VFR into IMC · NTSB CEN17FA361

CESSNA TR182 — Thief River Falls, MN

3 fatal IMC
DateSeptember 23, 2017
LocationThief River Falls, MN
AircraftCESSNA TR182
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceInitial climb Other weather encounter
Pilot age69
Pilot total time814 hrs · Building experience
Time in typeUnknown
Fatalities3

Probable cause

The noninstrument-rated pilot's decision to depart into instrument meteorological conditions, and his subsequent loss of control due to spatial disorientation.

NTSB findings

  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
  • Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Pilot - C
  • Personnel issues-Experience/knowledge-Experience/qualifications-Total instrument experience-Pilot - C
  • Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
  • Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot - C
  • Personnel issues-Task performance-Planning/preparation-Weather planning-Pilot
  • Personnel issues-Task performance-Planning/preparation-Flight planning/navigation-Pilot
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Decision related to condition
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Contributed to outcome

What happened

The noninstrument-rated private pilot and 2 passengers departed in instrument meteorological conditions (IMC) with an overcast cloud layer at 400 ft above ground level (agl). Data obtained from an onboard GPS unit showed the airplane depart toward the destination airport and climb and descend several times. About 2 minutes after takeoff, the airplane descended to 250 ft above ground level (agl), then turned and quickly climbed to 1,400 ft agl. The final GPS points showed the airplane in a descending right turn. A witness reported hearing the airplane overhead and stated that the engine was "screaming" before impact. The airplane impacted a field about 4 minutes after takeoff resulting in a debris path about 230 yards long, consistent with a relatively high forward airspeed at the time of impact.

A postaccident examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operation. The primary vacuum pump was not found in the wreckage; however, an examination of the standby vacuum pump revealed that the rotor was fractured by impact, but the vanes were intact. The heading indicator and turn coordinator gyros exhibited rotational scoring consistent with rotation at the time of impact. The damage to the propeller blades was consistent with the engine producing power at impact.

The autopsy report revealed no significant coronary artery disease; however, microscopic examination revealed focal areas of fine fibrosis suggestive of prior ischemic episodes. This finding was not significant enough to suggest an incapacitating event. No other significant natural disease was present that could pose a hazard to flight safety.

Review of the pilot's logbook and his statements to individuals who spoke with him before the accident suggested that he had a history of flying in and around IMC. Given the weather conditions at the time of departure and observations of the pilot checking the weather conditions before the flight, the pilot was aware that he would be required to fly in or under IMC during the flight and chose to do so despite not holding an instrument rating. Based on the reported weather conditions and GPS data, it is likely that, while maneuvering on course after takeoff, the pilot entered IMC; he likely subsequently experienced spatial disorientation, which resulted in a loss of control and descent into terrain.

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 →