Accident Details
Probable Cause and Findings
The non-instrument-rated pilot’s improper inflight decision making and his flight into instrument meteorological conditions, which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident were the pilot’s inadequate preflight weather planning.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn November 14, 2023, about 1409 eastern standard time, a Piper PA-28-180, N7806W, was destroyed when it was involved in an accident near Micanopy, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to air traffic control (ATC) communication records, before departure, the ground controller at Kissimmee Gateway Airport (ISM), Orlando, Florida, reported that the weather conditions were “IFR” and indicated that the broken cloud ceiling was at 800 ft agl. About 1 minute later, the controller stated there were updated weather conditions, which were few clouds at 800 ft agl, then issued a taxi clearance to the pilot. According to ADS-B flight track data, the airplane departed ISM about 1245.
ADS-B data revealed that after departure, the airplane flew on a northerly track until the airplane was about 20 nm south of the pilot’s destination. The airplane initially climbed to an altitude of 3,500 ft mean sea level (msl) and flew at altitudes between 2,900 and 3,500 ft msl until about 1314, when it descended to 2,000 ft msl. About 1322, the airplane descended further to 800 ft msl. About 1331, a brief turn toward the east was observed, followed by a left turn back to a northerly track. Subsequently, the airplane performed several erratic 360° turns and numerous climbs and descents to a maximum altitude of 6,900 ft msl and a minimum altitude of 500 ft msl, between 1335 and the last data point at 1409. The data ended after the airplane made two tight, left 360° turns while in a steep descent in excess of 5,000 ft per minute. The main wreckage was located about 650 ft northeast of the final ADS-B data point.
Review of air traffic control communications revealed that during the erratic maneuvering, the pilot called "mayday" and stated he "was lost in weather." During this period, ATC attempted to provide the pilot with radar vectors toward an area with better weather and also suggested control inputs when the ADS-B data showed he was flying off course or beginning a descent or climb. During the conversation, the pilot reported multiple times that multiple instruments had failed, specifically the vacuum-driven attitude indicator and the electrically-driven turn and bank indicator. The pilot also reported that he "mistakenly flew into weather,” "it's completely white,” and he could not see anything outside. At one point, the pilot reported to ATC that he thought he was “upside down.” PERSONNEL INFORMATIONAccording to FAA airman records, the pilot held a private pilot certificate with a rating for airplane single-engine land. He did not hold an instrument rating. The pilot’s paper logbook contained records of flights between September 1, 2020, and February 25, 2023. None of the pilot’s logged flight time was in the accident airplane. He had logged a total of 2.2 simulated instrument hours and 1 hour in actual instrument conditions. The most recent logged instrument hours were on January 30, 2021. AIRCRAFT INFORMATIONAccording to FAA records, the pilot purchased the airplane on October 31, 2023. A review of the airplane’s maintenance records revealed that the most recent annual inspection was completed on October 28, 2022, at an airframe total time of 3,554.1 hours. A mechanic performed a pre-buy inspection on May 11, 2023, and found several discrepancies, including that the attitude indicator had failed. There were no logbook entries indicating the attitude indicator had been repaired or replaced before the accident. METEOROLOGICAL INFORMATIONAccording to an NTSB weather study, the closest weather reporting station to the accident site was Gainesville Regional Airport (GNV), Gainesville, Florida. A special weather observation at 1412 for GNV reported visibility 2 miles in moderate rain and mist, few clouds at 1,600 ft agl, and ceiling broken at 4,500 ft agl and overcast at 9,000 ft agl.
The next closest airport to the accident site with weather reporting capability was Williston Municipal Airport (X60), Williston, Florida, located about 16 miles southwest of the accident site at an elevation of 76 ft. The weather observation for X60 at 1355 reported visibility of 10 miles or more and an overcast ceiling at 700 ft agl. The weather reports from GNV and X60 did not meet the basic minima for VFR flight, which include a cloud ceiling of 1,000 ft agl and 3 miles visibility.
Between 1030 and 1500, 32 PIREPs that reported sky cover were submitted within 100 miles of GNV and below 12,500 ft. Of these, 19 reported cloud bases below 3,000 ft, suggesting MVFR conditions, and 4 reported IFR to low IFR (LIFR) conditions. One of the reports immediately before the accident, over the Ocala VOR (OCF), about 24 miles south of the accident site, reported overcast clouds at 800 ft. A few aircraft reported cloud tops near 5,000 ft, while one aircraft about 40 miles west of the accident site reported being in instrument meteorological conditions at 11,000 ft at the time of the accident.
An atmospheric sounding using High Resolution Rapid Refresh numerical weather model data indicated stratus clouds with bases about 600 ft agl and an overcast layer of nimbostratus clouds at 1,000 ft agl with tops near 16,200 ft near the accident site at 1400.
At the time of departure, the National Weather Service Graphical Forecasts for Aviation depicted general MVFR conditions over the route of flight, with rain showers and broken clouds with bases at 1,600 to 4,000 ft and tops up to 26,000 ft expected. A graphical AIRMET for IFR conditions also covered a portion of the route. The GNV Terminal Aerodrome Forecast issued at 1240 expected visibility better than 6 miles in light rain and mist, ceiling broken at 1,500 ft agl, overcast at 7,000 ft agl, with a temporary period between 1300 and 1700 of visibility 4 miles in moderate rain showers and mist, ceiling broken at 1,000 ft agl, and overcast at 3,000 ft agl.
Neither the FAA Automated Flight Service Station provider nor third-party users of their system had any contact with the pilot on the day of the accident. The NTSB contacted ForeFlight, a flight planning software provider, who indicated that the accident pilot had a ForeFlight account and had programmed the route of flight into the ForeFlight application. However, their records indicated he did not file any flight plans or review any weather on the day of the accident. AIRPORT INFORMATIONAccording to FAA records, the pilot purchased the airplane on October 31, 2023. A review of the airplane’s maintenance records revealed that the most recent annual inspection was completed on October 28, 2022, at an airframe total time of 3,554.1 hours. A mechanic performed a pre-buy inspection on May 11, 2023, and found several discrepancies, including that the attitude indicator had failed. There were no logbook entries indicating the attitude indicator had been repaired or replaced before the accident. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest in a heavily wooded area, in a 4-ft-deep crater at an elevation of 100 ft msl. It struck several trees before impacting sandy terrain. All major components of the airplane were located in the vicinity of the main wreckage.
The fuselage was fragmented and the cabin was crushed forward. Flight control continuity was established from the cabin to all flight control surfaces through multiple cuts made by first responders and separations consistent with tensile overload failure. The right wing was separated from the fuselage at the wing root. The forward section of the right wing was crushed aft. The outboard 4 ft of the right wing was separated from the inboard section and located along the debris path. The left wing was fragmented. The inboard section of the left wing was crushed aft. The empennage was separated from the fuselage. The stabilator remained attached to the empennage. The trim tab remained attached to the stabilator. The vertical stabilizer and rudder were separated and located in the vicinity of the main wreckage. All airframe damage was consistent with impact forces rather than in-flight separation.
Examination of the attitude indicator revealed rotational scoring on the gyroscope and the gyroscope housing. Examination of the electric turn and bank indicator revealed vertical scoring on the gyroscope. The compass was separated from the instrument panel. During examination, the compass float moved when the instrument was manipulated.
The engine remained attached to the forward section of the fuselage through all engine mounts. The crankshaft could not be rotated by hand. The propeller flange was bent from impact but remained attached to the crankshaft. The rocker arms showed no anomalies. The cylinders were examined with a lighted borescope; sand and oil were present in the cylinders, but no other anomalies were observed. The magnetos produced spark on all towers. All spark plugs were removed except the No. 2 bottom spark plug, which was damaged from impact. The spark plugs were massive electrode type; all were light gray and exhibited worn out–normal wear when compared to the Champion Check-A-Plug Chart. The carburetor bowl did not contain fuel; however, the carburetor floats exhibited hydraulic deformation, consistent with the presence of fuel at the time of impact. The oil filter was free of metallic debris. The oil suction screen was unobstructed. The rotor and vanes of the vacuum pump were intact, and the drive splines were also intact.
The airplane was equipped with a two-blade, fixed-pitch propeller. Tip tearing, chordwise scratching, and S-bending were observed on the propeller, consistent with the engine producing power at the time of impact. Furthermore, a branch, about 2 inches in diameter, that was cut at a 45° angle, was located in the vicinity of the main wreckage. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot’s remains was conducted by the Office of the Medical Examiner ...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA24FA036