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NTSB investigation record

ERA17FA180

Completed

Beech A36Tc· N1804E

Date
May 12, 2017
Location
Hopkinsville, KY
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The noninstrument-rated pilot's intentional visual flight rules flight into instrument meteorological conditions, which resulted in a loss of airplane control due to spatial disorientation. Contributing to the accident were the pilot's overreliance on his limited instrument training.

Investigator assessment

Analysis narrative

The noninstrument-rated private pilot and the passenger were on a personal cross-country visual flight rules (VFR) flight in the airplane, and the pilot was in contact with air traffic control and receiving flight following services as he deviated due to weather along the route of flight. The pilot talked with a controller about diverting to a nearby airport, but he opted to continue, stating that the flight would likely be clear of the weather shortly based on the information he was receiving from his on-board equipment. Weather radar and satellite imagery indicated that the flight encountered instrument meteorological conditions (IMC) before it departed from controlled flight and entered a steep descent that continued to terrain impact. Examination of the airframe and engine did not reveal evidence of any preimpact mechanical malfunctions that would have precluded normal operation. The pilot had received about 71 hours of simulated instrument flight training and had accumulated about 16 hours in actual instrument conditions, though his most recent instrument training flight was more than 1 year before the accident. The pilot's decision to continue VFR flight into IMC may have been influenced by an overreliance on his limited instrument training that led him to underestimate the difficulty of maintaining airplane control in actual instrument conditions. After the airplane entered IMC, the pilot likely experienced spatial disorientation and lost control of the airplane. Although the pilot was using two medications (imipramine and doxylamine) that may have affected his aeronautical decision-making and increased his susceptibility to spatial disorientation, it could not be determined whether effects from these drugs contributed to the accident.

Source record

Factual narrative

The Office of the Chief Medical Examiner, Louisville, Kentucky, performed an autopsy of the pilot. The cause of death was reported as blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology testing on specimens from the pilot. According to the toxicology report, testing for carbon monoxide and cyanide was not performed, and no ethanol was detected in muscle or liver specimens. Unquantified amounts of atenolol, atorvastatin, desipramine, imipramine, and valsartan were detected in liver and/or muscle specimens, and 0.385 µg/ml and 0.083 µg/ml doxylamine were detected in liver and muscle specimens, respectively. Imipramine is a tricyclic antidepressant commonly marketed with the name Tofranil. It carries the warning, "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Doxylamine is a sedating antihistamine available over the counter in several products for colds, allergies, or to induce sleep. Atenolol and valsartan are prescription medications for blood pressure, and atorvastatin is a cholesterol lowering agent. None of these three medications are generally considered impairing. There was no record that the pilot obtained a preflight weather briefing using either Lockheed Martin Flight Service Station or DUATS. According to ForeFlight personnel, the pilot did not request any weather briefings on or around May 12, 2017. The pilot viewed some weather imagery on May 11 and 12; the images that the pilot viewed were extended convective forecast products. There was no record that the pilot used Foreflight to view any other weather information, such as weather observations or forecasts, that would have provided cloud cover or cloud ceiling information along the route of flight. An AIRMET advisory for IFR conditions in southwestern Kentucky and northern Tennessee was issued at 0945 and valid at the accident time for the accident site. A visible image from 1215 showed extensive cloud cover with tops about 32,000 ft msl around the accident site. The Fort Campbell, Kentucky, Weather Surveillance Radar-1988, Doppler (WSR-88D) base reflectivity images indicated that the airplane flew through an area of 5 to 25 dBZ reflectivity values, corresponding to light precipitation, during the last 5 minutes of the flight. The 0.5° and 1.5° elevation scans detected reflectivity values above the accident site between 800 ft msl and 5,000 ft msl. The reflectivity values increased in area and intensity above the accident site between 1140 and 1200. A visible satellite image from 1215 showed extensive cloud cover around accident site. The cloud tops were around 32,000 ft msl. The closest upper air sounding depicted the freezing level well above 10,000 ft. At 1153, a special surface weather observation taken at Campbell Army Airfield, located 16 nm south-southeast of the accident site, reported wind 360° at 6 knots, 10 miles visibility, moderate drizzle, overcast ceiling at 1,100 ft agl, temperature and dew point 18°C, and altimeter setting 29.84 inches of mercury. The pilot, age 69, held a private pilot certificate with an airplane single-engine land rating that was issued on September 20, 1997. He held a third-class medical certificate with a limitation to wear corrective lenses that was issued on March 1, 2017. A review of the pilot's logbook, which contained entries from March 17, 1997, to April 25, 2017, revealed that he had logged 726.7 hours of flight experience of which 19 hours were in the accident airplane in the last 90 days. Between December 1999 and April 8, 2016, he logged 16.4 hours actual instrument flight time of which 2.1 hours were as pilot-in-command (PIC), with the latest dated May 31, 2013. Of the 16.4 hours actual instrument flight time, 11.8 hours were accrued between December 1999 and April 2000, while the remainder of the flight time (4.6 hours) were accrued during 6 flights between May 22, 2013 and April 8, 2016. Between April 1997 and April 2000, he logged 80.1 hours simulated instrument time. The remainder of his simulated instrument time consisting of 1.6 hours was accrued during 2 separate flights, one in 2005 and one in 2009. Of his 81.7 hours logged simulated instrument time, 10.6 hours were as PIC. His last flight review in accordance with 14 CFR Part 61.56 occurred on either October 24 or 25, 2015, as documented in separate locations of his logbook. The flight review was conducted in a Cessna 177, and the flight duration was 2.5 hours. The six-place, low-wing airplane, serial number EA-231, was manufactured in 1981. It was powered by a 300-horsepower Continental Motors, Inc., TSIO-520-UB(2) engine and equipped with a constant-speed, three-bladed Hartzell propeller. The airplane was equipped with a portable Garmin GPS receiver, a JPI EDM 700 engine data monitor, and an Appareo Stratus 2S wireless ADS-B receiver. All three devices sustained extensive impact damage, and no data pertaining to the accident flight could not be recovered from the devices. The Stratus 2S device provided in-flight weather information via Flight Information System-Broadcast (FIS-B), GPS information, ADS-B traffic information, and was compatible with the ForeFlight Mobile App. Review of the airplane's maintenance records revealed that its last annual inspection was completed on April 4, 2017, at a recorded tachometer time of 3,182.57 hours. The tachometer reading at the time of the accident was 3,197.84 hours. According to the manager/registered agent of the corporation that owned the airplane, he last flew the airplane on May 4, 2017, on two separate flights lasting about 20 to 30 minutes each. He reported that on the first flight, when he attempted to "lean [the mixture] to lean of peak," the No. 5 cylinder would reach peak exhaust gas temperature (EGT) too soon and would run rough before the other cylinders had even reached peak EGT, but the engine ran fine when the mixture was full rich. On the second flight, he was able to lean the mixture to lean of peak and had no issues with the No. 5 cylinder EGT. The accident site was located in a wooded area near a house. Examination of the accident site revealed damage to trees and tree limbs consistent with a steep vertical descent. The descent angle between the tree contact height and the ground impact was about 53°. A ground scar associated with the left wing was oriented on a magnetic heading of 015°. Located inboard of the left-wing ground scar was a crater that contained components of the engine, airframe, landing gear, fuel tank bladder, and left wingtip with wing structure; immediately adjacent to the crater was the left elevator counterweight. Fuel blight was noted to the leaves of several trees immediately adjacent to the main wreckage. A 3.5-inch diameter tree trunk exhibited a smooth cut at a 45° angle consistent with being cut by a rotating propeller. The main wreckage consisting of the fuselage, section of wing, and empennage with attached flight control surfaces was located immediately adjacent to the crater. Outlying components of the airplane were found near the main wreckage. None of the components exhibited any evidence of fire. All components, including primary and secondary flight controls, necessary to sustain flight remained attached or were found near the main wreckage. Flight control cable continuity was confirmed for roll, pitch, and yaw except where cut for recovery or tension overload failure. Both elevator trim cables exhibited tension overload in the cockpit area, and both elevator trim tab actuators were symmetrically extended about 1 inch, which equated to 10° trailing edge tab up or airplane nose down. All flight control surface counterweights remained attached or were accounted for. Both wings were fragmented. Both flap actuators were extended about 2 inches, which equ

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