Pilot Debrief

PIPER PA-32-260 near Cordova, AK — 2022-10-16

Final reportANC23LA002
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Date
2022-10-16
Location
Cordova, AK, USA
Aircraft
PIPER PA-32-260
Registration
N3432W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

NTSB narrative

After departing on a cross-country flight, the pilot returned to the departure airport due to poor weather conditions along the route. After landing, the pilot discussed the poor weather with a friend and told him he wanted to fly to another airport where he could leave the airplane and continue his trip using a commercial airline. His friend recommended that he stay where he was until the weather improved. The pilot subsequently received two weather briefings informing him that visual flight rules (VFR) flight was not recommended along his planned route due to instrument meteorological conditions (IMC). The pilot departed on the flight and was in communication with flight service while airborne when the communications ended abruptly and an emergency locator transmitter (ELT) activated. An eyewitness saw the airplane flying in and out of clouds before disappearing into the clouds near the accident site location. The airplane wreckage was found along a steep mountainside at an elevation about 1,866 ft mean sea level. Examination of the wreckage did not reveal any anomalies that would have precluded normal operation. The weather forecast information applicable for the accident time indicated that an AIRMET was valid for mountain obscuration conditions, and a Terminal Area Forecast (TAF) near the accident site valid at the accident time stated that IMC conditions were likely. Toxicology testing detected the antidepressant amitriptyline and its active metabolite nortriptyline in the pilot’s blood at therapeutic levels. While these substances are associated with side effects such as drowsiness and dizziness, the operational findings of this accident do not suggest performance issues related to fatigue. Gabapentin and norcyclobenzaprine were detected in the pilot’s urine and not in his blood, so no therapeutic or side effects would be expected. Thus, the effects from the pilot’s use of amitriptyline, gabapentin, and cyclobenzaprine were not likely a factor in this accident. The pilot had high urinary glucose; the cause was unknown but could possibly be dietary, from kidney disease, from diabetes medications, or from being diabetic. However, no glucose was detected in his vitreous fluid and his hemoglobin A1C indicates his average blood glucose levels would be around 120 mg/dL. Thus, it is unlikely that the pilot had low blood glucose, which is the concern for flight safety. Based on the available information, the circumstances of the accident are consistent with the pilot’s decision to conduct a visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have heeded weather warnings and not attempted flight.

NTSB coding

Evidence available

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

Docket documents13

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