Pilot Debrief

CESSNA 172S near Hermantown, MN — 2022-10-02

Final reportERA23FA001
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Date
2022-10-02
Location
Hermantown, MN, USA
Airport
DLH
Aircraft
CESSNA 172S
Registration
N262TA
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Initial climb

Probable cause

The pilot’s loss of airplane control due to spatial disorientation during initial climb in dark night and low instrument meteorological conditions, which resulted in a descent into terrain. Contributing to the accident was the pilot’s fatigue due to a long day of flying and personal activities.

Contributing factors

Contributing to the accident was the pilot’s fatigue due to a long day of flying and personal activities.

NTSB narrative

The pilot and two passengers were departing on a night instrument flight rules (IFR) flight when the accident occurred just after takeoff. Weather at the time of and preceding the takeoff consisted of low ceilings, low visibility, and mist with low-instrument-flight-rule (LIFR) conditions expected through most of the area. The pilot received an IFR clearance with direction to climb to 6,000 ft on departure and was issued a departure frequency that was read back incorrectly by the pilot. The air traffic controller provided taxi and takeoff instructions, as well as the weather conditions, which included a recent pilot report indicating that the instrument meteorological conditions would likely persist after the accident pilot departed. The controller cleared the airplane for takeoff with a right turn direct on departure and reported the wind and runway visual range, which was acknowledged by the pilot. After takeoff the pilot made a right turn but failed to turn direct on course. The airplane then entered a tight teardrop turn to the left while climbing, and after completing 270° of turn it briefly leveled at 2,800 ft msl before it began a rapid descent. During this time, air traffic control contacted the pilot on the tower radio frequency and instructed him to contact departure. The pilot responded in the affirmative, but there were no further transmissions from the pilot on any radio frequency despite attempts from both the tower and departure air traffic controllers to reach him. The airplane subsequently impacted electrical transmission wires and a 2-story single family home, and damage signatures observed at the accident site indicated that the airplane was likely in 40° left bank at the time of impact. There was no evidence of any preimpact mechanical malfunctions or failures of the airframe or engine observed during a postaccident examination of the wreckage. The instrument-rated pilot had accumulated 7.9 hours of actual instrument flight experience, but only 0.3 hours of actual instrument flight experience in the preceding 15 months. This relative flight inexperience in actual instrument conditions, combined with his lack of instrument confidence, as reported by the pilot in a conversation with a student pilot on the day before the accident, indicate that the pilot was likely at increased risk for becoming spatially disoriented. The airplane’s erratic flight track in the final two minutes of flight, which included the incorrect turn direct, followed by a steep left turn with a rapid descent, were also consistent with the known effects of spatial disorientation. After takeoff, once the pilot entered the clouds about 250 ft above ground level, most of the ground lighting would have quickly disappeared, and combined with the prevailing LIFR conditions, would have made it difficult to recognize a loss of control due to spatial disorientation unless he was confident and assertive in his use of the airplane’s instrumentation. Although the pilot’s actual sleep and wake times prior to the accident could not be precisely determined, the pilot was likely experiencing some level of fatigue due to the late night flying the previous day combined with the flight the next morning and the 11-½-hour-long day at the wedding and reception before the planned accident flight. If the pilot had been fatigued, it would have further degraded his ability to recognize and recover from any spatial disorientation that he was experiencing. Postmortem toxicological testing detected codeine in the pilot’s urine at a low level. This finding could be consistent with prior codeine use or possibly even poppy seed consumption. Regardless, the pilot had no detectable codeine in his blood. This makes it unlikely that codeine effects contributed to the accident. Given the pilot’s lack of recent experience in actual instrument conditions, the LIFR weather, the dark night lighting conditions, and that he was likely fatigued, the pilot likely became spatially disoriented and lost control of the airplane when he entered a climbing turn shortly after takeoff.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have opted to delay takeoff due to low visibility conditions.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • ADS-B / radar
  • Photos
  • 25 docket documents
View NTSB final reportView NTSB docket

Docket documents25

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