Pilot Debrief

Piper PA23 near Ellensburg, WA — 2019-01-17

Final reportWPR19LA066
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Date
2019-01-17
Location
Ellensburg, WA, USA
Aircraft
Piper PA23
Registration
N14372
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The instrument rated pilot’s loss of control due to spatial disorientation.

NTSB narrative

The instrument rated pilot departed into marginal visual flight rules conditions between sunset and the end of civil twilight. Shortly after takeoff, he contacted air traffic control and stated that he was in the clouds at 5,000 ft mean sea level (msl) and requested an instrument landing system approach at the destination airport. The controller issued the airplane a discrete transponder code and asked the pilot if he wanted an IFR clearance; however, the pilot did not respond, and no further communications were received from the airplane. Radar data showed that the airplane entered a descending left turn before radar contact was lost about 3,050 ft msl. Witnesses and surveillance video indicated that the airplane descended out of the clouds in a steep, nose-low attitude and impacted terrain. The extensive fragmentation of the wreckage precluded a thorough examination of the airplane's flight controls, instruments, and other systems; however, no anomalies were noted during examination of the engines. AIRMETs for instrument flight rules (IFR), mountain obscuration, turbulence, and icing conditions were all valid for the area of the accident site at the time of the accident. Both the departure and destination airports reported overcast ceilings below 2,000 ft above ground level about the time of the accident, with surface temperatures just above freezing. An atmospheric sounding indicated a high potential for light rime icing and moderate turbulence at 5,000 ft in the vicinity of the accident site, and radar imagery suggested clouds and potential light icing conditions. There was no evidence that the pilot obtained a weather briefing before departure. Although impact damage precluded a thorough examination of the airplane's flight instruments, the restricted visibility and lighting conditions present at the time were conducive to the development of spatial disorientation, and the airplane's descending turn and high-energy impact are consistent with the known effects of spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have requested IFR clearance before entering clouds.

NTSB coding

Evidence available

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

Docket documents15

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