CEN24FA326

The non-instrument-rated pilot's decision to continue visual flight into an area of low cloud cover and precipitation which resulted in an inadvertent encounter with instrument meteorological conditions and a loss of control due to spatial disorientation.

The airplane departed in daylight, visual weather conditions and proceeded along a meandering flight path before heading towards Yankton, South Dakota, for an unknown destination. About an hour after departure, while over Yankton, the pilot made a telephone call to a friend to inquire about the weather and airport options, stating that he was unable to land due to the weather as he did not hold an instrument rating. The pilot was not instrument rated, the airplane was equipped for only visual flight rules (VFR) operations, and the weather conditions at the nearby airport included a cloud ceiling at 200 ft above ground level (agl) with 1/4-mile visibility in fog and light rain. The friend suggested two airports south of the pilot’s position with automated weather stations reporting VFR weather conditions. The friend also stated that the pilot seemed calm and did not mention if he was in instrument meteorological conditions (IMC). A NTSB weather study determined that a cold front and inversion in the area, along with low- and mid-level troughs, made for an environment conducive to sustained low-level cloud cover, moisture, and precipitation. A review of recovered flight track data from an onboard GPS unit revealed that about the time that the pilot called his friend, the airplane was at an altitude of 3,239 ft mean sea level (msl) tracking roughly southwest. The flight track remained consistent during the next 8 minutes for about 14 nm, suggesting that the pilot was in VFR conditions above the cloud tops. The airplane then began a right turn to the west with a slow climb to a maximum altitude of about 4,000 ft msl. About 1 minute later, the airplane began an S-turn, followed by a descending left turn for less than a minute before the data was lost. The accident site was located about 3/4 nm northeast of the last data point. The weather study determined that the accident flight was likely in IMC from 3,500 ft msl down to 200 ft agl, with visibility restricted to 1/4 mile or less below the cloud cover. The study also noted that a band of rain showers was moving northeast across the accident site at the accident time, which likely further reduced visibility below the cloud layer and had associated convective turbulence. A postaccident examination of the airplane revealed no evidence of mechanical malfunction or failure that would have precluded normal operation. However, flight control continuity could not be established due to impact damage. It is unknown what, if any, weather information the pilot checked before or during the flight, or whether the nearby airport (at the time that the pilot called his friend) was the intended destination. However, the reported weather at that airport from more than 2 hours before the accident flight departed through the time of the accident consistently included low instrument flight rules (LIFR) conditions. (LIFR is defined as a ceiling below 500 ft agl and/or visibility less than 1 mile.) The weather forecast information applicable for the accident time did not include any graphical or text AIRMETs for instrument flight rules (IFR) conditions, and no terminal aerodrome forecasts were available within 30 miles of the accident site. The National Weather Service (NWS) graphical forecast analysis products issued more than 3 hours before the accident flight departed forecast LIFR surface visibility for the area of the accident applicable about 1 hour 40 minutes before the accident and VFR surface visibility with a cloud ceiling at 2,300 ft msl (about 600 ft agl) for the area of the accident applicable about 1 hour 20 minutes after the accident. The weather conditions encountered by the accident pilot were worse than NWS forecasts valid for the accident time. Several pilot reports (PIREPs) reported cloud tops between 2,600 ft MSL and 3,500 ft MSL in the area. Loss of external visual references during VFR flight presents a high risk of spatial disorientation and loss of control. Several risk factors for spatial disorientation were present in this accident: the lack of IFR flight instruments, the non-instrument rated pilot, and the weather conditions. Based on these factors, as well as the airplane’s flight track and the orientation and fragmentation of the wreckage consistent with a high-energy impact, the pilot likely experienced spatial disorientation after entering an area of rain, convective turbulence, and IMC which may have been higher than the surrounding cloud tops, and he subsequently lost control of the airplane.

According to the pilot’s logbook, as of August 16, 2024, the pilot had logged 2.4 hours of simulated instrument experience and no experience in actual instrument weather conditions. According to the pilot’s friend, the accident pilot built the airplane and the friend helped. He stated that the airplane’s flight instruments included an altimeter and possibly one gyroscopic instrument. An autopsy of the pilot was performed by the Douglas County Morgue. The reported cause of death was multiple blunt force injuries. The FAA Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot. No drugs were detected. Ethanol at 12 (mg/dL, mg/hg) was detected in muscle tissue, and no ethanol was detected in liver tissue. Ethanol is the intoxicating alcohol in beer, wine, and liquor, but alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol sometimes may be produced by microbes in a person’s body tissues and fluids after death. Postmortem ethanol production is made more likely by extensive traumatic injury. In this case, some or all of the small amount of detected ethanol was likely the result of postmortem production. On August 26, 2024, about 0841, central daylight time, an experimental, amateur-built Rans S-19 airplane, N519JR, was destroyed when it was involved in an accident near Crofton, Nebraska. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Norfolk Regional Airport (OFK), Norfolk, Nebraska, about 0730 then proceeded along a meandering flight path before heading north toward an unknown destination. About 0830, while within 5 nm of Chan Gurney Municipal Airport (YKN), Yankton, South Dakota, the pilot made a telephone call to his friend, who was a certificated pilot, to inquire about the weather and airport options. The pilot reported that he was unable to land in Yankton due to the weather. The pilot did not hold an instrument rating, and the airplane was equipped for only VFR operations. The friend suggested Albion Municipal Airport (BVN), Albion, Nebraska, because VFR weather conditions were reported there. The Automated Weather Observation Station (AWOS) at BVN, which was about 77 nm southwest of the flight’s location, reported clear skies and 10 miles visibility at 0835. The friend stated that the pilot seemed calm and did not mention if he was in IMC. After the telephone conversation, the friend sent a text message to the pilot at 0842 stating that an airport in Columbus, Nebraska, was also showing VFR weather conditions. Columbus was about 85 nm south of Yankton. Recovered flight track information from the airplane’s Garmin GPSMAP 396 showed that, at 0830, the airplane was east of YKN at an altitude of 3,239 ft msl tracking roughly southwest. The flight track remained mostly consistent for about 14 nm. At 0838:23, the flight track turned right to the west and began a slow climb to a maximum altitude of about 4,000 ft msl. At 0839:30, the data showed a slow S-turn followed by a descending left turn before the data was lost at 0840:53, with the airplane at an altitude of 2,101 ft msl (about 432 ft agl) and 144 kts ground speed. The accident site was located in a field about 3/4 nm northeast of the last data point at an elevation of about 1,700 ft msl (see figure 1.). Figure 1. GPS flight track data and accident site location displayed in Google Earth. Law enforcement camera footage captured at the accident site about 50 minutes after the accident showed a cloud ceiling of about 260 ft agl when compared to the height of a nearby wind turbine. The accident site was located by law enforcement at 0930 in an agricultural field about 15 nm south-southwest of YKN. Ground impact marks and debris were consistent with the airplane impacting the terrain in a left-wing-low, nose-down attitude. The main wreckage came rest about 85 ft and 023° from the initial ground impact point, with most of the debris field within about 200 ft from the initial impact point. Additional cockpit-related debris, including the faceplates of several instruments, was found about 500 ft from the initial impact point. The main wreckage consisted of the rear fuselage, empennage, and both wings. The forward fuselage with the engine attached was found crushed longitudinally in a shallow crater. Both wing fuel tanks were found separated from the wing structure with tank wall fractures consistent with liquid hydraulic deformation. Flight control continuity could not be established due to impact damage. The cockpit was fragmented and crushed along with the forward fuselage from impact damage. No flight instruments could be located due to the extensive fragmentation and dispersal of the cockpit debris. Both sets of rudder pedals were found separated in and around the forward fuselage. The control stick could not be located in the forward fuselage. The Garmin GPSMAP 396 was found about 500 ft from the cockpit. The engine showed impact fragmentation and crush damage and remained attached to the firewall with all major components located. Oil residue was observed on the ground around the engine and fuel blighting was observed on nearby vegetation. The composite propeller was found fragmented throughout the accident site with rotational scoring signatures present. A search of archived information indicated that the accident pilot did not request weather information from Leidos Flight Service or have an account with ForeFlight. It is unknown what, if any, weather information the pilot checked before or during the flight. Conditions reported at YKN from 0600 through the time of the accident consistently included a broken cloud ceiling at 200 ft agl and an overcast cloud ceiling at 1,900 ft agl; visibility ranging from less than 1/4 mile to 3/4 mile; and fog, mist, and/or light rain. Pilot weather reports (PIREPs) distributed into the national airspace system within 2 hours of the accident time and within 100 miles of the accident site reported cloud tops between 2,600 ft msl and 3,500 ft msl. The Graphical Forecasts for Aviation (GFA) products issued by the NWS Aviation Weather Center around 0500 were valid at both 0700 and 1000. The GFA surface and cloud forecasts applicable at 0700 for the accident site indicated LIFR conditions with no chance of precipitation, a west wind of 5 kts, and few to scattered clouds with cloud bases around 2,100 ft msl. The GFA surface and cloud forecasts applicable at 1000 for the accident site indicated VFR surface visibility, a northwest wind of 5 kts, and a broken ceiling at 2,300 ft msl with cirrus clouds above. A G-AIRMET Sierra for IFR conditions was depicted extending over North Dakota and Minnesota north and northeast of the accident site. The accident site was on the border of G-AIRMET Zulu for icing conditions, which was valid for 1000. The only human-generated information reflected in the two GFA products were the G-AIRMETs. A NTSB weather study was conducted using archived weather imagery and data for the accident site and surrounding region. This included a review of the 0900 High-Resolution Rapid Refresh model sounding, which identified an unstable and conditionally unstable environment from the surface through 500 ft agl, then a stable layer between 500 ft and 5,250 ft agl. Sounding analysis indicated a cloud layer between 400 ft through 1,400 ft agl with another cloud layer starting at 13,000 ft. No icing was noted below 12,000 ft msl. The tops of subsidence inversions were indicated at 3,108 ft and 5,271 ft agl. A review of Geostationary Operational Environmental Satellite number 16 visible and infrared imagery was performed for the period from 0600 through 1400. Cloud cover was indicated above the accident site with the low-level cloud cover moving southward across the accident site at the accident time, and the mid- and upper-level cloud cove