Pilot Debrief

PIPER PA-23 near Millersburg, OH — 2011-08-08

Final reportCEN11FA557
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Date
2011-08-08
Location
Millersburg, OH, USA
Airport
10G
Aircraft
PIPER PA-23
Registration
N2286P
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain clearance with terrain during the landing approach in night conditions and fog. Contributing to the accident was the pilot’s inadequate preflight planning.

Contributing factors

Contributing to the accident was the pilot’s inadequate preflight planning.

NTSB narrative

The pilot received a weather briefing on the day before the visual flight rules flight during which he was informed that the weather conditions near his destination would be deteriorating. The pilot departed in night visual conditions. Toward the end of his planned flight, he flew over the destination airport but was unable to see it due to weather conditions that he described to an air traffic controller as “too thick.” The pilot informed the controller that he wanted to fly back toward Columbus, Ohio. About 1 minute later, the pilot informed the controller that he wanted to change his destination to a second airport, which is located about 24 miles northwest of his original destination. While en route to the second airport, the pilot was informed of a notice to airmen indicating that the runway lights at that airport were out of service. Fourteen minutes later, the air traffic controller in communication with the pilot asked if he wanted another airport or to proceed to his second destination. The pilot stated that, once again, he wanted to head back to Columbus. Shortly thereafter, the pilot informed the controller that he wanted to land at a third airport. On the approach to the third airport, the pilot was initially unable to see it because fog was in the area and the airport beacon was out of service; further, he was using the wrong frequency to activate the pilot-controlled runway lights. An air traffic controller informed the pilot of the correct frequency and shortly thereafter the pilot reported that he had the runway in sight. Several witnesses reported seeing and hearing the airplane as it flew over the area. One witness, who was a pilot living adjacent to the airport, stated that he heard the airplane make three passes over the airport from different directions beginning about 25 minutes before the accident. The airplane subsequently impacted trees and terrain in an upsloping wooded area that bordered the south side of the airport. A postaccident examination of the airplane and engines did not reveal any preimpact mechanical failures or malfunctions that would have precluded normal operation. It is likely that the pilot was unable to see the airport and continued to fly in the vicinity searching for the runway, and subsequently lost situational awareness and struck trees.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have diverted to another airport instead of continuing to 10G.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 28 docket documents
View NTSB final reportView NTSB docket

Docket documents28

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