Pilot Debrief

PIPER PA-28-140 near Unknown — 2011-08-01

Final reportERA11FAMS1
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Date
2011-08-01
Location
Unknown, USA
Aircraft
PIPER PA-28-140
Registration
N4533R
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The non-instrumented rated pilot’s flight into instrument meteorological conditions for undetermined reasons, resulting in an in-flight loss of control, uncontrolled descent, and collision with the water.

NTSB narrative

The non-instrument-rated pilot arranged with a flight instructor to fly with him for the purpose of obtaining a flight review. Before the pilot’s arrival at the airport, he phoned the operator’s facility and requested that the fuel tanks be filled. The fuel tanks were filled as requested, and after his arrival at the operator’s facility, he requested that the customer service representative take the flight instructor’s name off the reservation and put his name on it because he did not want the flight instructor responsible in case anything were to occur. This comment was overheard by the flight instructor, prompting him to reassure the pilot that they would have a good flight. The pilot was given the book and keys for the airplane and went to it, started the engine, taxied out, and departed from runway 9 about 7:14 am without the flight instructor. The flight instructor, who intended to fly with the pilot later, thought that the pilot was planning to execute several touch-and-go landings and takeoffs in advance of their lesson. When the pilot did not return, the instructor attempted to communicate with the pilot on a VHF frequency; however, the pilot did not respond. Uncorrelated radar data tracked the airplane from takeoff until it was lost from radar while over the Gulf of Mexico. The uncorrelated radar data indicates that after takeoff, the pilot proceeded northwest where he orbited several times, then proceeded south, flying over the Gulf of Mexico. The flight climbed to a maximum altitude of 13,100 feet mean sea level (msl), then descended to 10,900 feet msl, where 3-D modeling indicates the flight penetrated level 2 radar returns, which are known to have light to moderate turbulence, precipitation, updrafts and downdrafts. This was the last radar return from the airplane. About 3 hours 19 minutes after takeoff, the airplane was lost from radar; a search for the airplane was initiated by the U.S. Coast Guard; however, no wreckage, debris, or the pilot’s body were ever located. The pilot did not contact an air traffic control facility at any time during the flight.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's decision to fly without a flight plan and without proper oversight.

NTSB coding

Evidence available

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

Docket documents30

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