Pilot Debrief

Piper J3C near Fancy Gap, VA — 2018-10-06

Final reportERA19FA003
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Date
2018-10-06
Location
Fancy Gap, VA, USA
Aircraft
Piper J3C
Registration
N38811
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The non-instrument-rated pilot's improper decision to undertake a flight into forecast instrument meteorological conditions (IMC) and his subsequent decision to continue the flight after encountering IMC, which resulted in controlled flight into terrain. Contributing to the accident were the pilot's depression and use of impairing/sedating medications, which resulted in poor decision-making.

Contributing factors

Contributing to the accident were the pilot's depression and use of impairing/sedating medications, which resulted in poor decision-making.

NTSB narrative

The non-instrument-rated private pilot was conducting a visual flight rules (VFR) cross-country flight; instrument meteorological conditions (IMC) were forecast along the route, and the airplane was not equipped for flight in IMC. The pilot had entered a flight plan in the ForeFlight application that noted a cruise altitude of 2,100 ft mean sea level (msl) for the route of flight. Further, the ForeFlight application displayed a terrain cross-section overview which noted that the highest point along the route was 3,800 ft msl and indicated that the planned route and altitude for the flight conflicted with the rising terrain. About 1 hour 15 minutes after departure, the airplane impacted a mountain at 2,766 ft, about 150 ft below the summit. The accident site was about 36 miles from the destination airport along a direct route between the departure and destination airports. Accident site evidence and impact damage to the airplane were indicative of a high-speed impact, with a wreckage path that was oriented roughly opposite to the intended route of flight. Examination of the wreckage revealed no anomalies with the airplane that would have precluded normal operation before the accident. Weather observations near the departure and destination airports, AIRMETs, and visible satellite weather images all indicated that the pilot likely encountered IMC en route, and based on the direction of the wreckage path relative to the intended route of flight, was likely maneuvering to return to visual meteorological conditions when the airplane collided with terrain. The forecasts warning of IMC were issued prior to the pilot's departure, and while it could not be determined whether the pilot accessed these forecast materials, the flight planning application on his personal electronic device would have allowed him to view this information if an internet connection was available. Toxicology test results showed that the pilot was taking two antidepressants, indicating that he had significant depression, which can be associated with significant cognitive degradation. The testing also detected the presence of four impairing or sedating medications. The pilot made critical errors in judgment both when he decided to undertake the flight along a route where instrument meteorological conditions were forecast, and when he elected to continue flight after encountering those conditions. It is likely that the combination of his depression and his use of multiple impairing/sedating medications contributed to the pilot's poor decision-making and therefore contributed to the accident.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have avoided flight in IMC without instrument rating.

NTSB coding

Evidence available

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

Docket documents10

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