Pilot Debrief

PIPER PA 46-350P near Greensburg, IN — 2012-12-02

Final reportCEN13FA085
Sign in to save
Date
2012-12-02
Location
Greensburg, IN, USA
Airport
I34
Aircraft
PIPER PA 46-350P
Registration
N92315
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Approach

Probable cause

The pilot's failure to maintain airplane control while maneuvering in night instrument meteorological conditions due to spatial disorientation.

NTSB narrative

The instrument-rated private pilot was executing a nonprecision instrument approach procedure at night in deteriorating weather conditions. According to GPS track data, the pilot executed the approach as published but descended below the missed approach point's minimum altitude before executing a climbing right turn. This turn was not consistent with the published missed approach procedure. The airplane then began a series of left and right ascending and descending turns to various altitudes. The last few seconds of recorded data indicated that the airplane entered a descending left turn. Two witnesses heard the airplane fly overhead at a low altitude and described the weather as foggy. Reported weather at a nearby airport about 26 minutes before the accident was visibility less than 2 miles in mist and an overcast ceiling of 300 feet. A friend of the pilot flew the same route in a similarly equipped airplane and arrived about 30 minutes before the accident airplane. He said he performed the same approach to the missed approach point but never broke out of the clouds, so he executed a missed approach and diverted to an alternate airport. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Federal Aviation Administration Flight Training Handbook Advisory Circular 61-21A cautions that pilots are particularly vulnerable to spatial disorientation during periods of low visibility due to conflicts between what they see and what their supporting senses, such as the inner ear and muscle sense, communicate. The accident airplane's maneuvering flightpath, as recorded by the GPS track data, in night instrument meteorological conditions is consistent with the pilot's loss of airplane control due to spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have executed a missed approach instead of continuing in IMC.

NTSB coding

Evidence available

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

Docket documents17

Related mishaps