Pilot Debrief

Piper PA32 near Raleigh, NC — 2019-10-20

Final reportERA20FA014
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Date
2019-10-20
Location
Raleigh, NC, USA
Airport
RDU
Aircraft
Piper PA32
Registration
N534Z
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain a safe glidepath during final approach to the runway, which resulted in a collision with trees and terrain. Contributing was the pilot’s lack of recent instrument flight experience.

Contributing factors

Contributing was the pilot’s lack of recent instrument flight experience.

NTSB narrative

During a night, instrument flight rules flight in instrument meteorological conditions, the pilot checked in with approach control and was told to expect an instrument approach to a different runway than the one he had planned for. According to air traffic control communications, the pilot subsequently reported some issues interacting with his airplane’s GPS and autopilot. He had difficulty reading back instructions, missed radio calls, and did not maintain assigned altitudes and headings. The air traffic controller eventually provided him with radar vectors onto the final approach course, and when the airplane was about 9 miles away from the airport the pilot reported that he had broken out of the clouds and could see lights below. The controller cleared the pilot for a visual approach, but the pilot had difficulty visually acquiring the runway lights, and the controller increased their intensity. The controller subsequently issued two low altitude alerts to the pilot while on final approach. The pilot’s last radio transmission indicated he had the runway in sight, but radio and radar contact were lost when the airplane was on short final approach. The wreckage was found the next morning in a densely wooded and sparsely lit state park about just over a mile from the runway threshold with the wreckage facing the runway; the airplane was destroyed. Damage to the treetops indicated a controlled, gradual descent into the trees, indicative of the pilot not maintaining adequate clearance from the ground during final approach. Postaccident examination of the wreckage did not reveal evidence of a mechanical malfunction or anomaly with the airplane that would have precluded normal operation. A review of the pilot’s logbook revealed a lack of recent night and instrument experience; he had not logged the required night and instrument procedures to act as pilot-in-command for a flight carrying passengers at night and in IMC. The pilot’s issues with using his airplane’s GPS and autopilot during the accident flight were likely due to a lack of recent use in actual or simulated instrument conditions.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have aborted the approach when experiencing GPS and autopilot issues.

NTSB coding

Evidence available

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

Docket documents24

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