ERA20LA305

The noninstrument-rated pilot’s continued visual flight into instrument meteorological conditions, which resulted in spatial disorientation, a loss of control, and collision with terrain.

Throughout the afternoon of the accident flight, the noninstrument-rated pilot had delayed his departure due to poor weather along his intended route, and despite any meaningful change in the weather conditions along the route or at the presumed destination, he decided to depart. Data obtained from the pilot’s electronic flight bag (EFB) application, in addition to a course change in the airplane’s recorded flight track, indicated that, about 20 minutes into the flight, the pilot initiated a diversion to a new airport. Although the new airport was reporting visual flight rules (VFR) conditions, instrument flight rules (IFR) conditions and mountain obscuration were present along the route of flight. Each of these conditions were forecast before the pilot’s departure. Review of the weather conditions along the route indicated that the pilot passed airports with VFR conditions but chose to continue into an area of deteriorating visibility and cloud ceilings. As the pilot approached rising terrain toward the new destination, the flight track deviated to the left and right, followed by a left 360° level turn. The 360° turn was completed in about 1 minute. The airplane then continued in a second left turn, during which its altitude began to rapidly decrease, and the turn developed into a descending spiral. The final position was recorded with the airplane about 500 ft above terrain about ¼ mile east of the accident site. The airplane’s flight track was consistent with the known effects of spatial disorientation and a subsequent loss of control and impact with terrain. The wreckage was located 40 hours after the accident in heavily wooded terrain at the bottom of a steep ravine. The fragmentation of the wreckage indicated that the airplane impacted terrain in a high speed, uncontrolled descent. A postaccident examination of the airplane did not reveal any evidence of mechanical malfunctions. The pilot did not file a flight plan, obtain an official weather briefing, nor was he receiving air traffic control services at the time of the accident. It is likely that the pilot encountered instrument meteorological conditions (IMC), which included rain, clouds, and low visibility, as he neared the rising terrain and continued flight into IMC. The pilot did not possess the qualifications to operate in IMC, and the airplane was not equipped for IFR flight. The investigation found evidence that the pilot likely relied extensively on an EFB application for GPS navigation. Photos from the pilot’s past flights showed that he had mounted the EFB in the forward windscreen area and data retrieval from the EFB application found that the pilot was actively utilizing the EFB while enroute in the accident flight. It is possible that the pilot was utilizing the application’s attitude indicator/synthetic vision feature as he entered IMC. The EFB application pilot’s guide stated that the attitude indicator/synthetic vision feature may only be used for informational purposes and cannot be used as a primary reference.

According to FAA airman records, the pilot was issued a private pilot certificate on February 8, 2020, with a rating for airplane single-engine land. He did not hold an instrument rating. A family member reported that the pilot had accumulated an estimated 200 hours of flight experience. The pilot’s logbook was not located in the wreckage. An autopsy of the pilot was performed by Department of Health, Office of the Chief Medical Examiner, Manassas, Commonwealth of Virginia. The cause of death was stated as “Multiple blunt force injuries” and the manner of death was “accident.” Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for alcohol and other drugs. The airplane was not equipped with an attitude indicator or any panel-mounted navigation system, nor was it required for day VFR flight. An impact damaged Stratux ADS-B Dual Band Receiver and SiriusXM receiver was found in the wreckage. According to a user guide for the Stratux ADS-B receiver, the device has the capability via an electronic flight bag (EFB) application to display several weather products, such as METARs, TAFs, NEXRAD radar, AIRMETs, and SIGMETs. In addition, it can support the display of the airplane’s present position via WAAS GPS and can support the attitude indicator/synthetic vision feature through applications such as ForeFlight. Photos posted on social media by the pilot about one month before the accident revealed that, in past flights he had mounted an EFB and the ADS-B receiver in the forward windscreen area. In one photo, the attitude indicator and synthetic vision feature was being used. According to an “Important Notice” in the “Pilot’s Guide to ForeFlight Mobile,” Attitude Indicator/ Synthetic Vision chapter, the attitude indicator/ synthetic vision is for informational purposes and cannot be used as a primary instrument for any phase of flight. (see figure 3). Figure 3. Excerpts from the ‘Pilot’s Guide to ForeFlight Mobile’ 90th Edition. An FAA inspector responded to the accident site. The main wreckage was located at the bottom of a steep ravine in heavily wooded terrain about 2,300 ft msl. The wreckage was scattered in a southerly direction. The cockpit, wings, and fuselage were heavily fragmented. There was no evidence of fire at the accident site. The airframe and engine were examined at the recovery facility. Each flight control cable was cut by the recovery crew; however, flight control cable continuity was traced from the cuts to their respective attach points. Both wing fuel tanks were destroyed. The elevator trim jackscrew was exposed about 8 threads, which corresponded to a slight nose-down trim setting. The fuel gascolator was impact damaged, but the bowl was clear of debris. The fuel selector valve was not located in the recovered wreckage. The engine remained partially attached to the firewall and the propeller had separated from the hub. Continuity of the crankshaft, camshaft, and connecting rods were confirmed by visual examination. The carburetor was impact damaged and had separated from the engine. Its inlet fuel screen was removed and was clean. Both magnetos produced a spark at all four leads when rotated by hand. All spark plugs, with exception of the No. 2 cylinder bottom spark plug, which sustained heavy impact damage, remained attached to the respective spark plug leads. According to the Champion Check-A-Plug chart, the spark plugs displayed normal combustion. The oil pressure screen and the oil suction screen were both removed, and both were clean. The heat muffler exhibited impact damage, but no preimpact anomalies were observed. The two-bladed metal fixed-pitch propeller was separated from the engine. One blade was bent forward while the other was bent aft; both blades exhibited S-type bending with trailing and leading-edge damage. The propeller spinner was destroyed. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. On August 31, 2020, about 1900 eastern daylight time, a Piper PA-20-135 airplane, N7323K, was destroyed when it impacted trees and terrain near Luray, Virginia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a fixed-base operator (FBO) employee at Maryland Airport (2W5), Indian Head, Maryland, the pilot arrived a day or two before the accident and stayed in the local area. The pilot was reportedly on a “tour of the 48” lower United States and had originally departed from California for the cross-country trip. On the afternoon of the accident, the pilot discussed with the FBO employee and other pilots at the airport, that he planned to depart for Eastern WV Regional Airport/Shepherd Field (MRB), Martinsburg, West Virginia, as West Virginia was the next state in which he needed to complete a landing. The FBO employee reported that, throughout the afternoon, the pilot had been “waiting for the weather to clear” and he was looking at “storms” on his iPad. The pilot was also reportedly concerned with the terrain and cloud ceilings along the route; his “biggest concern were [cloud] ceilings.” The FBO employee reported that the other pilots at the airport told the accident pilot that he should not depart along the route, and when the FBO employee closed the FBO office and left the airport at 1800, the pilot had not departed. Review of Federal Aviation Administration (FAA) Automatic Dependent Surveillance - Broadcast (ADS-B) track data and air traffic control audio communications revealed that the airplane departed runway 20 at 2W5 at 1819. Shortly after takeoff, the pilot contacted Potomac Terminal Radar Approach Control Facility. The communications were routine; when the airplane exited the DC Special Flight Rules Area airspace, the pilot was given and accepted a frequency change. No further communications were received from the pilot. Figure 1 shows the airplane’s final 30 minutes of flight track overlaid on a visual flight rules (VFR) sectional chart. The magenta line depicts the airplane’s westbound flight track. Figure 1. Overview of the final 30 minutes of the ADS-B flight track At 1858, the airplane was flying westbound and entered a left turn at an altitude of about 4,500 ft mean sea level (msl) over Shenandoah National Park. Below and near the flight path, mountainous terrain ranged in elevation from about 2,000 to 3,500 ft msl. At 1859, the airplane had completed a left 360° turn and the altitude remained relatively constant. The airplane continued in a left turn; however, during this turn, its altitude began to rapidly decrease, and the turn developed into a rapidly-descending spiral. At 1859:27, the final position was recorded with the airplane at 2,950 ft msl about ¼ nautical mile east of the accident site. Figure 2 shows the final few minutes of the flight track. Figure 2. Overview of the final few minutes of the flight track and a marking of the main wreckage The wreckage was located by hikers about 1120, on Wednesday, September 2, 2020. There was no indication that an emergency locator transmitter (ELT) signal was received from the airplane. According to Leidos Flight Service, there was no record that the pilot filed a VFR flight plan for the flight, nor was an official weather briefing requested on the day of the accident. The pilot did have an account with ForeFlight, and several routes of flight data entries the pilot entered into the application prior to and during flight were recovered from their servers. About the time of departure, the pilot had entered a route of flight with the initial destination of MRB; however, at 1839 and again at 1843, the pilot entered a route of flight with a revised intermediate destination airport of Grant County Airport (W99), Petersburg, West Virginia. Review of the flight track showed