NTSB Factual Report

HISTORY OF FLIGHT

On November 12, 2017, at 1410 central standard time, a Piper PA-32-260, N3371W, was destroyed during an in-flight breakup and collision with terrain while maneuvering near Fountain Run, Kentucky. The private pilot and three passengers were fatally injured. The airplane was owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the personal flight, which departed Everett-Stewart Regional Airport (UCY), Union City, Tennessee, at 1303, and was destined for Lake Cumberland Regional Airport (SME), Somerset, Kentucky.

The pilot and passengers were returning from a hunting trip, and the spouse of one passenger had planned a surprise party for the afternoon of their return. Radar and voice information from the Federal Aviation Administration (FAA) revealed that the pilot contacted the Memphis Air Route Traffic Control Center (ARTCC) and was receiving visual flight rules (VFR) flight following services. The airplane was in cruise flight travelling eastbound about 5,500 ft mean seal level (msl) for about 30 minutes before the radar track depicted a slight turn to a northeasterly heading.

At 1357:44, the pilot informed the controller that he was going to climb the airplane in order to maintain VFR flight. Beginning at 1358, the radar track indicated a climb to about 6,600 ft followed by a series of left and right turns while maintaining a generally northeast track.

About 1404, the radar track depicted a nearly 180° left turn, followed immediately by a 180° right turn until the airplane resumed an approximate northeast heading. The airplane's altitude varied between 6,800 and 7,200 ft during the turns. At 1406:20, the pilot stated, "we hit some uh IMC. Is there any vectoring to an altitude here with some uh more visibility?" The controller advised the pilot to standby while he communicated with other aircraft and Nashville Approach Control. He then directed the pilot to "maintain VFR," which the pilot acknowledged.

At 1407:51, the controller shared a pilot report of cloud tops "around eight thousand or so". At that time, the airplane's altitude was about 7,325 ft. The pilot replied that he would climb the airplane to 8,000 ft. Over the next 30 seconds, the radar track depicted shallow left and right turns with altitudes that varied between 7,000 and 7,300 ft.

Beginning at 1408:41, the airplane's track depicted a shallow right turn at 7,299 ft and 144 knots followed by a descending right turn that increased in rates of bank and descent.

At 1408:58, at an altitude of 5,675 ft, the pilot transmitted, "We're going down."

The final radar target was located over the accident site at 1409:05, at an altitude of 2,838 ft and an airspeed of 125 knots.

One witness near the accident site described seeing the airplane "in a nosedive" before he lost sight of it behind trees. Another witness was deer hunting from a tree stand when his attention was drawn to the sound of the airplane. He watched the airplane appear out of the clouds and stated that the sound of the engine was "cutting in and out." He added that when the airplane came into his view, "it went into a spin and there was a loud pop and then [the airplane] just blew apart." He stated that the airplane came out of the clouds about 300 to 400 ft above the ground, and that the weather at the time was "solid fog."

PERSONNEL INFORMATION

The pilot held a private pilot certificate with a rating for airplane single-engine land. He did not possess an instrument rating. His most recent FAA third-class medical certificate was issued on October 14, 2014. A review of the pilot's logbook revealed that he had logged 251 total hours of flight experience, of which 246 hours were in the accident airplane make and model.

The pilot had logged 5.9 total hours of simulated (hood) instrument flight experience, of which 2 hours were in 2014, 2.1 hours in 2015, and 1.8 hours on July 8, 2017.

AIRCRAFT INFORMATION

According to FAA and maintenance records, the airplane was manufactured in 1965 and had accrued 2,776.97 total aircraft hours. The most recent annual inspection was completed on October 10, 2017, at 2,771.94 total aircraft hours.

METEOROLOGICAL INFORMATION

The 1415 weather observation at Glasgow Municipal Airport (GLW) Glasgow, Kentucky, 14 miles north of the accident site, included a broken ceiling at 500 ft above ground level (agl), an overcast ceiling at 1,300 ft agl, and 10 miles visibility. The wind was from 210° at 4 knots. The temperature and dew point were 11°C, and the altimeter setting was 30.25 inches of mercury.

The 1353 weather observation at Bowling Green-Warren County Regional Airport (BWG), Bowling Green, Kentucky, included a broken ceiling at 1,200 ft agl, an overcast ceiling at 1,300 ft agl, and 9 miles visibility. The wind was from 230° at 7 knots. The temperature was 12°C, the dew point was 11°C, and the altimeter setting was 30.25 inches of mercury.

The 1335 weather observation at UCY, included an overcast ceiling at 3,500 ft agl, and 10 miles visibility. The wind was from 240° at 5 knots. The temperature was 15°C, the dew point was 10°C, and the altimeter setting was 30.26 inches of mercury.

Geostationary Operational Environmental Satellite (GOES)-16 "visible" and infrared (imagery from 1407 revealed cloudy conditions over the accident site region. Infrared cloud-top temperatures in the area immediately surrounding the accident location varied between about 0°C and -7°C, which corresponded to cloud top heights about 8,500 ft and 15,000 ft, respectively.

At 1238, an AIRMET SIERRA for IFR conditions was issued for a region that bordered the accident location and advised of ceilings below 1,000 ft, visibility below 3 statute miles, and precipitation and mist.

The ceiling at the destination airport at the estimated time of arrival was 6,000 ft overcast.

The pilot did not file a flight plan, and there was no record of him having obtained a weather briefing from Leidos Flight Services, Direct User Access Terminal Service, or Foreflight before departure.

In an interview with police, the pilot's spouse stated that her husband "always" checked weather conditions before flight, and that the Foreflight application was "constantly" streaming to his iPad while flying.

WRECKAGE INFORMATION

The wreckage was examined at the accident site. There was an odor of fuel at the scene, and the majority of the airplane was accounted for except the left aileron balance weight, left tip tank, stabilator trim tab, and about 6 ft of the right wing and right aileron. Parts associated with the rudder and right wing were located about 0.75 mile northeast of the main wreckage. The wreckage displayed no evidence of an in-flight fire. The entire wreckage path was oriented about 240° magnetic, and the main wreckage path was about 100 ft long.

The initial impact point was in treetops about 60 ft high, and the main wreckage came to rest wedged between tree trunks. The cockpit, cabin area, and empennage were destroyed by impact. Pieces of angularly cut wood were entangled with the wreckage.

The airplane was fragmented and scattered along the length of the wreckage path. Control continuity to the wings, rudder, and elevator was confirmed through the control cables and bellcranks to the cockpit area. Separations in the control cables displayed signatures consistent with cuts by recovery personnel or overload separation.

The engine was separated from the airframe and marked the end of the debris path. The propeller was separated from the engine and came to rest 25 ft northeast of the engine. The propeller blades displayed similar "S" bending, trailing-edge gouges, and chordwise scratching.

The engine crankshaft was rotated by hand through the vacuum pump drive pad. Continuity was confirmed through the accessory section to the valve train and crankshaft. Compression was confirmed on all cylinders using the thumb method. The magnetos were intact in their mounts. Once removed, they produced spark at all terminal leads when tested.

The vacuum pump rotated smoothly, and when disassembled, the rotor and vanes were intact.

The carburetor and fuel pump were destroyed by impact.

Parts associated with the left aileron balance weight, left tip tank, the stabilator trim tab, and about 6 ft of the right wing and right aileron were located by hunters months after the accident and were recovered on October 30, 2018.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of The Chief Medical Examiner, Louisville, Kentucky, performed the autopsy on the pilot. The cause of death was listed as "blunt force injuries."

The laboratory at FAA Forensic Sciences, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The results were negative for the presence of drugs or alcohol.

ADDITIONAL INFORMATION

FAA Advisory Circular AC 60-22, Aeronautical Decision Making, stated, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'" One of the common behavioral traps identified was "Get-there-itis." The text stated, "Common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action."

According to the Pilot Handbook of Aeronautical Knowledge, FAA-H-8083-25B:

Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which combinations of normal motions and forces create convincing illusions that are difficult to overcome.

According to the Instrument Procedures Handbook, FAA-H-8083 (AB):

The vestibular sense (motion sensing by the inner ear) can confuse the pilot. Because of inertia, sensory areas of the inner ear cannot detect slight changes in aircraft attitude nor can they accurately sense attitude changes that occur at a uniform rate over time. Conversely, false sensations often push the pilot to believe that the attitude of the aircraft has changed when in fact it has not, resulting in spatial disorientation.

FAA Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness, stated,

According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC… The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough… VFR pilots in reduced visual conditions may develop spatial disorientation and lose control, possibly going into a graveyard spiral…

According to FAA publication AM-400-03/1, Medical Facts for Pilots,

The graveyard spiral is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings, this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground.

NTSB Safety Alert SA-017, In-Cockpit NEXRAD Mosaic Imagery, advised pilots that weather radar "mosaic" imagery created from Next Generation Radar (NEXRAD) data is subject to latency, and that the age associated with the image on the cockpit display is always older than indicated, sometimes by as much as 15 to 20 minutes.

NTSB Probable Cause

The noninstrument-rated pilot's intentional visual flight rules flight into instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing to the accident was the pilot's self-induced pressure to complete the flight.