Pilot Debrief

NANCHANG CJ6A near Keene, CA — 2017-04-27

Final reportWPR17FA091
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Date
2017-04-27
Location
Keene, CA, USA
Aircraft
NANCHANG CJ6A
Registration
N192NG
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot's failure to maintain airplane control following a descent into clouds.

NTSB narrative

The private pilot was part of a formation of four airplanes making a cross-country flight during day visual meteorological conditions over a broken-to-overcast cloud layer. During the flight, the accident airplane, which was positioned left of the lead airplane, began drifting to the left of and behind the formation, which resulted in the lead pilot losing sight of the airplane. The lead pilot twice asked the accident pilot if he was okay and received affirmative responses. However, the pilot in trail lost sight of the accident airplane as it dropped below and behind his airplane, and the pilot positioned to the right of the lead pilot observed the accident airplane descend in a wings level, slight nose-down attitude into clouds below and behind their position. Despite multiple attempts, no further radio communication was established with the accident pilot. A witness who was located near the accident site saw the airplane descend from the clouds in a near vertical attitude until she lost sight of it behind a nearby ridgeline. Examination of the accident site indicated that the airplane impacted terrain in a near vertical attitude. Postaccident examination of the airplane revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. Toxicology testing revealed ethanol in the pilot's muscle tissue; however, no ethanol was found in brain tissue making it likely the ethanol was produced postmortem. The pilot had a history of coronary artery disease and was at an increased risk for a sudden cardiovascular event; however, there is insufficient evidence to determine if his heart disease contributed to this accident.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have avoided entering cloud layer during descent.

NTSB coding

Evidence available

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

Docket documents7

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