Primary finding
Probable cause
The non-instrument rated pilot's improper decision to continue visual flight into instrument meteorological conditions, which resulted in spatial disorientation and subsequent in-flight collision with mountainous terrain.
Investigator assessment
Analysis narrative
The non-instrument-rated pilot, who was also the owner of the airplane, departed on a night visual flight rules (VFR) flight. Weather conditions at the departure airport were VFR, the weather conditions en route were a combination of marginal VFR and instrument flight rules (IFR), and the weather at the destination airport was IFR. The pilot had obtained a weather briefing earlier in the evening, during which he was informed that VFR flight was not recommended. About 30 minutes before the accident, the pilot's in-flight weather briefing indicated that instrument meteorological conditions, including low ceilings and mountain obscuration, were forecast for their intended route and at their destination. About 4 minutes before the accident, the pilot advised air traffic control personnel that "we are losing VFR, I need a deviation." Radio and radar contact were then lost. A postaccident examination of the wreckage indicated that the airplane struck the top of a tree, rolled inverted, and impacted the ground. No preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation were noted. The only navigational charts found at the accident scene were folded VFR charts and airport facility directories. No IFR charts were found. Analysis of the radar data and wreckage information revealed that the airplane made a series of erratic maneuvers, including a 360-degree heading change, before entering a descent and impacting the ground at high speed. These maneuvers took place in the last few minutes of the flight and were consistent with spatial disorientation. FAA guidance indicates that spatial disorientation can occur when there is no natural horizon or surface reference, such as a night flight in sparsely populated areas similar to that of the accident area and conditions. Although about 34 percent of the moon's disk was potentially illuminated at the time of the accident, given the cloud coverage in the area it is unlikely that the moon provided any illumination over the accident site. FAA guidance also indicates that spatial disorientation is more likely to occur if a pilot lacks proficiency in instrument flying.
Source record
Factual narrative
HISTORY OF FLIGHT On October 2, 2011, about 2045 eastern daylight time, a Piper PA-32-300R, N115CL, was substantially damaged when it impacted the trees and terrain in a mountainous, wooded area near Peru, West Virginia. The airplane departed from Danville Regional Airport (DAN), Danville, Virginia, about 1930 with an intended destination of John Murtha Johnstown-Cambria County Airport (JST), Johnstown, Pennsylvania. Night, instrument meteorological conditions (IMC) prevailed and no flight plan was filed. The private pilot and two passengers were fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Grand Strand Airport (CRE), North Myrtle Beach, South Carolina about 1800 with the pilot and three passengers. After an intended intermediate stop at DAN, one passenger deplaned and the flight continued to its intended destination of JST. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and personal records, the pilot held a private pilot certificate with airplane single-engine land privileges. The pilot had received his private pilot certificate on August 31, 2011 and his most recent pilot logbook entry was dated September 24, 2011. At that time, he had recorded 110.5 total hours of flight experience, including 40.4 total hours in the accident airplane make and model. He had also recorded 5.4 hours of simulated instrument experience, of which all were in a different aircraft make and model than the accident airplane. He had also recorded 7.6 total flight hours of night experience, of which 3.0 of those hours were in the accident airplane with a certificated flight instructor. On September 4, 2011, the accident pilot received an endorsement for "PIC [pilot in command] – Complex airplane" and "PIC – High performance airplane." The pilot did not possess an instrument rating. AIRCRAFT INFORMATION According to aircraft and FAA records, the airplane was issued an airworthiness certificate on July 23, 1977 and was registered to the pilot on August 18, 2011. The airplane's most recent annual inspection was recorded on March 2, 2011 at a recorded total time of 4,541.15 flight hours. It was equipped with a Lycoming IO-540-K1G5D engine, rated at 300 horsepower. The engine's most recent annual inspection was recorded on March 2, 2011 and indicated 734.15 flight hours since major overhaul (SMOH). The most recent entry in the engine maintenance records was on July 7, 2011 and at that time indicated 736.44 flight hours SMOH. METEOROLOGICAL INFORMATION The 2055 recorded weather observation at Grant County Regional Airport (W99), Petersburg, West Virginia, located approximately 11 miles northwest of the accident location, included calm winds, visibility 10 miles with light drizzle, broken clouds at 3,600 feet and 4,300 feet above ground level (agl) and overcast at 5,000 feet agl, temperature 8 degrees C, dew point 6 degrees C, and barometric altimeter 29.97 inches of mercury. The National Weather Service (NWS) surface analysis chart for 2000 EDT (0000Z) on October 2, 2011, depicted a low pressure system over southern New York with several troughs of low pressure extending westward and southward from the low. The station models over West Virginia indicated general winds from the west with overcast clouds and scattered rain showers. The NWS radar composite chart for 2045 depicted a large area of echoes extending from New York and Pennsylvania, into West Virginia, Eastern Kentucky, and Virginia. The closest upper air sounding from Sterling, Virginia, located about 74 miles east of the accident site, indicated a moist low-level environment with a relative humidity of 75 percent and greater from the surface to 12,800 feet. The freezing level was identified at 4,132 feet msl and supported icing in clouds and in precipitation to above 20,000 feet. The NWS area forecast, issued at 1341, expected broken clouds at 5,000 feet msl with tops to 9,000 feet, with overcast clouds at 4,000 feet after 2000. Occasional visibilities of 3 to 5 miles in light rain and mist were expected. The forecast included Airmen's Meteorological Information (AIRMET) Sierra for IFR conditions and mountain obscuration along the intended route of flight. According to Lockheed Martin Flight Service (LMFS) recorded data, the pilot contacted them earlier in the day. A representative from LMFS provided details of a preflight weather briefing. The briefing lasted about 9 minutes, during which time the pilot was notified of the existence of icing and IFR conditions due to precipitation and ceilings and visual flight rules (VFR) flight was not recommended for the planned flight from DNV to JST. According to the U.S. Naval Observatory, on the day of the accident, sunset occurred at 1858 and moonset was at 2258. The moon was a waxing crescent with 34 percent of the moon's visible disk illuminated. The 1935 recorded weather observation at DNV included wind from 340 degrees at 4 knots, visibility 10 miles, clear skies, temperature 14 degrees C, dew point 0 degrees C, and barometric altimeter 30.14 inches of mercury. The weather remained similar for several hours after the accident. The 2054 recorded weather observation at JST, the intended destination, included wind from 310 degrees at 9 knots, visibility 9 miles with light rain, overcast clouds at 400 feet agl, temperature 2 degrees C, dew point 2 degrees C; barometric altimeter 29.89 inches of mercury. From about 1400 until several hours after the accident, the clouds were overcast between 200 and 900 feet agl. COMMUNICATION The accident airplane was receiving flight following services from the FAA Air Route Traffic Control Center facility located in Leesburg, Virginia. Recordings of voice and radar tracking data were obtained from that facility. At 2038:08, the pilot, who had been flying direct JST on a northerly course at 5,500 feet, notified the controller, "we are losing VFR I need a deviation." At 2038:22, he stated "we're gonna try reversing course." The controller asked if the flight was IFR capable and if pilot wanted to file an IFR flight plan. The pilot reported “we are IFR capable”; but when asked if he wanted to file an IFR flight plan, the pilot declined, stating, in part, "I'm not even sure I've got the plates here…" and clarified his intention to return to DAN. At 2039:20, the pilot said that he was going to change frequencies to check the weather. At 2042:03, the pilot announced that he was back on the controller’s frequency. The controller stated "okay looks like you're going back opposite direction" to which the pilot stated "yeah we're headed back." Asked to clarify his intended destination, the pilot said “I think we’re gonna head back toward Danville…”. The controller identified an alternate airport 10 miles north of the airplane’s position but, at 2042:30, the pilot responded, "yeah I just as soon not do that I can't seem to find my plates I'm getting bounced around pretty good." Radar data indicated that during the time when the pilot reported to the controller that he was going to be off frequency checking weather, the airplane began a series of erratic maneuvers. About 2040:49, the airplane entered a gradual left turn. Between 2041:13 and 2041:25, the turn tightened and the airplane entered a steep left spiral dive, losing 700 feet in 12 seconds. The airplane briefly disappeared from radar on a westerly heading, but it reappeared at 2141:43, at a higher altitude and flying a southeasterly heading. At 2141:55, the airplane began to make a tight left turn. Shortly after the pilot informed the controller that he was back on the controller’s frequency, the airplane briefly stabilized on a northerly heading at 4,900 feet msl but, at 2142:30, as the pilot made his final transmission, the airplane disappeared from radar for the last time. Recordings of voi