Pilot Debrief

PIPER PA28 near Ontonagon, MI — 2019-08-03

Final reportCEN19FA247
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Date
2019-08-03
Location
Ontonagon, MI, USA
Aircraft
PIPER PA28
Registration
N5167L
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The non-instrument-rated pilot’s decision to continue visual flight into instrument meteorological conditions with thunderstorm activity, which resulted in spatial disorientation and a loss of airplane control.

NTSB narrative

The pilot, who was not instrument rated, was conducting a personal flight in visual meteorological conditions when he flew into an area of instrument meteorological conditions (IMC) with thunderstorm activity. After flying several minutes in IMC, the airplane entered a left turn that became increasingly tighter along with a with a rapid climb that was followed by a rapid descent until the airplane impacted the ground. The airplane was destroyed. Postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation of the airplane. The spiral flightpath with significant changes in altitude was consistent with the pilot experiencing the effects of spatial disorientation. Weather imagery indicated an outflow boundary ahead of the main cumulonimbus cloud line. The pilot likely encountered gusty and turbulent wind conditions when the airplane flew into the outflow boundary. The adverse weather conditions likely contributed to the pilot’s spatial disorientation. The pilot did not receive a weather briefing before the flight.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have avoided flying into IMC conditions after receiving weather warnings.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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