Pilot Debrief

AIR TRACTOR INC AT 401B near Ellis, KS — 2014-07-18

Final reportCEN14LA376
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Date
2014-07-18
Location
Ellis, KS, USA
Aircraft
AIR TRACTOR INC AT 401B
Registration
N4223F
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The noninstrument-rated pilot’s inadequate preflight weather planning and subsequent inadvertent encounter with instrument meteorological conditions, which resulted in spatial disorientation and the loss of airplane control. Contributing to the accident was the pilot’s decision to continue the flight in deteriorating weather conditions.

Contributing factors

Contributing to the accident was the pilot's decision to continue the flight in deteriorating weather conditions.

NTSB narrative

The noninstrument-rated commercial pilot departed on a cross-country positioning flight in an airplane that was not equipped for instrument flying. GPS data showed that, after entering an area of low cloud ceiling (700 to 1,000 ft above ground level) and visibility (below 3 miles with precipitation and mist), the airplane made two 90° descending left turns in less than 2 minutes. There was no record that the pilot received a preflight weather briefing. The airplane wreckage was found the next morning about 1/2 mile from the location of the second turn, and examination of the wreckage revealed that the airplane was oriented with the right wing down when it impacted terrain. Examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures. Analysis of weather information revealed that deteriorating weather conditions with low ceilings existed in the area at the time of the accident, which occurred in dark night conditions in which there would have been no visible horizon. These restricted visibility conditions would have been conducive to the development of spatial disorientation, and the airplane's maneuvering, unusual attitude, and high-velocity impact are consistent with the effects of spatial disorientation. It is likely the pilot experienced spatial disorientation after entering the deteriorating weather conditions, which led to a loss of airplane control.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have avoided flight in deteriorating weather conditions.

NTSB coding

Evidence available

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

Docket documents12

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