# NTSB WPR22FA026: Ayres S-2R, N8960Q, Shafter, CA, November 3, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 3, 2021, 11:30 local (18:30 UTC) - Place: Shafter, CA · open field - Coordinates: 35.519039, -119.21833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.5190&lon=-119.2183&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: Western Pacific Region - Parties: Federal Aviation Administration, Honeywell - NTSB case key (mKey): 104201 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA026 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104201/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104201 - Page: https://openairdocs.org/ntsb/WPR22FA026 ## Probable cause The pilot’s decision to depart into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause) ## 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 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 best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event) ## Aircraft - Registration: [N8960Q](https://openairdocs.org/aircraft/N8960Q), registered now, S/N 2450R, built 1978 (OpenAirDocs) - Reported make and model: AYRES CORPORATION S-2R - Registry model: [Ayres S-2R](https://openairdocs.org/model/ayres-s-2r) (registry code 0970101) (OpenAirDocs) - Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2450R - Year built: 1978 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; 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 ## 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 20211103018019A](https://openairdocs.org/incident/20211103018019A), Nov 3, 2021: Ayres Corporation S-2R, Shafter, CA, Destroyed, 1 fatal. At approximately 1930 UTC on November 3, 2021, [privacy data omitted] departed kmit for L88 in N890Q. Soon after takeoff N890Q impacted the terrain in a right… ## Other investigations on N8960Q (1) 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. - [NTSB LAX98LA238](https://openairdocs.org/ntsb/LAX98LA238), Jul 21, 1998: Ayres S2R (N8960Q), Shafter, CA, substantial damage. Probable cause: The pilot's failure to maintain an adequate clearance from the irrigation standpipe due to glare from the rising sun. ## Docket (11 files) The files NTSB released with the investigation on December 6, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104201. 27.2 MB in all. - Ntsb-onsite examination summary (item 1, PDF, 7 pages, 6 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16308224&FileExtension=pdf&FileName=WPR22FA026%20Onsite%20Examination%20Summary%20Report-Rel.pdf - Statement of party representatives to NTSB investigation-honeywell (item 2, PDF, 1 page, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16308105&FileExtension=pdf&FileName=McDuffie%20Party%20Form_Redacted-Rel.pdf - Witness statements (item 3, PDF, 4 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16308622&FileExtension=pdf&FileName=Witness%20Statements-redacted-Rel.pdf - Weather factual report (item 4, PDF, 18 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13177244&FileExtension=pdf&FileName=WPR22FA026_weatherfactualSuffernfinal-Rel.pdf - Weather attachment 1 (item 5, PDF, 2 pages, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13177071&FileExtension=pdf&FileName=attachment1_justKMITobservations_Redacted-Rel.pdf - Weather attachment 2 (item 6, GIF, 17.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13176714&FileExtension=gif&FileName=attachment2_animationSAT_VIS_1701to1901utc_CODNEXLAB-GOES-West-local-Cen_California-02-19_01Z-20211103_map-id_-25-1n-10-100-Rel.gif - Weather attachment 3 (item 7, PDF, 5 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13176818&FileExtension=pdf&FileName=attachment3_GFAimagedata-Rel.pdf - Tox report (item 8, PDF, 1 page, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16349589&FileExtension=pdf&FileName=Tox%20Report_Redacted-Rel.pdf - Medical factual (item 9, PDF, 3 pages, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14360450&FileExtension=pdf&FileName=WPR22FA026_Medical%20Factual%20Report-Rel.pdf - Ntsb-wreckage examination summary (item 10, PDF, 13 pages, 17 photos, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16308602&FileExtension=pdf&FileName=WPR22FA026%20Wreckage%20Examination%20Summary%20Report-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16308582&FileExtension=pdf&FileName=Retention-Release-of-Wreckage-Form%202015_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.