Pilot Debrief

Piper PA32R near Goodnews Bay, AK — 2019-11-11

Final reportANC20LA004
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Date
2019-11-11
Location
Goodnews Bay, AK, USA
Aircraft
Piper PA32R
Registration
N7721C
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

The pilot’s failure to monitor the airplane instruments during a night visual flight rules departure in dark light conditions, which resulted in spatial disorientation and the airplane’s descent into water.

NTSB narrative

The pilot was conducting the last segment of a scheduled visual flight rules (VFR) route to the company base airport with a pilot-rated observer on board. The weather conditions were night marginal VFR, and the departure airport was in a remote, dark area located on the edge of a large bay. The pilot stated that after takeoff to the east, while turning right to the northwest, he suddenly felt that the airplane was descending; he looked at the vertical speed indicator (VSI) and observed a 500 ft-per-minute descent. The airplane was about 500 ft above ground level at that time. He did not note abnormal engine indications or sounds and attempted to arrest the descent by pulling back on the control yoke, but nothing happened. The airplane impacted the water about 30 to 60 seconds later. He and the observer egressed with no injuries. The observer stated that after takeoff, he was adjusting his headlamp and not looking at the instruments or outside. He then saw what looked like heavy rain out the right window. He recalled that the engine sounded normal, and rpm sounded high just before the airplane “slammed” into the water, right wing first. He did not hear the pilot say anything about engine power or offer any warning to brace for impact. During an interview, the pilot stated that he believed that the airplane wasn’t producing sufficient power because the airplane continued to descend and had a negative VSI indication. He did not attempt to adjust the engine controls, perform any emergency procedures, prepare the airplane for a water landing, make a radio call, or activate the emergency locator transmitter because there was no time. He stated that he concentrated on flying straight ahead with the wings level and told the observer that they were going down. Photographs of the wreckage showed the right wing experienced significant fore-to-aft crush damage, the front fuselage was partially separated from the airframe, and the propeller blades were bent aft with spanwise torsional twists, indicative of engine power at impact. Based on the pilot’s statement that he did not observe abnormal engine indications or sounds, the observer’s recollection that the rpm sounded high before impact, and the propeller impact signatures, it is unlikely that the engine lost power. The pilot did not make sufficient corrections to prevent the impact, such as increasing rpm and throttle to maximum, performing restoring engine power procedures, or obtaining a landing attitude for ditching. Also, he stated that he pulled back on the yoke and the airplane did not respond, which would indicate an elevator control problem and not an engine problem. He made no radio call and did not activate the emergency locator transmitter before impact. Although the pilot indicated he concentrated on flying the airplane straight ahead with wings level, evidence is consistent with the airplane impacting the water in a nose-low, right-wing-down attitude. It is likely that the airplane impacted the water during the initial climbing turn phase, which was consistent with the observer’s recollection. The nearest weather observation about 4 minutes before the accident indicated an overcast cloud layer at 1,600 ft. The accident occurred about 1.5 hours after sunset and, according to the pilot and observer, the moonlight was obstructed by clouds. The pilot stated that it was very dark to the east, which was the direction the airplane was heading during the takeoff, initial climb, and the beginning of the right turn. He also recalled that there were some village lights in the distance to the west and that he did see a horizon. The dark night and lack of visual cues in the area were conducive to the effects of spatial disorientation and would have required an instrument scan to mitigate that hazard; however, based on the pilot’s statement, he was not monitoring the instruments until he felt that the airplane was descending. It is likely that the pilot experienced spatial disorientation during the right turn over dark terrain and water but did not recognize the descent as an indication of such and, therefore, did not correct by referencing the instruments and positively regaining control of the airplane.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have adjusted engine controls or performed emergency procedures earlier.

NTSB coding

Evidence available

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

Docket documents8

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