Pilot Debrief

PIPER PA28 near Venice, FL — 2022-12-04

Final reportERA23FA079
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Date
2022-12-04
Location
Venice, FL, USA
Airport
KVNC
Aircraft
PIPER PA28
Registration
N4676F
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Takeoff roll

Probable cause

The pilot’s spatial disorientation during takeoff in dark night visual meteorological conditions, which resulted in his failure to maintain a positive rate of climb and a subsequent descent into the water.

NTSB narrative

The pilot was departing on a visual flight rules flight from an airport located on the coast of the Gulf of Mexico in dark night conditions. Flight track information revealed that the airplane took off toward the Gulf and climbed to a peak altitude of about 75 ft above ground level before entering a descent. During the descent, the airplane accelerated before the track data ended in the vicinity of the accident site, which was located in the water about 1,800 ft past the departure end of the runway. Airport surveillance video from the time of the accident depicted an airplane departing with little to no angle of climb into a dark sky over dark water with no discernable horizon. Visual meteorological conditions prevailed at the airport at the time of the accident, with a broken cloud ceiling about 5,000 ft above ground level. Although the moon was above the horizon and about 83% of its visible disk was illuminated, it would have been located behind the pilot given the direction of the takeoff and was likely not readily visible due to the cloud ceiling. Examination of the wreckage revealed no pre-impact mechanical anomalies. The pilot began his flight training about 1 year before the accident, received his pilot certificate 4 months before the accident, and did not possess an instrument rating. The pilot had accrued 4.6 total hours of night-flying experience, 1.1 hours of which was accrued about 6 weeks before the accident, and his only night flight since receiving his pilot’s certificate. Since the pilot was not qualified for flight by reference to instruments, he would have been especially vulnerable to the onset of spatial disorientation when departing toward an area of open water devoid of cultural lighting. The flight track data and surveillance video were consistent with the pilot experiencing a form of spatial disorientation known as somatogravic illusion, in which the pilot incorrectly perceives the airplane’s acceleration as increasing pitch attitude. Such an illusion can be especially difficult to overcome because it typically occurs at low altitudes after takeoff, providing little time for recognition and subsequent corrective actions.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted takeoff due to dark conditions and lack of visual references.

NTSB coding

Evidence available

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

Docket documents11

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