FLIGHT FINDINGSAVIATION OCCURRENCE MAP
Back to map

ERA19FA116 · Piper PA28 161

5 Mar 2019 · Fellsmere, FL, United States

Piper PA28 161 · Accident: loss of visual reference during initial climb

From Vero Beach Regional Airport (VRB) to Palm Beach County Glades Airport (PHK)

Report a problem

Event

NTSB case
ERA19FA116
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
1 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Instrument Meteorological Cond

Piper PA28 161

Aircraft type
Piper PA28
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N556PU
Operator
Unknown
Onboard fatalities
Unknown
Route
From Vero Beach Regional Airport (VRB), Vero Beach, FLTo Palm Beach County Glades Airport (PHK), Pahokee, FL
Aircraft age
About 19 years (built 2000)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Initial climb
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of visual reference
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Environmental issues › Conditions/weather/phenomena
  • Personnel issues › Experience/knowledge
  • Personnel issues › Psychological
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The student pilot was scheduled to complete a solo cross-country flight the day before the accident, and her flight instructor had provided the required endorsements for that flight; however, the flight was subsequently cancelled due to weather and was rescheduled for the following morning. When the pilot arrived on the airport the morning of the accident, she was released for the flight by the operations duty officer (DO), who was responsible for confirming that students had the proper endorsements for solo flight, even though her endorsements for the previous day's flight would have been no longer valid. The DO was also responsible for ensuring that weather conditions along a student's planned route of flight met the student’s prescribed limitations, and found that although the departure airport was reporting visual flight rules (VFR) conditions, the destination airports were reporting instrument flight rules (IFR) conditions. He stated that airports in the area tended to be IFR in the early-morning hours due to fog, then quickly improve to VFR after sunrise. He signed the pilot's flight risk assessment so that she could conduct her preflight inspection, but stressed to her that she needed to check the weather again before takeoff, and if conditions were still IFR, then the flight needed to be cancelled.

Between the time the DO released the pilot for the flight and the time she subsequently departed just after sunrise, weather conditions at the departure airport deteriorated from VFR to low IFR, including a cloud ceiling around 400 to 500 ft above ground level. The airplane likely entered instrument meteorological conditions (IMC) immediately after takeoff. A review of radar data revealed that the pilot flew west-northwest of the airport and made a series of climbing and descending turns before the airplane impacted terrain around 6 minutes after takeoff about 7.3 miles northwest of the airport. Postaccident examination of the airplane and the engine revealed no discrepancies that would have precluded normal operation. The airplane's radar track after takeoff did not suggest an immediate loss of control upon entering IMC; however, the climbing and descending turns near the end of the data are consistent with the known effects of spatial disorientation.

On the morning of the accident, four other students departed on solo flights. Three of the pilots departed just before the accident pilot. Two of these pilots stated that they checked the weather before their flights and conditions were VFR; however, it was still dark out and they could not see the clouds. All three pilots entered the clouds immediately after takeoff but were able to climb to a safer altitude and divert to another airport.

Students were required to obtain a weather briefing and file a flight plan as part of the preflight planning process. It could not be determined what weather information, if any, the pilot obtained the morning of the accident, and she did not file a flight plan for the flight.

The pilot was behind in her flight training schedule and had expressed concerns about being removed from the flight program. It is possible that she felt self-imposed pressure to complete the flight to remain in the program. Additionally, she may have assumed that she was cleared to conduct the flight upon being released by the DO, though previous communications with her instructor indicated that she was aware of the endorsement requirements.

Although the pilot should have known that her decision to depart on the flight without a flight plan and without an instructor endorsement met neither Federal Aviation Administration nor the school's published requirements, the DO should have recognized that the endorsements contained in her logbooks were for the previous day and not released the pilot for the flight without consulting the instructor.

Probable cause

The student pilot's loss of control due to spatial disorientation following an encounter with instrument meteorological conditions shortly after takeoff. Contributing to the accident was the failure of both the pilot and the flight school to ensure that the pilot had received the proper endorsements for the flight and the pilot’s self-imposed pressure to complete the flight in order to remain in the flight program.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record ERA19FA116
Event ID
20190305X45612
Case number
ERA19FA116
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status, cause areas. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 9c5aa7a409a6c928315655b54cbca808fdacf0c24b6cdf34feee762f9001113c; retrieved 2026-09-15T06:54:57.753Z.