Pilot Debrief

CESSNA 172 near Chambers, NE — 2023-05-15

Final reportCEN23FA187
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Date
2023-05-15
Location
Chambers, NE, USA
Aircraft
CESSNA 172
Registration
N2946U
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The pilot’s continued VFR flight into instrument meteorological conditions at night and his failure to maintain adequate altitude, which resulted in controlled flight into terrain.

NTSB narrative

The pilot departed on the cross-country flight with instrument meteorological conditions (IMC) reported over the entire region along the route of flight. The NWS had multiple forecasts calling for instrument flight rule conditions as well as an AIRMET for the threat of low ceilings and low visibility over the area. There was no record of the pilot having received a weather briefing and no flight plan was filed. In addition, there were no known communications with the pilot during the flight. Witnesses reported hearing the airplane flying at a low altitude beneath the clouds just before the accident. They reported that the weather at the time was foggy, misty, and raining. The airplane was substantially damaged when it impacted the terrain in a slight nose-down, wings-level attitude. Postaccident examination of the airframe and engine did not reveal any anomalies that would have prevented normal operation of the airplane. The airplane was operating in conditions conducive to serious carburetor icing; however, the witnesses reported the airplane was loud when they heard it flying overhead just before impact. The pilot’s autopsy revealed coronary artery disease; however, there was no clear evidence that the disease contributed to the accident. Weather forecasts for the area called for precipitation and overcast ceilings at 300 ft. The forecasts were consistent with witness accounts of the weather at the time of the accident. The nighttime IMC conditions would have made visual navigation next to impossible without a discernable horizon. Based on the accident site, wreckage examinations, and the witness accounts, the pilot was likely attempting to fly beneath the low clouds when the airplane impacted the ground.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot did not obtain a weather briefing before departure.

NTSB coding

Evidence available

  • Video
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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