Pilot Debrief

PIPER PA32 near Windom, MN — 2020-12-06

Final reportCEN21LA075
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Date
2020-12-06
Location
Windom, MN, USA
Airport
MWM
Aircraft
PIPER PA32
Registration
N8178Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The pilot’s spatial disorientation shortly after takeoff into night instrument meteorological conditions, which resulted in loss of airplane control and subsequent impact with terrain.

NTSB narrative

After receiving an instrument flight rules (IFR) clearance for departure from the nontower-controlled airport, the pilot departed in night instrument meteorological conditions, which included an overcast ceiling at 400 ft above ground level. Radar data indicated that, during the initial climb, the airplane made multiple turns with large heading changes, then impacted terrain about 2.5 miles from the departure end of the runway. The distribution of the wreckage indicated a high-energy impact with terrain consistent with the known effects of spatial disorientation. A postaccident examination revealed no preimpact anomalies that would have precluded normal operation of the airplane. The most recent instrument approach recorded in the pilot’s logbook was about 5 months before the accident; this was the only instrument approach recorded during the 6 months preceding the accident. Toxicology testing identified citalopram and its metabolite, N-desmethylcitalopram, in the pilot’s liver tissue, but not in muscle tissue. Citalopram is an antidepressant that has not been shown to cause intellectual or psychomotor impairment. However, it is a psychoactive drug and carries a warning about the operation of machinery until the patient is convinced that the use of the drug does not interfere with their performance. In 2013, the pilot reported using an antidepressant and had undergone a review of his diagnosis of depression and its treatment and received a special issuance certificate. During subsequent medical certification, the pilot reported he was no longer taking the antidepressant medication. The pilot’s wife reported that the pilot was in good spirits during the months before the accident and that he was looking forward to meeting with a professional football player at the destination. Based on the information available, it was unlikely that the pilot was severely fatigued or depressed on the day of the accident and it is unlikely that the effects from the pilot’s treated medical condition contributed to his decision to fly in instrument conditions or his failure to do so safely. The pilot’s lack of recent experience in IFR conditions and the night instrument conditions present at the time of the accident were conducive to the development of spatial disorientation. It is likely that the pilot experienced spatial disorientation shortly after takeoff, which resulted in a loss of airplane control and impact with terrain.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted the flight after realizing spatial disorientation risk.

NTSB coding

Evidence available

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

Docket documents13

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