Pilot Debrief

PIPER PA28 near Bossier City, LA — 2020-12-16

Final reportCEN21LA089
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Date
2020-12-16
Location
Bossier City, LA, USA
Aircraft
PIPER PA28
Registration
N55168
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The student pilot’s decision to conduct a flight during night instrument meteorological conditions and his loss of airplane control due to spatial disorientation. Contributing to the accident was the student pilot’s use of an amphetamine and his attention deficit hyperactivity disorder.

Contributing factors

Contributing to the accident was the student pilot’s use of an amphetamine and his attention deficit hyperactivity disorder.

NTSB narrative

The non-instrument-rated student pilot departed for a flight with a passenger during night instrument meteorological conditions. The flight track showed that the airplane flew along an irregular flightpath before the airplane entered a spiraling descent and impacted terrain. The airplane was destroyed during the accident. Examination of the wreckage revealed no anomalies with the airframe or engine that would have precluded normal operation. The night instrument meteorological conditions were conducive to the development of spatial disorientation. The lack of visual references likely caused the pilot to become spatially disoriented, as evidenced by the airplane’s spiraling descent. Thus, the pilot’s spatial disorientation led to his loss of control of the airplane. Postaccident interviews with the student pilot’s flight instructors revealed that (1) he had been instructed not to fly solo without first discussing weather conditions and notices to air missions with a flight instructor, (2) he had been told that he was not allowed to fly with passengers, and (3) he had been specifically instructed not to fly on the day of the accident due to the expected poor weather conditions. However, the student pilot disregarded these instructions and conducted the flight. The student pilot held a third-class medical certificate without limitations. At his medical certification examination about 6 months before the accident, the student pilot reported no medications and no medical concerns. Postaccident interviews revealed that the student pilot had a diagnosis of attention deficit hyperactivity disorder and was treated with medication that metabolized to amphetamine. Toxicology testing detected amphetamine in the student pilot’s specimens. Both amphetamine and attention deficit hyperactivity disorder can negatively impact judgment and increase risk taking behavior and impulsivity. The student pilot’s decision to conduct a flight without the skills and experience to operate the airplane safely in night instrument conditions was inappropriate and demonstrated impulsivity and risk-taking behavior. Thus, the effects of the student pilot’s use of amphetamine and his attention deficit hyperactivity disorder were factors in this accident. Cetirizine (a sedating antihistamine) was detected in the student pilot’s urine but not in his blood; thus, his cetirizine use was not a factor in this accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Student pilot did not contact CFI for weather review before flight.

NTSB coding

Evidence available

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  • 13 docket documents
View NTSB final reportView NTSB docket

Docket documents13

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