VFR into IMC · NTSB ANC19FA033

Piper PA 24-180 — Ketchikan, AK

1 fatal High-time pilotLow altitude
DateJuly 11, 2019
LocationKetchikan, AK
AircraftPiper PA 24-180
Purpose of flightPersonal
ConditionsDay · Unk
Phase / occurrenceManeuvering VFR encounter with IMC
Pilot age68
Pilot total time12,580 hrs · High time
Time in type400 hrs
Fatalities1

Probable cause

The pilot’s decision to continue visual flight rules into instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

NTSB findings

  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Decision related to condition
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Effect on operation
  • Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
  • Aircraft-Aircraft oper/perf/capability-(general)-(general)-Not attained/maintained

What happened

The pilot was conducting a visual flight rules cross-country flight. He filed a flight plan before departure but declined a formal weather briefing. Although the weather information he gathered about the flight could not be determined, he indicated to his spouse before departure that the weather at his intended fuel stop was “not good,” but that he had sufficient fuel onboard to continue to the destination airport without refueling. GPS data showed that the airplane proceeded directly toward the airport where he intended to refuel, and while approaching the airport for landing the pilot reported via radio that he was “hung up” and would maneuver for a left downwind. There were no further radio communications from the pilot. GPS data revealed that, about the time the pilot made the final radio call, the airplane was about 500 ft above ground level; it then banked left and rapidly descended into rising terrain. The wreckage was located on a hillside about 4 nautical miles southeast of the airport.

The distribution of the wreckage was consistent with a high speed impact. Examination of the airframe, engine, and associated systems revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot held an instrument rating, his instrument currency could not be determined, and his wife, who flew with him often, stated that he rarely filed or flew instrument flight rules flights.

Weather camera images revealed the presence of low cloud layers and limited visibility in the area of the accident site around the time of the accident. Despite his apparent awareness of forecast marginal visual flight rules conditions and temporary instrument meteorological conditions, the pilot chose to depart and continue into an area of low cloud ceilings and rising terrain. It is likely that, while maneuvering at low altitude toward the airport, the pilot's in-flight visibility was limited by the cloud conditions, which resulted in spatial disorientation and a loss of control.

The pilot had a history of high blood pressure and diabetes, and toxicology revealed medications that were consistent with appropriate medical treatment and were not considered impairing. The pilot’s downloaded glucometer readings during the flight had no indications of an adverse diabetic event; therefore, the pilot’s diabetes and use of diabetes medication did not contribute to the accident. The coronary artery disease observed during the autopsy was below that generally considered significant. Although the pilot’s medical conditions placed him at increased risk for a sudden impairing or incapacitating cardiovascular event, there is insufficient evidence to determine whether such an event occurred.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →