Pilot Debrief

PIPER PA32R near Venice, FL — 2023-04-06

Final reportERA23FA181
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Date
2023-04-06
Location
Venice, FL, USA
Airport
VNC
Aircraft
PIPER PA32R
Registration
N635BD
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Climb

Probable cause

The pilot’s decision to initiate a visual flight rules flight into dark night conditions, which resulted in spatial disorientation during the initial climb and subsequent steep banking descent into water.

NTSB narrative

After flying into a coastal airport and having dinner, the instrument-rated commercial pilot conducted a night visual flight rules (VFR) departure over an oceanic basin. Witnesses reported seeing the airplane take off; shortly after takeoff, the airplane entered a right turn before it descended into the water. ADS-B track data indicated that the airplane took off and climbed on the runway heading to an altitude of about 300 ft as it maintained a ground speed of about 103 knots. The airplane then began to turn to the right and began to descend. The last data depicted the airplane at 100 ft, with a ground speed of about 136 knots and a vertical descent rate of 3,008 feet per minute. At the time of departure, dark night conditions prevailed, the winds were calm, and there was 10 miles of visibility with clear skies. Astronomical data indicated that, although the moon was full and moonrise had occurred, the moon was low on the eastern horizon, behind and to the left of the airplane, and there would not have been any visible horizon over the water. Examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures with the airplane or instruments. The airplane was equipped with an autopilot with an attitude recovery function; however, the autopilot was limited to operations over 500 ft above ground level which was about 200 ft higher than the airplane’s peak altitude. The autopilot On/Off switch was found in the Off position. Due to the pilot’s heart disease, the pilot was at an increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack. However, there was no forensic evidence that such an event occurred. Ethanol was detected in the pilot’s cavity blood at a very low level and was not detected in vitreous fluid. Some or all of the detected ethanol may have been from postmortem production. It is unlikely that ethanol effects contributed to the accident. The pilot had diabetes and the postmortem vitreous level of glucose was elevated, as was the hemoglobin A1c (HbA1c). The pilot’s elevated HbA1c was consistent with uncontrolled diabetes over the previous several months. Short-term effects of high blood sugar may include decreased cognitive performance, including slower informational processing speed and decreased executive function and attention. Chronic high blood glucose levels can lead to vision complications and an increased risk of cardiovascular disease. Whether the pilot’s uncontrolled diabetes caused such symptoms or contributed to the accident could not be determined. Based upon track, meteorological, and astronomical data, the pilot initiated a VFR flight into known dark night conditions, without a visible horizon, which would have prevented reliable control of the airplane using only external visual cues. The turning and rapidly descending flight track were consistent with a pilot who was experiencing spatial disorientation, which resulted in a loss of control in flight and an impact with water. The pilot’s instrument and night currency could not be determined.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have avoided night flight over water without visual horizon reference.

NTSB coding

Evidence available

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

Docket documents20

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