Pilot Debrief

Cessna A185 near Nome, AK — 2019-04-15

Final reportANC19TA017
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Date
2019-04-15
Location
Nome, AK, USA
Aircraft
Cessna A185
Registration
N5163E
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Climb

Probable cause

The pilot's decision to continue a visual flight rules flight into an area of mountainous terrain and instrument meteorological conditions, which resulted in spatial disorientation and controlled flight into terrain. Contributing to the accident was the pilot’s lack of instrument proficiency.

NTSB narrative

The pilot was conducting a visual flight rules (VFR) cross-country flight in marginal VFR conditions. While en route to his destination, he decided to maneuver off the intended course to surveil a mountainous area in the national park. While maneuvering in that area, he observed deteriorating weather. While he was looking down at the GPS display to confirm that he was navigating properly, the airplane entered instrument meteorological conditions (IMC). The pilot stated that he looked up and “probably” experienced spatial disorientation, so he commenced an instrument scan, confirmed that the wings were level, and started a right 180° turn to return to visual conditions. A review of GPS data indicated that the airplane was established on a relatively steady course about 600 ft above ground level, heading directly into higher terrain, then turned right for 50° and descended at a rate of about 520 ft per minute into terrain. The wreckage came to rest on the slope of a snow-covered ridge and was separated into sections along a 120-ft path, with signatures indicative of high-speed impact in a slight left-wing-low attitude. The fuselage, wings, and empennage sustained substantial damage. The weather forecast for the area indicated marginal VFR conditions, which was within the agency’s weather minimums. The pilot reported that while maneuvering to the ridgeline area, he noted “low” and “thick” clouds but felt comfortable because he was flying along the ridgeline that he recognized. A review of the pilot’s training records indicated that he was certified by his agency’s department for VFR-only flights and had no recent instrument flight experience. The agency had no instrument training or currency for reciprocating airplane pilots who were assigned to VFR flights. The pilot stated that he did receive simulated instrument training and was taught to turn back 180° for unintentional flight into IMC, although instrument training and inadvertent IMC were not documented on the annual check flight. Despite the forecast indicating marginal VFR conditions for the area, while en route, the pilot chose to divert from his planned route into an area of low cloud ceilings and rising terrain. The pilot inadvertently flew into the clouds, and by his own admission and the GPS data indicating an erratic flight profile, he likely experienced spatial disorientation, which resulted in the airplane’s descent into and impact with terrain. Contributing to the accident was the pilot’s lack of instrument proficiency which limited the skill required to perform the recovery technique while referencing only the instruments.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have avoided IMC by not flying over the ridgeline.

NTSB coding

Evidence available

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  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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