Pilot Debrief

Piper PA32 near La Grande, OR — 2019-09-08

Final reportWPR19FA256
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Date
2019-09-08
Location
La Grande, OR, USA
Aircraft
Piper PA32
Registration
N6300Z
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Descent

Probable cause

The pilot’s decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

NTSB narrative

The pilot departed on a visual flight rules cross country flight. GPS data revealed that, about 30 minutes into the flight, the airplane began deviating from its previously established on-course heading to the destination. During the last 5 minutes of the flight, the airplane’s altitude and heading varied, and during the last minute of the flight, the airplane climbed about 400 ft and its ground speed slowed from 140 knots (kts) to about 53 kts. The airplane then entered a descent that continued until the end of the recorded data, about 450 ft from the accident site. The fragmentation of the airplane and distribution of the wreckage were consistent with a high-speed impact. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Weather reports near the departure airport, along the route of flight, and at the destination airport indicated visual meteorological conditions with light rain, 10 statute miles visibility, and overcast cloud ceilings beginning at 3,300 ft above ground level; however, an AIRMET for instrument flight rules conditions and mountain obscuration was valid for the area of the accident site at the time of the accident. Satellite imagery identified cloudy conditions across the accident region, including the accident site, weather radar displayed light rain in the area of the accident site, and witnesses reported rain and heavy fog in the area near the accident site about the time of the accident; therefore, it is likely that the pilot encountered instrument meteorological conditions. The extent of the pilot’s preflight weather planning and what information he may have accessed before departure could not be determined. The pilot held an instrument rating, and the airplane was equipped for instrument flight; however, neither the recency of the pilot’s instrument experience nor his level of instrument proficiency could be determined. Based on the available information, the pilot likely encountered instrument meteorological conditions in flight, which resulted in spatial disorientation, a loss of control, and subsequent impact with terrain.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot could have chosen to avoid flight in poor weather conditions.

NTSB coding

Evidence available

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

Docket documents17

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