Pilot Debrief

PIPER PA-28-236 near Orleans, MA — 2021-10-31

Final reportERA22LA043
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Date
2021-10-31
Location
Orleans, MA, USA
Airport
CQX
Aircraft
PIPER PA-28-236
Registration
N2186U
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s spatial disorientation and subsequent loss of airplane control while maneuvering over water in dark night conditions.

NTSB narrative

The private pilot departed on a cross-country flight, and after takeoff, the airplane flew in a straight line at an altitude about 8,000 ft mean sea level (msl). It began a descent toward a presumed destination airport in dark night visual meteorological conditions. Continuing on the established track, the airplane descended to and maintained 1,000 ft msl. The flightpath turned slightly before the airplane overflew and continued past the destination airport, turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. During the overwater portion of the flight, the airplane’s altitude varied between 750 ft and 1,100 ft msl. Before track data were lost, the airplane began a descending right turn from about 1,025 ft to 675 ft msl. The debris field located about 2.5 miles offshore and 7 miles from the destination airport. The airplane was not recovered. The uniformity of the flight track and altitude data for most of the flight suggests that the pilot was using the airplane’s autopilot. After overflying the airport, the airplane’s track and altitude variations were consistent with the pilot having disengaged the autopilot to hand-fly the airplane; however, continued flight over the ocean would have resulted in a near absence of cultural lighting and external visual references, requiring the use of instruments to maintain control. The pilot was neither qualified nor proficient to conduct the flight by reference to instruments and would have been vulnerable to the onset of spatial disorientation during the overwater portion of the flight. It is likely that, while maneuvering over the ocean, the pilot became spatially disoriented, resulting in a loss of control and impact with the water.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have chosen to divert to CQX instead of continuing past the airport.

NTSB coding

Evidence available

  • ADS-B / radar
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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