Pilot Debrief

PIPER PA-28-140 near Wayne, NE — 2024-08-26

Final reportCEN24FA327
Sign in to save
Date
2024-08-26
Location
Wayne, NE, USA
Aircraft
PIPER PA-28-140
Registration
N9626K
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The non-instrument-rated pilot’s encounter with instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

NTSB narrative

The non-instrument-rated pilot departed on a visual flight rules (VFR) cross-country flight in visual meteorological conditions. Flight track data indicated that the airplane departed and flew northeast for about 15 minutes at altitudes less than 1,000 ft above ground level (agl) before entering a right turn with varying altitude, heading, and ground speed changes. A witness near the accident site stated that the clouds were about 100 ft agl when he heard the airplane fly over his house. Shortly thereafter, he heard the engine sound increase; the airplane impacted the ground and a postimpact fire ensued. The last flight track data point indicated the airplane was 1,030 ft agl, heading north at a ground speed of 51 knots. The accident site was located about 1,000 ft north-northwest of the last data point, about 27 nautical miles from the departure airport. The airplane impacted the ground in a steep descent and came to rest inverted. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The wreckage debris path and propeller damage signatures, in addition to the witness statement, were consistent with the engine producing power at the time of impact. Review of weather information revealed conditions favorable for sustained, low-level cloud cover, but there were no AIRMETs in effect for instrument flight rules conditions. Although forecasts indicated few to scattered clouds around 600 ft agl, recorded weather conditions from the airport closest to the accident site indicated an overcast ceiling at 600 ft agl. Based on available weather information, it is likely that the accident pilot encountered instrument meteorological conditions shortly after takeoff. The pilot’s friend stated that the pilot checked the weather on his tablet on the morning of the accident; however, there was no record of the pilot obtaining weather information from an access-controlled source such as Leidos Flight Service or ForeFlight. Therefore, the extent of the pilot’s preflight weather planning could not be determined. The circumstances of the accident are consistent with the non-instrument-rated pilot’s encounter with instrument meteorological conditions, which resulted in the loss of visual references, spatial disorientation, and loss of airplane control. The pilot’s postmortem toxicology results indicated he had used the sedating antihistamine medication diphenhydramine and may have been experiencing associated impairing effects at the time of the accident. It is possible that his diphenhydramine use might have increased his susceptibility to spatial disorientation. No blood was available for testing, and more specific conclusions about diphenhydramine effects could not be drawn from the toxicology results in tissue. Visual flight into instrument meteorological conditions by a non-instrument-rated pilot carries a high risk of spatial disorientation even in the absence of impairment. Overall, whether the pilot’s use of diphenhydramine contributed to the accident could not be determined. One laboratory detected ethanol at a high level in a brain tissue specimen, while another laboratory did not detect ethanol in brain or muscle tissue specimens. In the setting of extensive injuries, the detected ethanol likely was from postmortem sources, rather than alcohol consumption. It is unlikely that ethanol effects contributed to the accident.

NTSB coding

Evidence available

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

Docket documents13

Related mishaps