Pilot Debrief

PIPER PA-24-180 near Brewster, MA — 2012-01-15

Final reportERA12LA145
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Date
2012-01-15
Location
Brewster, MA, USA
Aircraft
PIPER PA-24-180
Registration
N7648P
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The flight crew’s loss of airplane control.

NTSB narrative

The pilot was practicing instrument approaches with a flight instructor. While in a holding pattern, an air traffic controller contacted the pilot after observing his erratic altitude control. The pilot responded, “there’s smoke in the cabin.” About 24 seconds later, the pilot stated that “we’ve cleared the smoke” and that they would continue the flight. This was the last transmission received from the pilot, and it was cut off, and radar contact was then lost. The airplane subsequently crashed into Cape Cod Bay. General fragmentation of the wreckage indicated a high-energy impact with the water. Examination of the wreckage did not reveal any evidence of an in-flight fire or other anomaly or malfunction that would have precluded normal operation. Examinations of several electrical components, including avionics, wires, and circuit breakers revealed no evidence of overheating or fire. A study of weather data revealed that, at the time of the accident, the airplane was in instrument meteorological conditions with snow. The National Weather Service Current Icing Product indicated a greater than 50 percent chance of icing at 2,000 feet, which was near the altitude of the airplane before the accident. However, the pilot did not mention icing conditions to the controller. The pilot tested positive for several medications during postaccident specimen analysis, including diazepam, nordiazepam, tramadol, and warfarin. Since the blood samples obtained were collected from a body cavity, the assessment of pilot impairment was not reliable due to concerns with postmortem redistribution of drugs. The pilot had not reported these medications on his latest third-class medical certificate application. The pilot and flight instructor both tested negative for carbon monoxide and cyanide.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have aborted the flight upon realizing smoke in the cabin.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 35 docket documents
View NTSB final reportView NTSB docket

Docket documents35