Pilot Debrief

BEECH 58 near Defiance, MO — 2022-01-09

Final reportCEN22FA096
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Date
2022-01-09
Location
Defiance, MO, USA
Aircraft
BEECH 58
Registration
N585CK
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

Probable cause

The pilot’s loss of airplane control while flying in night instrument conditions due to spatial disorientation and the flight crew’s inability to recover from an unusual airplane attitude.

NTSB narrative

The commercial pilots departed during night, instrument conditions on a positioning flight. After leveling off at 8,000 ft mean sea level with moderate turbulence conditions likely, the airplane slowly turned left from a west to southeast heading. The airplane continued turning left and entered a rapid descent until terrain impact. The airplane was destroyed when it impacted terrain. Examination revealed no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Although the pilot and copilot were both instrument current, their flying experience predominantly involved visual flight rules operations. The pilot in command (PIC) did not have the required experience to operate as PIC on Part 135 flights and was the PIC of this Part 91 positioning flight to gain experience. Immediately before the accident flight, the pilot communicated to her boyfriend that she had concerns about the flight due to the weather, along with her and the copilot’s instrument flying skills. The pilot likely became spatially disoriented during night instrument conditions that included moderate turbulence. Because of the airplane’s single set of flight instruments and “throwover yoke” control column, which required pulling a T-handle latch on the back of the control arm to change the yoke from one side of the cockpit to the other, the copilot likely wasn’t able to assume control of the airplane. As a result, the copilot wasn’t able to recover control of the airplane from its unusual attitude before impact with terrain.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot's concerns about weather and co-pilot's IFR skills should have led to a flight cancellation.

NTSB coding

Evidence available

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

Docket documents31

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