Pilot Debrief

PIPER PA-44-180 near Woodruff, WI — 2010-09-24

Final reportCEN10FA557
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Date
2010-09-24
Location
Woodruff, WI, USA
Airport
ARV
Aircraft
PIPER PA-44-180
Registration
N570ER
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot's decision to attempt an instrument approach in turbulent night instrument meteorological conditions with a recently-identified deficiency with his instrument flight proficiency, which resulted in a loss of airplane control as a result of spatial disorientation.

NTSB narrative

The accident occurred during a night cross-country flight in instrument meteorological conditions with reported moderate turbulence. Review of air traffic control data indicated that the instrument-rated pilot had difficulty navigating from the initial approach fix to the final approach fix. Radar track data showed that the pilot initially turned the wrong direction and ultimately made several course reversals that were not in accordance with the published approach procedure. Radar data also indicated that the pilot had difficulty maintaining an altitude appropriate for the segment of the approach; the airplane's altitude increased and decreased in excess of 500 feet. In addition, on several instances, the pilot allowed the airplane to descend below the prescribed minimum altitudes for the approach. The airplane eventually impacted a river in an uncontrolled descent about ½ mile north of the final approach fix. A postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. During a recent checkout in the accident airplane, the pilot demonstrated a lack of instrument flight proficiency, and following the checkout, he was authorized to rent the accident airplane for visual flight rules (VFR) flights only. The flight instructor who provided the checkout flight reported that the pilot had difficulty maintaining situational awareness and aircraft control when flying only by reference to the flight instruments.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach when realizing they were off course.

NTSB coding

Evidence available

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

Docket documents26

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