Pilot Debrief

CESSNA R182 near Gainesville, GA — 2021-02-26

Final reportERA21FA140
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Date
2021-02-26
Location
Gainesville, GA, USA
Airport
GVL
Aircraft
CESSNA R182
Registration
N3652C
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Initial climb

Probable cause

The pilot’s loss of control due to spatial disorientation. Contributing to the accident was the pilot’s decision to depart into low instrument meteorological conditions.

Contributing factors

Contributing to the accident was the pilot’s decision to depart into low instrument meteorological conditions.

NTSB narrative

The instrument-rated pilot departed on an instrument flight rules (IFR) flight plan into instrument meteorological conditions (IMC) that included a cloud ceiling 400 ft above ground level (agl), mist, and low-level wind shear. The pilot was instructed to fly a heading that would have required a 30° right turn from the departure runway heading after takeoff and to climb to 3,000 ft mean sea level (msl). After departure, the airplane entered a right turn to more than 180° from the departure runway heading and performed a series of climbs and descents with corresponding deviations in groundspeed, reaching a maximum altitude of 2,500 ft msl before descending rapidly into trees and terrain. Postaccident examination of the airplane and engine did not reveal any preimpact failures or malfunctions that would have precluded normal operation. The accident site and distribution of the wreckage were consistent with impact at high speed and with the engine producing power. A friend of the pilot reported that the pilot was proficient in the operation of modern digital flight instruments, but not proficient in the use of analog flight instruments like those installed in the accident airplane. The friend reported that he advised the pilot not to fly the accident airplane in IMC until he upgraded the instrumentation and avionics. The friend also reported that the pilot had likely not previously flown by himself in low IMC, like those present at the time of the accident. The pilot had received preflight weather briefings that advised of the low cloud ceilings, visibility, and wind shear; however, the conversations indicated that the pilot was focused on the potential for icing at cruise altitude. The airplane’s pitch attitude deviations after takeoff, as evidenced by its climbs, descents, and groundspeed changes, are consistent with the pilot experiencing a type of spatial disorientation known as a somatogravic illusion, which resulted in spatial disorientation, loss of control, and impact with trees and terrain. It is likely that the pilot’s decision to depart into low instrument flight rules conditions, which resulted in his entry into low-visibility conditions during a high-workload phase of flight such as the takeoff and initial climb, increased his susceptibility to the effects of spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot should have aborted takeoff due to low visibility and weather conditions.

NTSB coding

Evidence available

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

Docket documents20

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