Primary finding
Probable cause
The pilot's loss of control while maneuvering in night instrument conditions that included light-to-heavy rain with severe turbulence, updrafts and downdrafts, and hail. Contributing to the accident was the pilot experiencing spatial disorientation, his lack of flight experience in actual instrument conditions, and his failure to request weather avoidance assistance from air traffic control.
Investigator assessment
Analysis narrative
The commercial pilot and two student pilot passengers were conducting an instrument flight rules (IFR) flight. The accident airplane was part of a group of several airplanes from the same flying club. About 2 hours 50 minutes after takeoff, the air traffic controller advised the accident pilot of areas of precipitation along the airplane's route of flight; the flight subsequently diverted west for about 6 minutes before re-establishing its northwesterly course. Review of weather information indicated that the airplane subsequently passed through an area of light-to-heavy rain with severe turbulence, updrafts and downdrafts, and small hail; temperatures at the airplane's cruise altitude were above freezing. The airplane entered a right turn at its cruise altitude; shortly thereafter, the turn rate increased, and the airplane began to rapidly descend. Radar contact was lost, and the airplane was subsequently located in a heavily wooded area. Examination of the airplane revealed no evidence of preimpact failure or malfunction of the airframe, flight controls, or engine. The significant fragmentation of the wreckage was consistent with a high-energy impact following a loss of control. Although components of the vacuum-operated attitude indicator and directional gyro exhibited rotational scoring, examination of the engine-driven vacuum pump could not determine whether it was operating at impact. The initial right turn, which was about standard rate, was likely the pilot's attempt to fly out of the adverse weather. The subsequent right turn, at greater than standard rate, was likely due to spatial disorientation in adverse instrument conditions and not the result of a vacuum system malfunction. The weather encountered during the flight was forecast, but the extent to which the pilot had familiarized himself with the weather conditions before the flight could not be determined, because there was no record of the pilot receiving a weather briefing from an official, access-controlled source. Although the pilot had recently completed an instrument proficiency check (IPC), recovery from unusual attitudes was not a requirement of the IPC. None of his instrument flight experience was conducted in actual instrument conditions, and his most recent night flight experience was about 10 months before the accident. While the pilot was expecting weather avoidance assistance from the pilot of another airplane based on their verbal agreement before departure, the two pilots did not communicate during the accident flight. Given that the accident airplane was not equipped with onboard weather information, it could not be determined why the pilot chose to deviate in the direction that he did, rather than asking the controller for more information regarding the weather or for assistance in deviating around it. If the pilot had requested assistance, the controller likely would have been able to provide him with vectors to avoid the adverse conditions.
Source record
Factual narrative
The day before the accident, the accident pilot and another pilot from the group obtained weather information from a National Oceanic and Atmospheric Administration website for the accident flight, which included significant weather prognostic charts. They noted the location of a cold front and expected rain during the last portion of the flight. The freezing level was forecast to be 14,000 ft. Earlier on the accident date while at MYR, Myrtle Beach, South Carolina, the accident pilot and the pilot of C-GNOP discussed the weather which included the locations of cold and warm fronts, making note they might need to deviate to the west to avoid the cold front. According to personnel from Lockheed Martin, there was no record of a weather briefing associated with the airplane's call sign; further, there was no record with the Direct User Access Terminal (DUAT) vendor for flight plan or weather briefing. Additionally, there was no record of any of the airplane occupants having a subscription with ForeFlight. According to an NTSB Weather Study, the 1953 automated surface observation at Bradford Regional Airport (BFD), Bradford, Pennsylvania, located about 21 nautical miles west-northwest of the accident site, reported wind from 310° at 4 knots, 5 miles visibility, light rain, mist, few clouds at 4,000 ft agl, a broken ceiling at 4,800 ft agl, overcast skies at 8,000 ft agl, temperature and dewpoint both 16°C, and altimeter setting 30.05 inches of mercury. The observations from BFD about the accident time indicated marginal visual flight rules (MVFR) to IFR conditions due to low visibility, with light-to-moderate rain. These surface conditions matched the weather radar imagery and the rain shower line that the accident flight likely encountered. A High-Resolution Rapid Refresh model sounding was created for the accident site for 2000 EDT. The sounding depicted the freezing level at 11,963 ft. The possibility of low-level wind shear was indicated by Rawinsonde Observation program between the surface and 3,000 ft, and several layers of possible light to moderate clear-air turbulence were identified between the surface and 14,000 ft. Visible and infrared data from the Geostationary Operational Environmental Satellite number 13 (GOES-13) from 1945 and 2015 indicated cooler brightness temperatures and cloud tops (green and blue colors) located to the east of the accident site and northeastward into central New York. The clouds were moving from west to east, with most of the higher clouds east of the accident site around the accident time. Based on the brightness temperatures above the accident site and the vertical temperature profile provided by the sounding, the approximate cloud top heights over the accident site were 28,000 ft at 1945. Interpolation of the flight path onto a weather radar summary image indicated that the accident flight entered clouds or light precipitation around 1946, and subsequently entered an area of light-to-heavy rain with severe turbulence, updrafts and downdrafts, and small hail by 1954. There were no lightning strikes near the accident site at the accident time; however, the accident flight still likely encountered instrument meteorological conditions. There were no SIGMET advisories valid for the accident site at the accident time. The Center Weather Service Unit (CWSU) in Cleveland (ZOB) issued a Meteorological Impact Statement (MIS) that was valid for the accident site at the accident time. No CWSU Center Weather Advisories were valid for the accident site at the accident time. The MIS issued by ZOB at 1324 was valid through 2130 and discussed, in part, MVFR conditions with isolated IFR conditions in rain showers and mist. The area of precipitation would move northwest to southeast, with ceilings below 5,000 ft msl spreading southeastward. AIRMET advisories Tango, Zulu, and Sierra were issued at 1645 and valid at the accident time for the accident site. The AIRMETs valid at the accident flight's altitude were AIRMETs Tango and Sierra, forecasting moderate turbulence below 10,000 ft and mountain obscuration conditions due to clouds, precipitation, and mist. AIRMET Tango for moderate turbulence below 10,000 ft was in effect before the accident flight departed. The Area Forecast, issued at 1345 and valid at the accident time, forecast scattered to broken clouds at 10,000 ft with tops at 25,000 ft. Between 1600 and 1800, the ceiling was forecast to decrease to 6,000 ft msl with scattered light rain showers and isolated light rain and thunderstorms with cumulonimbus tops to 35,000 ft. The pilot, age 25, seated in the right seat, held a Canadian commercial pilot license with airplane single engine land, airplane multiengine land, and instrument rating group 1 (which was issued because the flight test was conducted in an other-than-center-thrust multi-engine airplane). He also held a Class 4 airplane instructor certificate with a flight test date of June 17, 2016, and an expiration date of July 1, 2017. He held a Canadian first-class medical certificate with no limitations, which was issued February 25, 2016. He held a US FAA commercial pilot certificate with ratings for airplane single- and multiengine land, and instrument airplane, issued November 4, 2015. He held an FAA first-class medical certificate with no limitations, which was issued on October 19, 2015. His pilot logbook contained entries between January 9, 2010 (first logged flight), and September 27, 2016, and revealed about 494 total hours of flight experience, with 301 hours as pilot-in-command (PIC). Of the 494 hours, about 77 were logged as simulated instrument time, with 3 hours simulated instrument time in the previous 90 days. His logbook did not contain any record of flight in actual instrument flight conditions. He logged about 36 hours of night flight experience, of which 27 were as PIC. His last logged night flight as PIC of a single-engine airplane was October 26, 2015, and his last logged night flight receiving dual instruction in a single-engine airplane was December 10, 2015. According to the most senior flight instructor of the flying club, in April and May 2016, during the accident pilot's flight instructor training, the accident pilot had undergone 5 hours of instrument training. During these flights, they conducted holding procedures and instrument approaches. He reported that they practiced departure and arrival procedures during simulator sessions, and reviewed IFR knowledge during undocumented ground sessions. The accident pilot reportedly, "flew well during departure, en-route, and during approaches." The pilot's training records indicated that he received instrument training during the month before the accident in preparation for an instrument proficiency check (IPC). The senior flight instructor reported that while the extra training wasn't a requirement, the pilot had expressed interest in obtaining additional training to "help bring him back up to standard." The pilot subsequently completed his IPC on October 11, 2016 in the accident airplane(The IPC did not require demonstration of recovery from unusual attitudes). The left seat passenger, age 19, held a Canadian student pilot airplane permit issued May 18, 2016. According to the operator, he had accrued a total time of 56 hours in all aircraft, of which 55 were in the accident make and model airplane. The four-place, low-wing, Piper PA-28-161 airplane, serial number 28-7816311, was manufactured in 1978. It was powered by a 160-horsepower, Lycoming O-320-D3G engine and equipped with a Sensenich 74DM6-0-60, two-bladed, fixed-pitch, aluminum propeller. The airplane was exported to Canada in May 2012 and was issued a Canadian certificate of airworthiness on August 30, 2012. The airplane was not equipped with onboard weather radar but was equipped with an electrically-operated turn coordinator. The most recent pitot/static check was performed on Au