ERA22LA043

NTSB accident investigation · Piper PA-28-236 · Orleans, MA · October 31, 2021

Accident · FatalClass 3 · LimitedFinal report
Date
October 31, 2021, 19:00 local (23:00 UTC)
Place
Orleans, MA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N2186UPiper PA-28-236
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Piper Aircraft
FAA report
20211031018289A
Case key
104196

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

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Probable cause

The pilot’s spatial disorientation and subsequent loss of airplane control while maneuvering over water in dark night conditions.

Findings · 4

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 · PilotPiper PA-28-236: 8 casesAll aircraft: 9,295 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-28-236: 3 casesAll aircraft: 448 casesProbable cause
Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-236: 1 caseAll aircraft: 97 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

The private pilot departed on a cross-country flight, and after takeoff, the airplane flew in a straight line at an altitude about 8,000 ft mean sea level (msl). It began a descent toward a presumed destination airport in dark night visual meteorological conditions. Continuing on the established track, the airplane descended to and maintained 1,000 ft msl. The flightpath turned slightly before the airplane overflew and continued past the destination airport, turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. During the overwater portion of the flight, the airplane’s altitude varied between 750 ft and 1,100 ft msl. Before track data were lost, the airplane began a descending right turn from about 1,025 ft to 675 ft msl. The debris field located about 2.5 miles offshore and 7 miles from the destination airport. The airplane was not recovered. The uniformity of the flight track and altitude data for most of the flight suggests that the pilot was using the airplane’s autopilot. After overflying the airport, the airplane’s track and altitude variations were consistent with the pilot having disengaged the autopilot to hand-fly the airplane; however, continued flight over the ocean would have resulted in a near absence of cultural lighting and external visual references, requiring the use of instruments to maintain control. The pilot was neither qualified nor proficient to conduct the flight by reference to instruments and would have been vulnerable to the onset of spatial disorientation during the overwater portion of the flight. It is likely that, while maneuvering over the ocean, the pilot became spatially disoriented, resulting in a loss of control and impact with the water.

Factual narrative

On October 31, 2021, about 1900 eastern daylight time, a Piper PA-28-236 airplane, N2186U, was presumed destroyed when it was involved in an accident near Orleans, Massachusetts. The private pilot was not located and presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a fuel receipt, the pilot fueled the airplane with 53.8 gallons of 100LL aviation fuel at Freeman Municipal Airport (SER), Seymour, Indiana, at 1203. Automatic Dependent Surveillance-Broadcast (ADS-B) track data provided by the Federal Aviation Administration (FAA) indicated that the airplane departed SER at 1256. At 1623, the airplane landed at Reading Regional Airport/Carl A Spaatz Field (RDG), Reading, Pennsylvania, where it was fueled with 48.6 gallons of 100LL aviation fuel. The airplane departed RDG on the accident flight at 1653. During the flight, the autopilot-equipped airplane flew at an altitude of about 8,000 ft mean sea level (msl), in a straight line, until it began the descent toward Chatham Municipal Airport (CQX), Chatham, Massachusetts. Continuing its established flight track, the airplane descended to and maintained 1,000 ft msl, and then the flight path turned slightly before the airplane overflew CQX on a 080° heading. The airplane continued past the airport, and the altitude began to vary between 1,100 ft and 750 ft. The airplane turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. At 1849:26, the airplane began a descending right turn from about 1,025 ft msl before track data was lost at 1849:33, at an altitude of 675 ft msl. The following figure provides an overview of the final portion of the accident flight track, CQX, and the location of the debris field. The flight track is depicted in green. The airport is depicted by the pin labeled CQX, and the location of the debris field is depicted by the airplane labeled N2186U. Figure – Flight track information A debris field was located on November 3, 2021, at a water depth of about 80 ft about 2.5 miles from the Cape Cod National Seashore and 7 miles from CQX; however, the airplane was not recovered. The FAA did not provide any air traffic control services to the pilot during the accident flight. According to the airport manager at CQX, the airport lighting system was tested the day of the accident and the day after the accident and was fully functional. According to FAA airman records, the pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued November 12, 2019. At that time, he reported 300 total hours of flight experience, of which 75 hours were within the previous 6 months. The pilot did not hold an instrument rating. The pilot reported no concerns on his recent medical application and no significant issues were identified by the aviation medical examiner. According to FAA airworthinessrecords, the airplane was powered by a Lycoming O 540 series engine equipped with a Hartzell propeller. Review of maintenance records revealed that the airplane’s most recent annual inspection was completed on January 14, 2021, at a total time of 3,336.4 airframe hours and 1,291.6 hours since major overhaul of the engine. According to astronomical data, on the day of the accident, the sunset was at 1735 and the end of civil twilight was at 1803. Moonrise was at 0150 and moonset was at 1547. The phase of the moon was waning crescent, with 20% of the moon’s visible disk illuminated; however, at the time of the accident, the position of the moon was under the horizon. The 1852 recorded weather observation at CQX included wind from 230 at 6 knots, 10 miles visibility, clear skies, temperature 13°C, dew point 18°C; and an altimeter setting of 29.63 inches of mercury. The FAA's Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) stated that: Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which combinations of normal motions and forces can create convincing illusions that are difficult to overcome. The Handbook also advised, "unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible."

Aircraft

Registration
N2186U
Reported as
Piper PA-28-236
Category
Airplane
Serial number
28-7911121
Built
1979
Airframe hours
3,336.4
Engine
Lycoming O-540 SERIES, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 14, 2021
Departed
RDG · Reading, PA
Destination
CQX · Chatham, MA
Airport
CQX · Chatham Municipal Airport
Equipment
Unknown

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
66
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Flight hours
300 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
230° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 55 °F
Altimeter
29.63 inHg
Observed at
CQX, 6 nm away
METAR
KCQX 312252Z AUTO 23006KT 10SM CLR 14/13 A2963 RMK AO2 SLP035 T01440133

Docket · 10

The files NTSB released with the investigation on September 7, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 91.0 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.