Pilot Debrief

Piper PA 23 near Beaver Island, MI — 2018-12-31

Final reportCEN19LA051
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Date
2018-12-31
Location
Beaver Island, MI, USA
Airport
SJX
Aircraft
Piper PA 23
Registration
N2146P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to maintain a positive rate of climb after takeoff which resulted in an impact with trees and terrain. Contributing to the accident was the pilot's inability to see a visible horizon due to the dark night lighting conditions and limited ground lights in the vicinity of the airport.

Contributing factors

Contributing to the accident was the pilot's inability to see a visible horizon due to the dark night lighting conditions and limited ground lights in the vicinity of the airport.

NTSB narrative

The instrument, multi-engine rated private pilot was departing into dark night visual meteorological conditions at the time of the accident. The airport was located in an area with minimal ground lighting with no discernable horizon visible after takeoff. Witnesses heard the airplane take off toward the west and subsequently turn to the north. They described the sound of the engines as "very loud." One witness added that the engines seemed to be operating normally. Another witness noted that the sound changed to a lower pitch similar to when a pilot transitions to climb power after takeoff. The sound ended abruptly when the airplane impacted a wooded area about 1/3 mile from the airport on a north-northeasterly heading. Examination of the airframe and engines did not reveal any anomalies consistent with a preimpact failure or malfunction. It is possible that the pilot experienced some level spatial disorientation which led to a loss of control and impact with the trees and terrain. However, it is also possible that the pilot became distracted configuring the airplane for climb during the initial turn after takeoff which led to the airplane entering an inadvertent descent and controlled flight into terrain. This scenario is consistent with the witness statement noting a transition to climb power immediately after takeoff. In addition, the earwitness reports did not describe a typical loss-of-control event. The lack of a visible horizon due to the dark night lighting conditions and lack of ground lights in the vicinity of the airport would have contributed to either scenario.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted takeoff due to dark night conditions.

NTSB coding

Evidence available

  • Photos
  • 6 docket documents
View NTSB final reportView NTSB docket

Docket documents6

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