CEN21FA150

NTSB accident investigation · Aviat A-1B · Berwyn, NE · March 6, 2021

Accident · FatalClass 3 · FieldFinal report
Date
March 6, 2021, 06:10 local (12:10 UTC)
Place
Berwyn, NE · The airplane impacted a small canyon
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N166WWAviat A-1B
Defining event
Enroute-cruise: Loss of visual reference
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration, Lycoming
FAA report
20210306008589A
Case key
102722

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of control and subsequent impact with terrain as a result of spatial disorientation during cruise in dark night conditions.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAviat A-1B: 33 casesAll aircraft: 9,295 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on personnelAviat A-1B: 1 caseAll aircraft: 448 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Primary radar first picked up the airplane about 0555, 1/2 mile south of the private runway. The airplane track proceeded generally west-southwest for about 11 miles when it made a left turn toward the south at a speed of about 88 knots. The track then made right 360-degree turn; during which, the speed of the airplane increased to about 114 knots. Followed by a tighter 360-degree turn at 49 knots and decreasing. The track then zig zagged at an average of 30 knots until 0609 when the track terminated about 1,000 ft from the accident site. The airplane impacted a field perpendicular to a gully in a very rural area; the debris field was about 300 ft long. The first identified point of impact was a long narrow area of disturbed dirt with the right wingtip nearby. Next were two slash marks consistent with propeller blade slices; followed by a large area of disturbed dirt with propeller blade fragments. The main wreckage came to rest at the bottom of the gully; the last major piece of debris was the engine. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operations. The pilot flew the accident airplane regularly over his land and pastures. It was not abnormal for him to takeoff before sunrise despite not holding an instrument rating. At the time of the accident the moon was 22.97 degrees above the horizon at third quarter phase. Its illumination was 45.1% of the moon’s full potential. There were no high-altitude cloud layers to block the moonlight. Therefore, it was dark with the exception of any ground lights and moon illumination. The flight track immediately before the accident was consistent with a pilot experiencing spatial disorientation and subsequently losing airplane control. Several factors support this conclusion, which include the low moonlight; few ground lights in a rural area; the pilot’s lack of instrument rating; and the airplane’s abrupt roll, heading, and speed changes leading up to the accident site.

Factual narrative

On March 6, 2021, about 0610 central standard time, an Aviat A-1B airplane, N166WW, was destroyed when it was involved in an accident near Berwyn, Nebraska. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The purpose of the flight was to fly from the pilot’s private runway to Holyoke, Colorado for an annual inspection. About 0555, primary radar first picked up the airplane about 1/2 mile south of the private runway. The airplane track proceeded generally west-southwest for about 11 miles when it made a left turn toward the south at a speed of about 88 knots. The track then made right 360-degree turn; during which, the speed of the airplane increased to about 114 knots. Followed by a tighter 360-degree turn at 49 knots and decreasing. The track then zig zagged at an average of 30 knots until 0609 when the track terminated about 1,000 ft from the accident site. A GPS was recovered from the accident site; however, the unit and memory card exhibited extensive impact damage and data was unable to be extracted. The Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot with positive results for Diltiazem and Warfarin in the liver and muscle. ‘ Diltiazem is a prescription blood pressure medication that may also be used to treat fast heart rates associated with atrial fibrillation, an abnormal heart rhythm. Warfarin is a blood thinner used to prevent blood clots in patients with previous ischemic stroke, atrial fibrillation, or other forms of blood clots. Neither are generally considered impairing. At the time of the accident the moon was 22.97 degrees above the horizon in third quarter phase. Its illumination was 45.1% of the moon’s full potential. There were no high-altitude cloud layers. Dawn started at 0636 and sunrise was at 0704. The pilot was issued a private pilot certificate on May 26, 1969. The pilot flew the accident airplane regularly over his land and pastures; and was used to maneuvering at low altitudes. It was not abnormal for him to takeoff before sunrise, especially if he needed to get somewhere and return in the same day. The airplane impacted a field perpendicular to a gully in a very rural area; the debris field was about 300 ft long. The first identified point of impact was a long narrow area of disturbed dirt with the right wingtip nearby. Next were two slash marks consistent with propeller blade slices; followed by a large area of disturbed dirt with propeller blade fragments. The main wreckage came to rest at the bottom of the gully; the last major piece of debris was the engine. The airframe came to rest in a ball and exhibited extensive thermal damage. The fabric was completely gone and only the frame remained. Flight control continuity was mostly established throughout the airframe. The rudder controls were untraceable within thecockpit area; they were in an area of melted material. Both composite propeller blades were fracture separated at the blade root, and one blade was also fractured midspan. Both blades exhibited chordwise scratching on the face and chamber sides. The engine was found fracture separated from the airframe; it exhibited extensive thermal damage and there were no visual signs of catastrophic anomalies. The firewall was removed, and the engine was attached to an engine hoist for further examination. The spark plugs were removed and consistent with normal operations. The fuel flow divider was disassembled, and fuel residue was present. The fuel servo remained attached, but the engine controls were fracture separated consistent with impact damage. The valve covers were removed, and the valves were unremarkable. The crankshaft was rotated by the propeller hub and continuity was established to the accessory section. Thumb compression was established on all cylinders and the valves moved accordingly. The engine was borescoped; the cylinder walls, piston heads, and valves displayed normal operating signatures. Spark was obtained on the right magneto; the left magneto was unable to be rotated and exhibited heavy thermal damage. The ignition harness was unable to be functionally tested due to damage consistent with impact.

Aircraft

Registration
N166WW
Reported as
Aviat A-1B
Category
Airplane
Serial number
2372
Built
2006
Engine
Lycoming IO-360-A1D6, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
PVT · Mason City, NE
Destination
HEQ · Holyoke, CO

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
74
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Restraint
4-point
Toxicology
Performed
Flight hours
2,395 total · 2,395 in this make and model

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
30 °F, dew point 28 °F
Altimeter
30.15 inHg
Observed at
BBW, 13 nm away

Docket · 13

The files NTSB released with the investigation on March 8, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.