land and up a ridgeline. The airplane impacted a near-vertical mountain side in a nose-up, wings-level attitude. Witnesses reported hearing the airplane, but they were unable to see it due to the poor visibility near the accident site. Postaccident examination of the airplane revealed leading edge damage to both wings indicative of a controlled flight into terrain. An examination of the available wreckage did not reveal any anomalies that would have prevented normal operation of the flight controls. Although several engine components were not located at the accident site, witnesses reported hearing the engine operating up to the time of impact. Toxicology testing of the pilot’s blood detected the presence of gabapentin, which can produce impairing effect such as sleepiness, dizziness, and/or diminished coordination. However, if the pilot’s judgment was impaired, the copilot could have mitigated his improper decision making. Thus, it is unlikely that gabapentin’s effects on the pilot contributed to the accident. Based on the level attitude of the airplane when it impacted the rising terrain, it is likely the pilot had control of the airplane and flew into terrain that was obscured by the poor visibility.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have turned back to avoid poor weather conditions.

NTSB coding

Evidence available

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

Docket documents7

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