VFR into IMC · NTSB CEN10FA065

NEW PIPER AIRCRAFT INC PA-46-500TP — Mendoza, TX

2 fatal High-time pilotIMC
DateDecember 7, 2009
LocationMendoza, TX
AircraftNEW PIPER AIRCRAFT INC PA-46-500TP
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceApproach-IFR initial approach Air traffic event
Pilot age64
Pilot total time3,513 hrs · High time
Time in typeUnknown
Fatalities2

Probable cause

***This report was modified on May 22, 2014. Please see the docket for this accident to view the original report.*** The pilot's spatial disorientation, which resulted in his loss of airplane control. Contributing to the pilot's spatial disorientation was the sequence and timing of the instructions issued by the air traffic controller. The pilot's operation of the airplane after using impairing medication may also have contributed.

NTSB findings

  • Personnel issues-Action/decision-Action-Incorrect action selection-ATC personnel - F
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-(general)-Effect on personnel
  • Personnel issues-Psychological-Perception/orientation/illusio-Spatial disorientation-Pilot - C
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
  • Personnel issues-Physical-Impairment/incapacitation-OTC medication-Pilot - F

What happened

***This report was modified on May 22, 2014. Please see the docket for this accident to view the original report.***

The pilot was established on the localizer portion of the instrument landing system approach outside the final approach fix in visual meteorological conditions above clouds. He was then given vectors away from the localizer course by an air traffic controller. The vectors were close together and included a left 90-degree turn, a descent, and a 180-degree right turn back toward the localizer course. During the right turn and descent, the airplane continued turning with increasing bank and subsequently impacted the ground. According to a pilot weather report and flight path data the pilot entered clouds as he was starting the right turn toward the localizer. The combination of descending turns while entering instrument conditions were conducive to spatial disorientation. Further, the heading changes issued by the air traffic controller were rapid, of large magnitude, and, in combination with a descent clearance, likely contributed to the pilot's disorientation.Diphenhydramine, a drug that may impair mental and/or physical abilities, was found in the pilot's toxicological test results. While the exact effect of the drug at the time of the accident could not be determined, it may have contributed to the development of spatial disorientation.

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 →