WPR22FA026

NTSB accident investigation · Ayres S-2R · Shafter, CA · November 3, 2021

Accident · FatalClass 3 · FieldFinal report
Date
November 3, 2021, 11:30 local (18:30 UTC)
Place
Shafter, CA · open field
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8960QAyres S-2R
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Honeywell
FAA report
20211103018019A
Case key
104201

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

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot’s decision to depart into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The instrument-rated commercial pilot departed from the airport and was planning to conduct a visual flight rules aerial application flight in an airplane that was not equipped for instrument flight rules (IFR) operations. Shortly after departure, the airplane entered instrument meteorological conditions (IMC). The airplane impacted terrain about 1 1/4 mile from the departure airport. The wreckage field was about 800 ft in length. A postaccident examination of the airframe and engine revealed no mechanical anomalies that would have prevented normal operation. A witness who spoke with the pilot before the flight reported that the pilot said that the fog had cleared for a few moments and that he had missed his opportunity to depart the airport. About 20-30 minutes later the pilot departed the airport with a 200 ft cloud ceiling and 1/2 mile of visibility. Another witness who spoke with the pilot stated that the pilot had checked the weather. Multiple weather sources indicated low ceilings and the presence of fog, which is conductive to low IFR conditions, before and at the time of the accident for the area near the accident site. Given the weather data and witness statements, the airplane likely flew into an area of fog and low clouds during departure and just before the accident. Based on the wreckage distribution, which was consistent with a high-speed impact, and the low visibility and ceiling present at the time of the accident, it is likely that the pilot experienced spatial disorientation and lost airplane control.

Factual narrative

The factual narrative776 words

On November 3, 2021, about 1130 Pacific daylight time, a Thrush Ayers Corporation S-2R airplane, N8960Q, was destroyed when it was involved in an accident near Shafter, California. The pilot was fatally injured. The airplane was operated by Inland Aviation, Inc., as a Title 14 Code of Federal Regulations Part 91 repositioning flight prior to conducting aerial application activity. A witness who spoke with the pilot before the flight stated that the pilot said the fog had cleared for a few moments and that he had missed his “window to leave.” About 20-30 minutes later he heard the pilot’s airplane start and take off. Another witness who spoke with the pilot reported that the pilot had been in and out of the office to use the phone and to check weather. His last comment to the witness was, “…you just have to get high enough over the top of the weather to get in the clear.” A third witness who was at his house about 6 miles west of the airport stated that around 1220 the visibility was 1/2 to 1 mile, with patchy fog and low ceilings of about 400 ft above ground level (agl). According to the post-accident meteorology report, weather conditions along the accident pilot’s flight path was IMC. The accident pilot’s flight in IMC might have led to his inability to see outside visual references. When there are no outside visual references, pilots must rely on use of flight instruments to understand their position in space. If a pilot does not reference the aircraft flight instruments and there are no outside visual references, the pilot might experience spatial disorientation. In this case, the aircraft was not equipped with equipment that would be necessary for IFR flight, and therefore the accident pilot likely did not have all the required flight instruments to adequately assess his position in flight in IMC, and he likely experienced spatial disorientation. It is likely the accident pilot was not referencing his flight instruments or was experiencing an increase in workload because of spatial disorientation, and he did not recover the aircraft from its descent into terrain. According to the operator, the purpose of the flight to New Cuyama Airport (L88), California, was to load the accident airplane with dry seed to disperse at a farm near L88. The pilot attempted to depart Shafter Airport-Minter Field (MIT), Shafter, California, earlier in the morning but had canceled the flight due to the overcast conditions at MIT. The pilot departed on the accident flight about 1130. MIT was situated at an elevation of 424 ft above mean sea level (msl). It was equipped with three paved runways. The runway used, designated 8/26, which measured 3,680 ft by 60 ft, was not equipped with an air traffic control tower. Postaccident examination of the accident site revealed that the airplane impacted level, fallow terrain about 1 1/4 miles northwest of runway 26 at MIT. The debris field was about 800 ft in length on a westerly heading. The airplane impacted terrain andcollided with an irrigation standpipe located near the middle of the debris field. A postimpact fire ensued. The single-seat, low-wing, fixed-gear airplane was configured for aerial application operations with an aerial spray system. The airplane was not equipped with any instruments required for instrument flight. The accident pilot did not request weather information from Leidos Flight Service on the day of the accident. A search of archived ForeFlight information indicated that the accident pilot did not request weather information from ForeFlight on the day of the accident. The accident site was in an area of relatively high surface pressure, calm wind conditions, and moist surface conditions. In addition, two temperature inversions were located above the accident site, one inversion below 3,000 ft msl and another inversion below 5,000 ft msl. At 1125, an automated weather observing system (AWOS) located at MIT, reported wind from 160° at 3 knots, visibility was 1/2 statute mile, overcast ceiling at 200 ft agl, temperature 14°C, dew point temperature of 14°C, and an altimeter setting of 30.20 inches of mercury. The Geostationary Operational Environmental Satellite-17 (GOES-17) provided visible imagery from 1130 PDT indicating cloud cover above the accident site and southeastward towards Meadows Field Airport (BFL), Bakersfield, California. The cloud cover was decreasing in areal coverage with time. Figure 1-GOES-17 visible image at 1130 PDT. KBFL was the closest airport to the accident site (9 miles southeast of the accident site) with an National Weather Service Terminal Aerodrome Forecast (TAF). The KBFL TAF that was valid at the time of the accident expected calm wind, 1/2 mile visibility, fog, and an overcast ceiling at 400 ft agl.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N8960Q
Reported as
Ayres S-2R
Category
Airplane
Serial number
2450R
Built
1978
Engine
Garrett TPE-331-6-252M, 600 horsepower, turbo prop
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial application · Part 137
Operator
Max A. Hanner
Registered owner
Inland Crop Dusters Inc
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · February 3, 2021 · 7,220 hours before
Destination
L88 · New Cuyama, CA
Flight plan
Company VFR
Airport
MIT · Shafter-Minter Fld, runway 26, 3,680 × 60 ft, asphalt
Equipment
Stall warning system

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
62
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Single
Restraint
5-point
Flight hours
18,400 total

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 4 knots
Visibility
0.75 statute miles
Lowest ceiling
400 ft overcast
Temperature
57 °F, dew point 55 °F
Altimeter
30.19 inHg
Icing
Unknown
Turbulence
Unknown
Observed at
KBFL, 8 nm away
METAR
KBFL 031819Z 23004KT 1 3/4SM BR OVC004 14/13 A3019 RMK AO2 TWR VIS 2 T01390133

Docket · 11

The files NTSB released with the investigation on December 6, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.2 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.

Other investigations on N8960Q · 1

Matched to the same aircraft by N-number and date.