VFR into IMC · NTSB ERA19FA116
Piper PA28 — Fellsmere, FL
| Date | March 5, 2019 |
| Location | Fellsmere, FL |
| Aircraft | Piper PA28 |
| Purpose of flight | Instructional |
| Conditions | Day · Instrument Meteorological Cond |
| Phase / occurrence | Maneuvering Loss of visual reference |
| Pilot age | 24 |
| Pilot total time | 96 hrs · Student / very low time |
| Time in type | 96 hrs |
| Fatalities | 1 |
Probable cause
NTSB findings
- Personnel issues-Psychological-Personality/attitude-Motivation/respond to pressure-Student/instructed pilot
- Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Student/instructed pilot
- Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot
- Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Clouds-Effect on operation
- Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Student/instructed pilot
- Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Flt operations/dispatcher
- Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Clouds-Contributed to outcome
What happened
The student pilot was scheduled to complete a solo cross-country flight the day before the accident, and her flight instructor had provided the required endorsements for that flight; however, the flight was subsequently cancelled due to weather and was rescheduled for the following morning. When the pilot arrived on the airport the morning of the accident, she was released for the flight by the operations duty officer (DO), who was responsible for confirming that students had the proper endorsements for solo flight, even though her endorsements for the previous day's flight would have been no longer valid. The DO was also responsible for ensuring that weather conditions along a student's planned route of flight met the student’s prescribed limitations, and found that although the departure airport was reporting visual flight rules (VFR) conditions, the destination airports were reporting instrument flight rules (IFR) conditions. He stated that airports in the area tended to be IFR in the early-morning hours due to fog, then quickly improve to VFR after sunrise. He signed the pilot's flight risk assessment so that she could conduct her preflight inspection, but stressed to her that she needed to check the weather again before takeoff, and if conditions were still IFR, then the flight needed to be cancelled.
Between the time the DO released the pilot for the flight and the time she subsequently departed just after sunrise, weather conditions at the departure airport deteriorated from VFR to low IFR, including a cloud ceiling around 400 to 500 ft above ground level. The airplane likely entered instrument meteorological conditions (IMC) immediately after takeoff. A review of radar data revealed that the pilot flew west-northwest of the airport and made a series of climbing and descending turns before the airplane impacted terrain around 6 minutes after takeoff about 7.3 miles northwest of the airport. Postaccident examination of the airplane and the engine revealed no discrepancies that would have precluded normal operation. The airplane's radar track after takeoff did not suggest an immediate loss of control upon entering IMC; however, the climbing and descending turns near the end of the data are consistent with the known effects of spatial disorientation.
On the morning of the accident, four other students departed on solo flights. Three of the pilots departed just before the accident pilot. Two of these pilots stated that they checked the weather before their flights and conditions were VFR; however, it was still dark out and they could not see the clouds. All three pilots entered the clouds immediately after takeoff but were able to climb to a safer altitude and divert to another airport.
Students were required to obtain a weather briefing and file a flight plan as part of the preflight planning process. It could not be determined what weather information, if any, the pilot obtained the morning of the accident, and she did not file a flight plan for the flight.
The pilot was behind in her flight training schedule and had expressed concerns about being removed from the flight program. It is possible that she felt self-imposed pressure to complete the flight to remain in the program. Additionally, she may have assumed that she was cleared to conduct the flight upon being released by the DO, though previous communications with her instructor indicated that she was aware of the endorsement requirements.
Although the pilot should have known that her decision to depart on the flight without a flight plan and without an instructor endorsement met neither Federal Aviation Administration nor the school's published requirements, the DO should have recognized that the endorsements contained in her logbooks were for the previous day and not released the pilot for the flight without consulting the instructor.