Pilot Debrief

LANCAIR 320 near Manitowoc, WI — 2023-10-25

Final reportCEN24FA024
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Date
2023-10-25
Location
Manitowoc, WI, USA
Airport
MTW
Aircraft
LANCAIR 320
Registration
N320P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions and failure to maintain clearance from trees and terrain during an unapproved instrument approach. Contributing to the accident was the pilot’s inadequate preflight weather planning.

Contributing factors

Contributing to the accident was the pilot’s inadequate preflight weather planning.

NTSB narrative

The airplane was operated on a personal cross-country flight. Recorded data indicated that the airplane made an approach to an airport but did not land and the airplane apparently diverted due to the instrument meteorological weather conditions (IMC) present at that airport. The airplane then flew toward another airport about 60 nautical miles away. The airplane was aligned with the extended runway centerline but impacted trees and terrain about 2.5 miles from the diversion airport. The weather conditions at the diversion airport were night IMC with a 400-ft ceiling. Data indicated that the originally intended destination was IMC at the time of the airplane’s departure. The pilot did not request weather information from known sources, and it is unknown what weather information, if any, the pilot checked or received before or during the flight. During the flight, the airplane’s transponder beacon code was set to 1200, indicating that the airplane was operating as a visual flight rules flight, and the investigation did not find record of communication with any air traffic control facility. Based on the flight track data it appeared that the pilot was attempting an approach to the diversion airport when the accident happened. The airplane was configured with one navigation radio that was approved for instrument flight navigation. It also was equipped with a handheld GPS receiver that was capable of monitoring approaches but was not approved for instrument flight navigation. Investigators could not determine which system the pilot was using to navigate. Examination of the airplane and engine did not reveal any pre-accident mechanical failures or malfunctions that would have precluded normal operation. Exhaust gas temperature recordings from the airplane’s engine monitoring system indicated that the engine was operating at the time of the accident. Additionally, the engine monitor recorded fuel pressure until the end of the recorded data, indicating that the airplane’s engine was still receiving fuel. ADS-B data showed that the airplane was descending at 900 ft/min during the final portion of the flight. Based on the available information, the experienced pilot chose to operate in instrument meteorological conditions without an instrument flight rules clearance and without communicating with any air traffic control facility. He then executed an unapproved instrument approach. During the approach the airplane descended into trees and terrain. There was no indication of any failure or malfunction of the airplane that contributed to the accident.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain a weather briefing before the flight.

NTSB coding

Evidence available

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

Docket documents14

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