Pilot Debrief

PIPER PA32 near Jackson, OH — 2024-02-24

Final reportERA24FA120
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Date
2024-02-24
Location
Jackson, OH, USA
Airport
JRO
Aircraft
PIPER PA32
Registration
N8963N
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Takeoff roll

Probable cause

The non-instrument-rated pilot’s decision to depart under visual flight rules into instrument meteorological conditions, which resulted in an inflight collision with terrain while maneuvering.

NTSB narrative

The non-instrument-rated private pilot and two passengers departed on the cross-county flight under visual flight rules (VFR) during a period of heavy snow, as reported by witnesses of the accident flight. The airplane subsequently collided with terrain while maneuvering in the vicinity of the airport several minutes after takeoff. A postimpact fire consumed and destroyed most of the airplane, precluding determination of control position settings and instrument readings. Weather observations and satellite imagery indicated that instrument meteorological conditions (IMC) prevailed at the departure airport and its vicinity at the time of the accident, with surface visibilities ranging from 3/4 to 2 statute miles and ceilings around 1,200 ft above ground level (agl). Before the flight, the pilot received a weather briefing from ForeFlight that included an AIRMET warning of IMC in effect at the time of the accident for the departure airport and enroute. Witness accounts described even lower ceilings and visibilities than indicated in official weather reports, with one characterizing the snowfall as “very hard and windy” during the flight’s run-up and for 20 minutes afterward. Another witness stated that the airplane was only aloft for about 3 to 5 minutes; in that time, the airplane was maneuvering in the vicinity of the airport and departure runway. The airplane’s track was not captured by ADS-B data, and no onboard devices that capture digital data were recovered; therefore, the investigation could not determine how the airplane was maneuvering and whether the final impact was due to pilot spatial disorientation. A survey of the accident site revealed a linear debris path terminating in wreckage that was upright and relatively intact, suggesting that the airplane impacted the ground with relatively little energy, consistent with low-speed, controlled flight into terrain. While the airplane was exposed to the potential for airframe icing after removal from the hangar and through the end of the flight, the more imminent and pressing challenge the pilot faced would have been navigating and maintaining aircraft orientation under VFR given the restriction to visibility imposed by the period of heavy snow reported by witnesses. The postimpact fire precluded determination of whether airframe icing contributed to the accident. The pilot’s logbook was not available during the investigation. A flight instructor with whom the pilot had been working to obtain an instrument rating estimated that the pilot had logged 20 hours of instrument flight “under the hood.” Postaccident toxicology testing of specimens obtained from the pilot indicated he had used the sedating antihistamine diphenhydramine, which might have adversely affected his performance or increased his susceptibility to spatial disorientation. However, the diphenhydramine results in his postmortem tissues cannot be used to determine the details of his diphenhydramine use or whether he was significantly impaired by diphenhydramine effects at the time of the accident. The pilot’s decision to attempt a VFR flight in IMC with inadequate training and experience was inappropriate regardless of whether he was impaired and attributing that decision to diphenhydramine effects would be implausible.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should not have taken off in heavy snowfall and low visibility conditions.

NTSB coding

Evidence available

  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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