# NTSB CEN21LA075: Piper PA32, N8178Y, Windom, MN, December 6, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: December 6, 2020, 06:25 local (12:25 UTC) - Place: Windom, MN · Plowed Farm Field - Coordinates: 43.956102, -95.116913 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.9561&lon=-95.1169&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Hartzell Propeller Inc., Piper Aircraft, Flight Standards District Office - NTSB case key (mKey): 102378 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102378/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102378 - Page: https://openairdocs.org/ntsb/CEN21LA075 ## Probable cause The pilot’s spatial disorientation shortly after takeoff into night instrument meteorological conditions, which resulted in loss of airplane control and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-301T, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103220), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Decision related to condition; cases with it: [Piper PA-32R-301T, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=7103220), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=7103220), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Experience/qualifications: recent instrument experience](https://openairdocs.org/ntsb-findings/02031050): Personnel issues › Experience/knowledge · Pilot; cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/02031050/cases.md?model=7103220), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02031050/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-32R-301T, 4 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7103220), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-32R-301T, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103220), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis After receiving an instrument flight rules (IFR) clearance for departure from the nontower-controlled airport, the pilot departed in night instrument meteorological conditions, which included an overcast ceiling at 400 ft above ground level. Radar data indicated that, during the initial climb, the airplane made multiple turns with large heading changes, then impacted terrain about 2.5 miles from the departure end of the runway. The distribution of the wreckage indicated a high-energy impact with terrain consistent with the known effects of spatial disorientation. A postaccident examination revealed no preimpact anomalies that would have precluded normal operation of the airplane. The most recent instrument approach recorded in the pilot’s logbook was about 5 months before the accident; this was the only instrument approach recorded during the 6 months preceding the accident. Toxicology testing identified citalopram and its metabolite, N-desmethylcitalopram, in the pilot’s liver tissue, but not in muscle tissue. Citalopram is an antidepressant that has not been shown to cause intellectual or psychomotor impairment. However, it is a psychoactive drug and carries a warning about the operation of machinery until the patient is convinced that the use of the drug does not interfere with their performance. In 2013, the pilot reported using an antidepressant and had undergone a review of his diagnosis of depression and its treatment and received a special issuance certificate. During subsequent medical certification, the pilot reported he was no longer taking the antidepressant medication. The pilot’s wife reported that the pilot was in good spirits during the months before the accident and that he was looking forward to meeting with a professional football player at the destination. Based on the information available, it was unlikely that the pilot was severely fatigued or depressed on the day of the accident and it is unlikely that the effects from the pilot’s treated medical condition contributed to his decision to fly in instrument conditions or his failure to do so safely. The pilot’s lack of recent experience in IFR conditions and the night instrument conditions present at the time of the accident were conducive to the development of spatial disorientation. It is likely that the pilot experienced spatial disorientation shortly after takeoff, which resulted in a loss of airplane control and impact with terrain. ## Factual narrative The Federal Aviation Administration (FAA) Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a "loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth." This document lists flight factors contributing to spatial disorientation: changes in angular acceleration, flight in IFR conditions, low-level flight over water, frequent transfer from VFR to IFR conditions, and unperceived changes in aircraft attitude. This document concludes with, "anytime there is low or no visual cue coming from outside of the aircraft, you are a candidate for spatial disorientation." The FAA's Airplane Flying Handbook, FAA-H-8083-3A, describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. On December 6, 2020, about 0625 central standard time, a Piper PA32 airplane, N8178Y, was destroyed when it was involved in an accident near Windom, Minnesota. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to video at Windom Municipal Airport (MWM), which was not equipped with a control tower, the pilot taxied to runway 35 about 0606. The pilot entered the runway, then exited and taxied back to the runway hold short line. According to air traffic control (ATC) recordings, the pilot activated his previously filed instrument flight rules (IFR) flight plan and obtained an IFR clearance that included a climb to 7,000 ft mean sea level (msl) and a right turn direct to Warren County Memorial Airport (RNC), McMinnville, North Carolina. According to radar data, the airplane departed runway 35 about 0621 and made multiple turns starting at 0623:24. The last ATC radar data was recorded at 0625:12 near the accident site, which was about 2.5 miles north of Runway 35. (see figure 1). The radar returns did not include the airplane’s altitude. No radio communications from the pilot were received by ATC. Figure 1. Radar Data of Accident Airplane’s Flight Track Toxicology testing identified citalopram and its metabolite, N-desmethylcitalopram, in the pilot’s liver tissue, but not in muscle tissue. Citalopram is an antidepressant that has not been shown to cause intellectual or psychomotor impairment. However, it is a psychoactive drug and carries a warning about the operation ofmachinery until the patient is convinced that the use of the drug does not interfere with their performance. In 2013, the pilot reported using an antidepressant and had undergone a review of his diagnosis of depression and its treatment and received a special issuance certificate. During subsequent medical certification, the pilot reported he was no longer taking the antidepressant medication. The pilot’s wife reported that the pilot was in good spirits during the months before the accident and that he was looking forward to meeting with a professional football player at the destination. A review of weather radar imagery did not identify any pertinent reflectivity in the accident region and there were no convective or non-convective SIGMET advisories applicable to the accident location and at the accident time. Review of the pilot’s logbook revealed that his initial flight in the accident airplane occurred on August 29, 2019. The last instrument approach flown was recorded by the pilot on June 29, 2020, which was the only instrument approach recorded during the 6 months preceding the accident. The airplane impacted a plowed field on an easterly heading about 2.5 miles from the end of runway 35 and slightly west of the extended runway centerline. The initial impact point included portions of the right wing position light and the debris path was about 220 ft long, consistent with a low-angle, high-energy impact. The engine crankcase was fractured in multiple locations, which prevented rotation of the engine. The three-bladed propeller remained attached to the crankshaft propeller flange. All three blades were bent aft near the hub and exhibited twisting and bending along their spans. The stabilator trim screw was in a position that corresponded to a full nose-up trim setting. The main landing gear remained attached to the wing and appeared to be in the extended position. The instrument panel was destroyed with only small pieces identified. Three gyro instruments that were identified had scoring on the gyro mass and adjacent housing that was consistent with rotation at impact. No preimpact anomalies were noted that would have precluded normal operation of the airplane. ## Aircraft - Registration: [N8178Y](https://openairdocs.org/deregistered/N8178Y-2022-12-31), registration cancelled 2022-12-31, S/N 32R-8029074, built 1980 (OpenAirDocs) - Reported make and model: PIPER PA32 (301T) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R8029074 - Year built: 1980 - Airframe hours: 3503 - Engines: Lycoming TIO-540-S1AD 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 25, 2020, 8 hours before - Departed: MWM, Windom, MN - Destination: RNC, McMinnville, TN - Flight plan: IFR - Airport: MWM, Windom Municipal Airport, runway 35, 3,598 × 75 ft, concrete - Equipment: Stall warning system, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, waiver time limited special; last flight review August 30, 2019; seat: left; toxicology performed; flight hours: 1,612 total, 93 in this make and model, 8 in the last 90 days, 1.3 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night - Wind: 10° at 7 knots - Visibility: 5 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 28 °F, dew point 28 °F - Altimeter: 30.14 inHg - Observed at: KMWM, 3 nm away - METAR: KMWM 061242Z AUTO 01007KT 5SM BR OVC004 M02/M02 A3014 RMK AO2 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20201206017829A](https://openairdocs.org/incident/20201206017829A), Dec 6, 2020: Piper PA-32R-301T, Windom, MN, Destroyed, 1 fatal. 2020-12-06, N8178Y Piper saratoga, departed runway 35 Windom, MN (kmwm). Time on deck was 0621L. 3 minutes later the aircraft crashed in a plowed farmers field… ## Docket (13 files) The files NTSB released with the investigation on June 15, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102378. 10.9 MB in all. - Airport video - correspondence (item 1, PDF, 1 page, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172763&FileExtension=pdf&FileName=Airport%20video%20information_Redacted-Rel.pdf - Pilot logbook (item 2, PDF, 10 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13173371&FileExtension=pdf&FileName=Pilot%20Logbook%20-%20back%20to%202019_Redacted-Rel.pdf - Meteorology specialist's factual report (item 3, PDF, 8 pages, 812 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11757860&FileExtension=pdf&FileName=WX_CEN21LA075_Specialists_Factual-Rel.pdf - Attachment 1 to the meteorology specialist's factual report (item 4, PDF, 12 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11757971&FileExtension=pdf&FileName=WX_CEN21LA075_Attachment_1_redacted-Rel.pdf - Flight plan information (item 5, PDF, 1 page, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194632&FileExtension=pdf&FileName=Foreflight%20info_Redacted-Rel.pdf - Radar flight data information (item 6, PDF, 2 pages, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13173558&FileExtension=pdf&FileName=Radar%20data%20information-Rel.pdf - Photos of wreckage (item 7, PDF, 4 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194642&FileExtension=pdf&FileName=Photos-Rel.pdf - Wreckage debris field information (item 8, PDF, 3 pages, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172174&FileExtension=pdf&FileName=Debris%20Field%20Diagram-Rel.pdf - Wreckage examinations summary (item 9, PDF, 4 pages, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13171590&FileExtension=pdf&FileName=Aircraft%20Examinations%20-%20Summary-Rel.pdf - Toxicological report (item 10, PDF, 1 page, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13173401&FileExtension=pdf&FileName=tox%20-_Redacted-Rel.pdf - Autopsy memorandum (item 11, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172753&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 2 pages, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13173282&FileExtension=pdf&FileName=Wreckage%20release_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 3 pages, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13174653&FileExtension=pdf&FileName=Party%20form%20-%20combined_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.