Pilot Debrief

Piper PA 24-180 near Ketchikan, AK — 2019-07-11

Final reportANC19FA033
Sign in to save
Date
2019-07-11
Location
Ketchikan, AK, USA
Airport
KTN
Aircraft
Piper PA 24-180
Registration
N5840P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s decision to continue visual flight rules into instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

NTSB narrative

The pilot was conducting a visual flight rules cross-country flight. He filed a flight plan before departure but declined a formal weather briefing. Although the weather information he gathered about the flight could not be determined, he indicated to his spouse before departure that the weather at his intended fuel stop was “not good,” but that he had sufficient fuel onboard to continue to the destination airport without refueling. GPS data showed that the airplane proceeded directly toward the airport where he intended to refuel, and while approaching the airport for landing the pilot reported via radio that he was “hung up” and would maneuver for a left downwind. There were no further radio communications from the pilot. GPS data revealed that, about the time the pilot made the final radio call, the airplane was about 500 ft above ground level; it then banked left and rapidly descended into rising terrain. The wreckage was located on a hillside about 4 nautical miles southeast of the airport. The distribution of the wreckage was consistent with a high speed impact. Examination of the airframe, engine, and associated systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot held an instrument rating, his instrument currency could not be determined, and his wife, who flew with him often, stated that he rarely filed or flew instrument flight rules flights. Weather camera images revealed the presence of low cloud layers and limited visibility in the area of the accident site around the time of the accident. Despite his apparent awareness of forecast marginal visual flight rules conditions and temporary instrument meteorological conditions, the pilot chose to depart and continue into an area of low cloud ceilings and rising terrain. It is likely that, while maneuvering at low altitude toward the airport, the pilot's in-flight visibility was limited by the cloud conditions, which resulted in spatial disorientation and a loss of control. The pilot had a history of high blood pressure and diabetes, and toxicology revealed medications that were consistent with appropriate medical treatment and were not considered impairing. The pilot’s downloaded glucometer readings during the flight had no indications of an adverse diabetic event; therefore, the pilot’s diabetes and use of diabetes medication did not contribute to the accident. The coronary artery disease observed during the autopsy was below that generally considered significant. Although the pilot’s medical conditions placed him at increased risk for a sudden impairing or incapacitating cardiovascular event, there is insufficient evidence to determine whether such an event occurred.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have opted to divert to KTN instead of attempting to land in poor weather.

NTSB coding

Evidence available

  • ATC audio
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

Related mishaps