Pilot Debrief

CESSNA 210L near Midway, GA — 2020-12-21

Final reportERA21LA085
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Date
2020-12-21
Location
Midway, GA, USA
Airport
1GA0
Aircraft
CESSNA 210L
Registration
N2246S
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot's intentional visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing to the accident was the pressure to complete the flight to work in an emergency room.

Contributing factors

Contributing to the accident was the pressure to complete the flight to work in an emergency room.

NTSB narrative

The pilot departed on a visual flight rules (VFR) flight into night instrument meteorological conditions (IMC) to an airport that was not equipped with any instrument approach procedures. Automatic dependent surveillance-broadcast (ADS-B) data showed that, in the final minutes of the accident flight, the pilot turned toward the airport, descended below the reported overcast cloud layer, and flew at altitudes between 100 to 300 ft mean sea level at groundspeeds of 100 to 115 knots. While descending, the airplane impacted 80-100 ft tall pine trees about 5 nautical miles from the destination airport. The pilot’s son reported that the pilot used a GPS and an app on his personal electronic device (PED) in which he had “built a flight path” into the destination airport. It was customary for the pilot to use this app and descend to pattern altitude or below cloud level, then continue to the airport by reference to the ground and the app. Postaccident examination of the airplane revealed no preimpact mechanical anomalies that would have precluded normal operation. The distribution of the wreckage indicated that the airplane impacted terrain in a near-level attitude with high forward velocity. There was no indication that the pilot obtained a weather briefing before departure; however, he did discuss the poor weather conditions at the destination airport with his son via text message and stated that he would check the weather before he departed. Although the pilot was instrument rated, he chose to fly VFR in low instrument flight rules (IFR) conditions over a dark swamp into an airport with no instrument approach procedures rather than file an IFR flight plan to an airport with an instrument approach. The pilot was expected at work at a nearby hospital emergency room the next morning, and it is likely that his desire to be at work contributed to his decision. Although conditions were conducive to the development of spatial disorientation, the airplane’s low impact angle was more consistent with controlled flight into terrain rather than a loss of control due to spatial disorientation. The extremely low altitude and moderate speeds at which the pilot was operating under the impoverished visual conditions at the time of the accident, and his reported use of a PED for navigation and hazard avoidance, would have made precise altitude control challenging given the division of attention and workload required. Given the impoverished visual conditions, low altitude, and the distance from the airport, the pilot likely would have had difficulty identifying the airport environment. He may have been attempting to locate the airport and lost awareness of the airplane’s altitude as it continued to descend until it impacted trees.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should have aborted the flight due to low IFR conditions.

NTSB coding

Evidence available

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

Docket documents15

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