CEN24LA144 · Piper PA28 236

The instrument-rated pilot was repositioning the airplane to a maintenance facility for a pitot-static test required to complete instrument flight rules (IFR) certification. The pilot initially filed a visual flight rules (VFR) flight plan but later filed an IFR flight plan instead. The airplane departed and proceeded toward the destination airport. The destination airport local control (LC) controller advised the departure radar east (DRE) controller that the destination airport was instrument meteorological conditions (IMC) and the RNAV runway 14 approach was in use. The DRE controller then instructed the pilot to advise when he had the updated weather information for the destination airport and advised him to expect the RNAV runway 14 approach. The pilot responded that he had the updated weather information, and he acknowledged the RNAV runway 14 approach was in use. As the pilot approached the airport, the LC controller cleared the pilot to land on runway 14. According to air traffic control (ATC) surveillance data, the airplane tracked west of the final approach course. The pilot advised that he needed to perform a 360° turn and reported the field in sight, which the LC controller acknowledged. The LC controller then coordinated with the DRE controller and advised that the pilot was performing a 360° turn to realign with the approach. The DRE controller then asked the LC controller if the pilot was going to return to the approach. The LC controller stated that the pilot was doing a “quick 360.” The DRE controller advised the LC controller that he was going to vector an uninvolved airplane that had been following the accident airplane and would re-sequence it for the approach. The DRE controller asked the LC controller to let him know when the accident airplane landed, and the LC controller acknowledged. The LC controller advised the pilot that there was another airplane inbound for the approach behind him and instructed the pilot to advise when he was reestablished on final approach. The pilot acknowledged and stated he would report reestablished. The pilot then completed two clockwise 360° turns and, midway through a third turn, ATC surveillance data stopped approximately 0.8 nautical miles (nm) southwest of the runway 14 threshold. Two pedestrians who were walking together on a public walking trail sustained serious injuries when the airplane impacted wooded terrain. During the impact sequence, the wings and the empennage separated from the fuselage and the airplane was destroyed. Examination of the airframe, engine, and propeller found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The flaps were found at the fully extended position. The pitch trim was found in the full nose-down position. The airplane had not had an altimeter test, a pitot static test, or a transponder test performed within the 24 months before the accident, as required for operation under IFR in controlled airspace. A review of the pilot’s logbook showed that he had not met the required instrument experience requirements within the preceding 6 months. There was no record of the pilot obtaining an instrument proficiency check within the preceding 12 months. The owner of the maintenance facility the pilot was departing from reported that the pilot experienced difficulties operating and understanding the onboard navigation system, but that he knew of no issues with the systems. The pilot’s toxicology testing identified diphenhydramine. The quantity of the pilot’s specimen was not sufficient for quantitative testing. The specimen tested was also drawn at the same time as the pilot was receiving a large amount of donated blood products. Therefore, whether the diphenhydramine detected resulted from the pilot’s use or from transfused blood products could not be determined, and its contribution to the accident could not be established. During the post-accident evaluation, the pilot was found to have an intracranial vascular abnormality, or cavernous malformation. Cavernous malformations are common vascular brain lesions in adults. These lesions are increasingly identified due to more frequent use of brain imaging. Without symptoms such as seizures or headaches, the risk of serious effects is low. In this case, the pilot reportedly had no symptoms and was unaware of the lesion’s presence. It is unlikely that the cavernous malformation contributed to the accident. Neither post-accident drug nor alcohol testing were ordered nor conducted with the LC controller. Based on the available evidence, the pilot, who was not instrument current, initiated an IFR flight in an airplane that was not in compliance with required IFR equipment and inspection requirements. During the instrument approach, the pilot likely did not properly configure the onboard navigation system, resulting in the airplane tracking off course. When the pilot initiated a 360° turn during the instrument approach, the LC controller did not issue missed approach instructions in accordance with the tower’s standard operating procedures. Had the appropriate missed approach instructions been provided by the LC controller, the airplane likely would have been resequenced for another approach, rather than continuing the 360° turns. The presence of known IMC at the destination airport at the time of the accident was conducive to the development of spatial disorientation, and the airplane’s flight track is consistent with the known effects of spatial disorientation. The pilot’s 360° turns may have been appropriate in visual meteorological conditions (VMC); however, in IMC, they likely resulted in spatial disorientation and a subsequent loss of control.

Verbatim NTSB analysis and probable cause from the NTSB dataset