Pilot Debrief

CESSNA 172 near Holland, MI — 2010-01-17

Final reportCEN10FA101
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Date
2010-01-17
Location
Holland, MI, USA
Airport
BIV
Aircraft
CESSNA 172
Registration
N8405E
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot's decision to take off in known instrument meteorological conditions without instrument currency or recent instrument experience, which led to spatial disorientation resulting in an inadvertent spin. Contributing to the accident was the pilot's lack of adequate rest prior to the flight.

Contributing factors

Contributing to the accident was the pilot's lack of adequate rest prior to the flight.

NTSB narrative

The pilot rented the airplane for most of the day to give rides to friends and had fueled it to capacity. He told a lineman that he planned to takeoff and, if necessary, would file an instrument-flight-rules flight plan and return to the airport. Witnesses saw the airplane take off and disappear into the overcast. Shortly thereafter, they heard an airplane make four passes over the airport. The sound became progressively louder but they could not see the airplane. On the fifth pass, the airplane was seen approximately 50 feet above the ground and it barely cleared a stand of trees. Recorded ATC transscripts revealed that the pilot contacted approach control and told the controller that he was caught in heavy fog and wanted vectors back to the airport. The airplane crashed shortly thereafter in a snow-covered field. An examination of the airplane showed impact damage consistent with having descended to the ground in an uncontrolled spin. An examination of the airplane's systems showed no anomalies. Although the pilot was instrument rated, he had not flown with instruments since receiving his rating 2 years ago. He had logged 1.8 hours in actual instrument meteorological conditions, 50.8 in simulated IMC, and 6.7 hours in a flight simulator. Ceiling and visibility at the time of the accident was below landing minimums and was recorded as 200 feet overcast and 3/4-mile in mist. The RNAV (GPS) RWY 8 approach chart was found on the pilot’s lap. Although the airplane was IFR certified, it was not RNAV or GPS equipped. Toxicology results indicated the presence of propoxyphene, a prescription narcotic medication. The concentration present was consistent with use at a time outside of 24 hours prior to the accident and would not have caused impairment. Cellular telephone records showed that the pilot had engaged in calls and text message conversations with the passenger the night before the accident. Starting at 6:00 P.M. the night before the accident, the pilot received or made calls or text messages every hour, through midnight, until 3:12 A.M. In one conversation, the passenger told the pilot that he would be in good flying shape for the next day, and the pilot replied that he needed to get 4 hours of rest before he flew. The final outgoing call to the passenger was placed at 7:59 A.M. on the day of the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have filed an IFR flight plan before takeoff in IMC conditions.

NTSB coding

Evidence available

  • ATC audio
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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