Pilot Debrief

PIPER PA-28-161 near Johns Island, SC — 2023-03-25

Final reportERA23FA164
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Date
2023-03-25
Location
Johns Island, SC, USA
Aircraft
PIPER PA-28-161
Registration
N21480
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s decision to continue flight under visual flight rules into instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control. Contributing to the accident was the pilot’s degraded judgement and performance due to fatigue.

Contributing factors

Contributing to the accident was the pilot’s degraded judgement and performance due to fatigue.

NTSB narrative

The non-instrument-rated pilot was on his second day of a long cross-country flight. The first night of his trip he slept in a pilot lounge at an en route airport. He departed the following morning and made one stop for fuel. During the fuel stop, pilot spoke with an airport employee, who said the pilot appeared tired. The pilot said he had been fighting a strong headwind the entire trip. The pilot checked the airport’s automated weather observation system (AWOS) and told the employee that he might stay the night and wait out the approaching weather; however, he ultimately decided to continue his flight. After takeoff, the pilot climbed to 1,600 ft mean sea level (msl) and told air traffic control that he wanted to stay low to maintain visual flight rules (VFR) and avoid any clouds. A short while later, the controller observed the airplane in a descending right turn, and asked the pilot if he was maneuvering to stay below the clouds. The pilot responded, “Mayday Mayday…in the clouds…I’m going down.” The airplane impacted swampy terrain in a nose-down attitude. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation of the engine or airframe. A review of archived information revealed the pilot did not obtain a documented weather briefing on the day of the accident. However, he was aware that the weather conditions along his route of flight would deteriorate and expressed that he may have to delay the trip. A postaccident review of weather information indicated the pilot encountered an area of clouds with tops about 3,500 ft msl. The pilot decided to continue with the flight, and based on available evidence, was unable to maintain visual conditions and entered a cloud layer, losing visual reference to his surroundings. As such, the pilot likely became spatially disoriented and lost control of the airplane. It is also possible that the pilot was experiencing some level of fatigue at the time of the accident due to the long flights over the preceding days and the less-than-optimal sleeping conditions the night before. Fatigue has been shown to reduce one’s judgement and degrade performance, and it is likely that fatigue contributed to the pilot’s decision to continue the flight into deteriorating weather conditions.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have chosen to wait for weather to improve instead of departing.

NTSB coding

Evidence available

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

Docket documents17

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