Pilot Debrief

BEECH P35 near Chadron, NE — 2015-10-06

Final reportCEN16FA005
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Date
2015-10-06
Location
Chadron, NE, USA
Aircraft
BEECH P35
Registration
N877DM
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's continued visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into rising terrain during cruise flight.

NTSB narrative

The airline transport pilot departed in the single-engine airplane on a cross-country flight under visual flight rules (VFR) in visual meteorological conditions (visibility 9 miles and ceiling broken at 1,500 ft above ground level); however, instrument meteorological conditions existed along the planned route of flight. Shortly after departure, the pilot established radio communications with air traffic control and requested activation of the instrument flight rules (IFR) flight plan he had previously filed. The flight was issued a discrete transponder code; however, due to other workload in his airspace sector, the controller did not immediately confirm radar contact or issue an IFR clearance to the pilot. Because the pilot had not received an IFR clearance, he remained under VFR and responsible for maintaining terrain, obstacle, and cloud clearance. According to track data and topographic elevation data, the airplane encountered rising terrain as it flew south from the departure airport. The airplane subsequently impacted treetops and a ridgeline about 10 miles south of the departure airport at 4,200 ft msl. The height of the ridgeline was about 900 ft above the departure airport elevation. An individual working outside near the accident site reported that weather conditions included light precipitation, mist, fog, and low clouds that obscured the surrounding ridgelines. Thus, the airplane likely encountered instrument meteorological conditions before it collided with the ridgeline during cruise flight. Further, a postaccident wreckage examination did not reveal any anomalies that would have precluded normal operation of the airplane during the flight. Although the departure airport was equipped with a remote communication outlet, it was out of service at the time of the accident and could not be used to obtain an IFR clearance. However, the pilot could have obtained an IFR clearance on the ground by telephoning a flight service station. Alternatively, the pilot could have departed under VFR and maneuvered over the airport in visual meteorological conditions until he received an IFR clearance. The pilot's decision to attempt VFR flight into instrument meteorological conditions resulted in controlled flight into rising terrain during cruise flight.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain a weather briefing before departure.

NTSB coding

Evidence available

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

Docket documents20

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