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Spatial disorientation fatal for two

By NTSB · February 2, 2024 ·

The flight was conducted as an instrument flight rules (IFR) flight from Effingham County Memorial Airport (1H2) in Illinois to Findlay Airport (KFDY) in Ohio.

The filed IFR flight plan stipulated a cruise altitude of 9,000 feet mean sea level (msl), an estimated time en route of 1 hour 28 minutes, with 4 hours of fuel on board the Piper PA-32.

A review of Automatic Dependent Surveillance-Broadcast (ADS-B) data revealed that the Piper departed 1H2 about 1956 central standard time, climbed to about 7,000 feet msl and proceeded on a relatively direct track toward DOYET, the initial approach fix for the RNAV/GPS runway 25 instrument approach.

After passing DOYET, the airplane made about a 30° left turn, consistent with a teardrop entry into the procedure turn. The airplane aligned with the outbound side of the holding pattern for about a mile before turning left again.

As the airplane flew north of the published holding pattern in its final minute of flight its altitude decreased from about 3,000 feet to about 2,600 feet before climbing back to about 3,000 feet. About four nm from the IAF, the airplane turned right, descended rapidly in a spiral, and hit terrain on a heading of 340°.

A review of commercially available communications data revealed that the last confirmed communication between the airplane and air traffic control (ATC) took place when ATC instructed the pilot to cross DOYET at or above 3,000 feet and cleared them for the RNAV Runway 25 approach, to which the pilot read back the clearance and altitude restriction.

Shortly after, ATC attempted to contact the pilot and subsequently issued a low altitude alert, but no reply or acknowledgement was received.

A witness inside their residence described hearing an airplane low near their house in Fostoria, Ohio. They described the noise as a loud engine or high rpm engine followed by silence.

Another nearby witness saw the lights of the airplane, but did not hear anything because they were in a car with the radio on. They said that at first sight, the airplane was estimated between 300 and 500 feet above ground level (agl). When they lost sight of the airplane as it descended behind houses, they estimated the altitude between 150 and 250 feet AGL.

The airplane impacted a field in a relatively flat attitude and continued on a 340° track into a forest, where it collided with multiple trees and became highly fragmented. Flight control continuity could not be established due to the highly fragmented nature of the wreckage, but all lengths of control cables were accounted for at the accident location. All major pieces of the airplane were observed at the accident location.

The aircraft was destroyed in the crash, while both the pilot and passenger were fatally injured.

A post-accident examination of the engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation.

The FAA Forensic Sciences laboratory performed toxicological testing on the pilot and found two types of sedating antihistamine medication, diphenhydramine and doxylamine.

Sedating antihistamines can cause cognitive and psychomotor slowing and drowsiness, and products containing sedating antihistamines often carry warnings that they may impair performance of tasks like driving and operating heavy machinery.

The FAA states that pilots should not fly within 60 hours of using diphenhydramine or doxylamine to allow time for the drugs to be cleared from circulation.

Probable Cause: The pilot’s loss of airplane control in night instrument meteorological conditions during the procedure turn of an instrument approach due to spatial disorientation, which resulted in a collision with terrain.

NTSB Identification: 104683

To download the final report. Click here. This will trigger a PDF download to your device.

This February 2022 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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