Pilot Debrief

PIPER PA28 near Sommerville, TN — 2014-12-02

Final reportERA15FA066
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Date
2014-12-02
Location
Sommerville, TN, USA
Airport
FYE
Aircraft
PIPER PA28
Registration
N8607W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The noninstrument-rated pilot's improper decision to attempt visual flight in instrument meteorological conditions, which resulted in an in-flight loss of airplane control due to spatial disorientation. Contributing to the accident was the pilot’s impaired decision-making due to the effects of ethanol and chlordiazepoxide.

Contributing factors

Contributing to the accident was the pilot's impaired decision-making due to the effects of ethanol and chlordiazepoxide.

NTSB narrative

According to a family member, the noninstrument-rated private pilot was planning to refuel the airplane on the evening of the accident. After purchasing fuel, he subsequently departed in night instrument meteorological conditions, which included low clouds and mist. A witness heard the airplane flying overhead and then sounds associated with increased engine power, followed by a loud crash. The airplane impacted a heavily wooded area about 0.75 mile from the departure airport and was destroyed by impact forces and a postcrash fire. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Dark night instrument meteorological conditions can lead to spatial disorientation, particularly for a noninstrument-rated pilot. In addition, the wreckage distribution and the witness observation of increasing engine noise and the wreckage are consistent with the pilot losing control of the airplane due to spatial disorientation. The pilot's toxicology results identified ethanol at 0.109% in muscle tissue and 0.039% in brain tissue. Although some of the ethanol may have been produced postmortem, it is likely that some was ingested before the accident. In addition, chlordiazepoxide (a prescription medication for the treatment of anxiety) and its metabolite, nordiazepam, were detected in the liver. It is likely the combined effects of chlordiazepoxide and ethanol significantly impaired the pilot's executive functioning, judgment, and decision-making, leading to his decision to fly in weather that he was unprepared to manage.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have delayed takeoff due to night IMC conditions.

NTSB coding

Evidence available

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

Docket documents12

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