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NTSB investigation record

CEN23FA187

Completed

Cessna 172· N2946U

Date
May 15, 2023
Location
Chambers, NE
Conditions
IMC
Record
Published February 26, 2025

Primary finding

Probable cause

The pilot’s continued VFR flight into instrument meteorological conditions at night and his failure to maintain adequate altitude, which resulted in controlled flight into terrain.

Investigator assessment

Analysis narrative

The pilot departed on the cross-country flight with instrument meteorological conditions (IMC) reported over the entire region along the route of flight. The NWS had multiple forecasts calling for instrument flight rule conditions as well as an AIRMET for the threat of low ceilings and low visibility over the area. There was no record of the pilot having received a weather briefing and no flight plan was filed. In addition, there were no known communications with the pilot during the flight. Witnesses reported hearing the airplane flying at a low altitude beneath the clouds just before the accident. They reported that the weather at the time was foggy, misty, and raining. The airplane was substantially damaged when it impacted the terrain in a slight nose-down, wings-level attitude. Postaccident examination of the airframe and engine did not reveal any anomalies that would have prevented normal operation of the airplane. The airplane was operating in conditions conducive to serious carburetor icing; however, the witnesses reported the airplane was loud when they heard it flying overhead just before impact. The pilot’s autopsy revealed coronary artery disease; however, there was no clear evidence that the disease contributed to the accident. Weather forecasts for the area called for precipitation and overcast ceilings at 300 ft. The forecasts were consistent with witness accounts of the weather at the time of the accident. The nighttime IMC conditions would have made visual navigation next to impossible without a discernable horizon. Based on the accident site, wreckage examinations, and the witness accounts, the pilot was likely attempting to fly beneath the low clouds when the airplane impacted the ground.

Source record

Factual narrative

The National Weather Service (NWS) Surface Analysis Chart and Prognostic Charts depicted a low-pressure system over eastern Kansas with an extensive area of overrunning clouds and precipitation extending over Kansas and Nebraska. Weather observations over the area reported northeasterly winds and visibility restricted in light rain, with low overcast ceilings at 300 ft in the immediate vicinity of the accident site.  Witness accounts also reported misty and foggy conditions at the time of the accident. The NWS had multiple forecasts current calling for instrument flight rule conditions and had an AIRMET for the threat of low ceilings and low visibility over the area.  No records were found of the pilot obtaining a weather briefing before his departure.  A review of the astronomical conditions indicated the end of civil twilight occurred about 5 minutes before the accident, so dark nighttime conditions existed at the time of the accident with no illumination from the moon. Witness accounts of the local weather were consistent with the official weather forecast and reports. Weather conditions were conducive for carburetor ice at cruise power. However, witnesses reported hearing the airplane just before the impact and described it as loud. An autopsy on the pilot was conducted at the Douglas County Morgue, Omaha, Nebraska. The cause of death was blunt force injuries. Coronary artery disease was present, including 75-90% narrowing of the left anterior descending coronary artery by calcified plaque, 10-25% narrowing of the right coronary artery by plaque, and less than 10% narrowing of the left main and left circumflex coronary arteries by plaque. No coronary artery clot or heart muscle scarring was seen. Toxicology tests conducted by the Federal Aviation Administration’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, were negative for drugs and alcohol. The wreckage debris path was oriented about 049° magnetic. The path extended about 152 ft from the initial impact area. Examination of the airframe and the engine did not reveal any preimpact anomalies. Flight control continuity was confirmed from the cockpit to all flight surfaces. The propeller blades showed polishing and bending consistent with rotation at impact. The carburetor heat knob was found in the off position. Fuel samples taken from the wing tanks tested negative for water and contaminants. Ground scars at the accident site were consistent with the airplane impacting the ground in a shallow, wings-level attitude. On May 14, 2023, about 2125 central daylight time, a Cessna 172D airplane, N2946U, was substantially damaged when it was involved in an accident near Chambers, Nebraska. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Federal Code of Regulations Part 91 personal flight. According to the airplane owner, the flight departed from Newton City/County Airport (EWK), Newton, Kansas. Its intended destination was Glen Ullin Regional Airport (D57), Glen Ullin, North Dakota. There were no records of the pilot filing a flight plan or obtaining a weather brief. There were no recorded communications from the pilot during the flight. Several witnesses reported that they heard an airplane flying low over their residence, about 1.6 miles south of the accident site. Another witness observed the airplane flying low, slightly above tree top height. The witness stated that he saw that the airplane’s landing light was on and saw the flashing lights of the airplane. The witnesses stated that there were low clouds, fog, and mist in the area at the time they saw the airplane. A home video surveillance camera showed what appeared to be the landing light of the airplane descending toward the ground. The video also showed precipitation and fog. The airplane was not equipped with ADS-B. No radar data was available for the flight and no distress calls were heard from the pilot. The wreckage was located by a local rancher about 1300 on May 16th.

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