Pilot Debrief

Piper PA28R near Pleasant Plain, OH — 2020-03-19

Final reportCEN20LA127
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Date
2020-03-19
Location
Pleasant Plain, OH, USA
Aircraft
Piper PA28R
Registration
N3943T
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s encounter with convective turbulence and low-level wind shear in dark night instrument meteorological conditions that resulted in spatial disorientation and the loss of airplane control.

NTSB narrative

The instrument-rated pilot was on the final segment of an instrument flight rules (IFR) flight in dark night instrument meteorological conditions (IMC). After being cleared for an RNAV approach to his intended destination, the pilot made several course deviations inbound to the initial approach fix. The pilot informed air traffic control (ATC) that he was experiencing autopilot problems, "heavy turbulence," and "heavy downdrafts." Radar and automated dependent surveillance-broadcast data showed the airplane enter a rapidly descending left turn. ATC issued a low-altitude alert to the pilot and advised him to climb to 4,000 ft immediately. The pilot did not respond, and there were no further communications from the pilot. Radar contact was lost as the airplane descended through 1,400 ft. The airplane wreckage was found severely fragmented amidst a heavily wooded area. Examinations of the airframe, flight controls, and engine did not reveal any pre-impact mechanical anomalies. The airplane was flying in an area of a stationary frontal system, which resulted in an extensive area of IFR conditions, low ceilings, low visibilities, drizzle, and rain. The weather in the accident area was conducive to low-level windshear and convective turbulence at the time of the accident. There was no record of the pilot obtaining a preflight weather briefing, and his flight plan did not list an alternate airport. The pilot’s report of heavy turbulence and downdrafts was consistent with the existing weather conditions. It is likely when the pilot encountered the turbulence and wind shear in dark night conditions, he became spatially disoriented and lost control of the airplane.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not obtain a preflight weather briefing before departure.

NTSB coding

Evidence available

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

Docket documents9

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