Pilot Debrief

Piper PA28R near Auburn Township, OH — 2019-05-28

Final reportERA19FA181
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Date
2019-05-28
Location
Auburn Township, OH, USA
Aircraft
Piper PA28R
Registration
N3933T
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot's loss of control due to spatial disorientation in dark night conditions. Contributing to the accident was his inadequate weather planning, lack of experience flying at night and the deteriorating weather conditions.

Contributing factors

Contributing to the accident was his inadequate weather planning, lack of experience flying at night and the deteriorating weather conditions.

NTSB narrative

The pilot departed on a visual flight rules cross-country flight in dark night conditions. Radar data indicated that, about 9 miles from the destination airport, the airplane turned left from its previously established heading and shortly thereafter, it entered a steep, descending right turn that continued until radar contact was lost. The airplane impacted heavily-wooded terrain about 8 miles from the airport. Examination of the wreckage revealed no preimpact mechanical deficiencies that would have precluded normal operation of the airplane or engine. AIRMETs for instrument flight rules conditions and turbulence were valid at the time of the accident for the area of the accident site. Although the weather observation nearest the accident site around the time of the accident indicated visual flight rules conditions with an overcast cloud ceiling about 5,000 ft above ground level, a witness near the accident site reported an "extremely low cloud deck" at the time of the accident. Further, the weather observations at an airport south of the pilot's destination airport indicated weather conditions were deteriorating. While the pilot did text his girlfriend an image of convective weather activity, there was no record that the pilot obtained a weather briefing for the flight or requested any weather information from flight service or commercial sources. The pilot had received his private pilot certificate about 2 months before the accident and did not have an instrument rating. Autopsy of the pilot revealed evidence of severe atherosclerotic coronary artery disease and an old myocardial infarction; however, the circumstances of the accident are more consistent with a loss of control due to spatial disorientation than with pilot incapacitation. The pilot's lack of an instrument rating and the dark night conditions both would have been conducive to the development of spatial disorientation, and the airplane's descending turn and high-energy impact are both consistent with the known effects of spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have chosen to avoid flight in adverse weather conditions.

NTSB coding

Evidence available

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

Docket documents11

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