Piper PA20
Luray, VA — August 31, 2020
Event Information
| Date | August 31, 2020 |
| Event Type | ACC |
| NTSB Number | ERA20LA305 |
| Event ID | 20200902X44047 |
| Location | Luray, VA |
| Country | USA |
| Coordinates | 38.64038, -78.30716 |
| Highest Injury | FATL |
Aircraft
| Make | Piper |
| Model | PA20 |
| Category | AIR |
| FAR Part | 091 |
| Aircraft Damage | DEST |
Conditions
| Light Condition | DAYL |
| Weather | IMC |
Injuries
| Fatal | 1 |
| Serious | 0 |
| Minor | 0 |
| None | 0 |
| Total Injured | 1 |
Event Location
Probable Cause
The noninstrument-rated pilot’s continued visual flight into instrument meteorological conditions, which resulted in spatial disorientation, a loss of control, and collision with terrain.
Full Narrative
HISTORY OF FLIGHTOn August 31, 2020, about 1900 eastern daylight time, a Piper PA-20-135 airplane, N7323K, was destroyed when it impacted trees and terrain near Luray, Virginia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to a fixed-base operator (FBO) employee at Maryland Airport (2W5), Indian Head, Maryland, the pilot arrived a day or two before the accident and stayed in the local area. The pilot was reportedly on a “tour of the 48” lower United States and had originally departed from California for the cross-country trip. On the afternoon of the accident, the pilot discussed with the FBO employee and other pilots at the airport, that he planned to depart for Eastern WV Regional Airport/Shepherd Field (MRB), Martinsburg, West Virginia, as West Virginia was the next state in which he needed to complete a landing.
The FBO employee reported that, throughout the afternoon, the pilot had been “waiting for the weather to clear” and he was looking at “storms” on his iPad. The pilot was also reportedly concerned with the terrain and cloud ceilings along the route; his “biggest concern were [cloud] ceilings.” The FBO employee reported that the other pilots at the airport told the accident pilot that he should not depart along the route, and when the FBO employee closed the FBO office and left the airport at 1800, the pilot had not departed.
Review of Federal Aviation Administration (FAA) Automatic Dependent Surveillance - Broadcast (ADS-B) track data and air traffic control audio communications revealed that the airplane departed runway 20 at 2W5 at 1819. Shortly after takeoff, the pilot contacted Potomac Terminal Radar Approach Control Facility. The communications were routine; when the airplane exited the DC Special Flight Rules Area airspace, the pilot was given and accepted a frequency change. No further communications were received from the pilot. Figure 1 shows the airplane’s final 30 minutes of flight track overlaid on a visual flight rules (VFR) sectional chart. The magenta line depicts the airplane’s westbound flight track.
Figure 1. Overview of the final 30 minutes of the ADS-B flight track
At 1858, the airplane was flying westbound and entered a left turn at an altitude of about 4,500 ft mean sea level (msl) over Shenandoah National Park. Below and near the flight path, mountainous terrain ranged in elevation from about 2,000 to 3,500 ft msl. At 1859, the airplane had completed a left 360° turn and the altitude remained relatively constant. The airplane continued in a left turn; however, during this turn, its altitude began to rapidly decrease, and the turn developed into a rapidly-descending spiral. At 1859:27, the final position was recorded with the airplane at 2,950 ft msl about ¼ nautical mile east of the accident site. Figure 2 shows the final few minutes of the flight track.
Figure 2. Overview of the final few minutes of the flight track and a marking of the main wreckage
The wreckage was located by hikers about 1120, on Wednesday, September 2, 2020. There was no indication that an emergency locator transmitter (ELT) signal was received from the airplane.
According to Leidos Flight Service, there was no record that the pilot filed a VFR flight plan for the flight, nor was an official weather briefing requested on the day of the accident. The pilot did have an account with ForeFlight, and several routes of flight data entries the pilot entered into the application prior to and during flight were recovered from their servers. About the time of departure, the pilot had entered a route of flight with the initial destination of MRB; however, at 1839 and again at 1843, the pilot entered a route of flight with a revised intermediate destination airport of Grant County Airport (W99), Petersburg, West Virginia. Review of the flight track showed that about 1839, the course generally turned toward W99.
PERSONNEL INFORMATIONAccording to FAA airman records, the pilot was issued a private pilot certificate on February 8, 2020, with a rating for airplane single-engine land. He did not hold an instrument rating. A family member reported that the pilot had accumulated an estimated 200 hours of flight experience. The pilot’s logbook was not located in the wreckage.
AIRCRAFT INFORMATIONThe airplane was not equipped with an attitude indicator or any panel-mounted navigation system, nor was it required for day VFR flight. An impact damaged Stratux ADS-B Dual Band Receiver and SiriusXM receiver was found in the wreckage.
According to a user guide for the Stratux ADS-B receiver, the device has the capability via an electronic flight bag (EFB) application to display several weather products, such as METARs, TAFs, NEXRAD radar, AIRMETs, and SIGMETs. In addition, it can support the display of the airplane’s present position via WAAS GPS and can support the attitude indicator/synthetic vision feature through applications such as ForeFlight.
Photos posted on social media by the pilot about one month before the accident revealed that, in past flights he had mounted an EFB and the ADS-B receiver in the forward windscreen area. In one photo, the attitude indicator and synthetic vision feature was being used.
According to an “Important Notice” in the “Pilot’s Guide to ForeFlight Mobile,” Attitude Indicator/ Synthetic Vision chapter, the attitude indicator/ synthetic vision is for informational purposes and cannot be used as a primary instrument for any phase of flight. (see figure 3).
Figure 3. Excerpts from the ‘Pilot’s Guide to ForeFlight Mobile’ 90th Edition.
METEOROLOGICAL INFORMATIONRadar and satellite imagery at the time of the accident depicted an extensive area of low and mid-level clouds from the surface through 20,000 ft at the accident site. Light to moderate precipitation was identified along the final portions of the flight. The closest weather reporting station to the accident site was Luray Caverns Airport (LUA), Luray, Virginia, located about 9 miles west of the accident site at an elevation of 902 feet msl. At 1855, LUA reported visibility of 7 miles in moderate rain, overcast ceiling at 2,300 ft above ground level (agl), temperature 19°C, dew point 19°C, altimeter setting 30.01 inches of mercury (Hg), with remarks that the hourly precipitation was 0.07 of an inch. An additional observation at Front Royal-Warren County Airport (FRR), Frontal Royal, Virginia, located about 17 miles north of the accident site at an elevation of 704 ft, reported greater than 10 miles visibility with a broken ceiling at 2,000 ft agl.
Culpeper Regional Airport (CJR), Culpeper, Virginia, was located about 22 miles east of the accident site, at 1855, CJR reported 10 miles or more visibility with a ceiling overcast at 4,800 ft agl, and calm wind.
Review of the MRB hourly observations found that routine and special METARs reported instrument flight rules (IFR) conditions before the pilot’s departure. At 1745, MRB reported a special observation of visibility 1 3/4 miles, moderate rain, mist, scattered clouds at 700 ft agl, and overcast clouds at 1,600 ft agl. At 1752, a routine hourly observation was issued with nearly identical conditions. At 1806, MRB reported another special observation of visibility of 2 miles and moderate rain, mist, few clouds at 1,400 ft agl, broken clouds at 3,300 ft agl, and overcast clouds at 4,400 ft agl. At 1822, MRB reported visibility of 4 miles, light rain, mist, broken clouds at 3,600 ft agl and 4,500 ft, and overcast clouds at 5,500 ft. agl.
At 1815, W99 reported visibility of 10 miles with an overcast ceiling of 3,700 ft agl. At 1835, the weather observation remained similar, with an overcast ceiling at 3,100 ft agl.
In addition to the weather observation reports issued prior to the pilot’s departure, several forecast weather products warned of IFR and marginal visual flight rules (MVFR) conditions near the accident site. The National Weather Service (NWS) Low-Level Significant Weather Prognostic chart valid at the time of the accident predicted IFR and MVFR conditions near the accident site. The forecast for MRB from 1700 through 2000 expected wind from 120° at 7 knots, visibility 2 miles in moderate rain showers and mist, and an overcast ceiling at 800 ft agl.
AIRMET Sierra was issued before the pilot’s departure and was in effect at the time of the accident for the route of flight, for IFR conditions, precipitation, mist, and mountain obscuration.
AIRPORT INFORMATIONThe airplane was not equipped with an attitude indicator or any panel-mounted navigation system, nor was it required for day VFR flight. An impact damaged Stratux ADS-B Dual Band Receiver and SiriusXM receiver was found in the wreckage.
According to a user guide for the Stratux ADS-B receiver, the device has the capability via an electronic flight bag (EFB) application to display several weather products, such as METARs, TAFs, NEXRAD radar, AIRMETs, and SIGMETs. In addition, it can support the display of the airplane’s present position via WAAS GPS and can support the attitude indicator/synthetic vision feature through applications such as ForeFlight.
Photos posted on social media by the pilot about one month before the accident revealed that, in past flights he had mounted an EFB and the ADS-B receiver in the forward windscreen area. In one photo, the attitude indicator and synthetic vision feature was being used.
According to an “Important Notice” in the “Pilot’s Guide to ForeFlight Mobile,” Attitude Indicator/ Synthetic Vision chapter, the attitude indicator/ synthetic vision is for informational purposes and cannot be used as a primary instrument for any phase of flight. (see figure 3).
Figure 3. Excerpts from the ‘Pilot’s Guide to ForeFlight Mobile’ 90th Edition.
WRECKAGE AND IMPACT INFORMATIONAn FAA inspector responded to the accident site. The main wreckage was located at the bottom of a steep ravine in heavily wooded terrain about 2,300 ft msl. The wreckage was scattered in a southerly direction. The cockpit, wings, and fuselage were heavily fragmented. There was no evidence of fire at the accident site.
The airframe and engine were examined at the recovery facility. Each flight control cable was cut by the recovery crew; however, flight control cable continuity was traced from the cuts to their respective attach points. Both wing fuel tanks were destroyed. The elevator trim jackscrew was exposed about 8 threads, which corresponded to a slight nose-down trim setting. The fuel gascolator was impact damaged, but the bowl was clear of debris. The fuel selector valve was not located in the recovered wreckage.
The engine remained partially attached to the firewall and the propeller had separated from the hub. Continuity of the crankshaft, camshaft, and connecting rods were confirmed by visual examination. The carburetor was impact damaged and had separated from the engine. Its inlet fuel screen was removed and was clean.
Both magnetos produced a spark at all four leads when rotated by hand. All spark plugs, with exception of the No. 2 cylinder bottom spark plug, which sustained heavy impact damage, remained attached to the respective spark plug leads. According to the Champion Check-A-Plug chart, the spark plugs displayed normal combustion. The oil pressure screen and the oil suction screen were both removed, and both were clean. The heat muffler exhibited impact damage, but no preimpact anomalies were observed.
The two-bladed metal fixed-pitch propeller was separated from the engine. One blade was bent forward while the other was bent aft; both blades exhibited S-type bending with trailing and leading-edge damage. The propeller spinner was destroyed.
Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation.
ADDITIONAL INFORMATIONSpatial Disorientation
The FAA Civil Aerospace Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude.
The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part:
The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.
MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by Department of Health, Office of the Chief Medical Examiner, Manassas, Commonwealth of Virginia. The cause of death was stated as “Multiple blunt force injuries” and the manner of death was “accident.” Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for alcohol and other drugs.
About This NTSB Record
This aviation event was investigated by the National Transportation Safety Board (NTSB). NTSB investigates all U.S. civil aviation accidents to determine probable cause and issue safety recommendations to prevent future accidents.