ASN Wikibase Occurrence # 222622
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| Date: | Tuesday 5 March 2019 |
| Time: | 08:03 LT |
| Type: |  Piper PA-28-161 Warrior III |
| Owner/operator: | FlightSafety International Inc |
| Registration: | N556PU |
| MSN: | 2842093 |
| Year of manufacture: | 2000 |
| Total airframe hrs: | 13103 hours |
| Engine model: | Lycoming O-320-D3G |
| Fatalities: | Fatalities: 1 / Occupants: 1 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | south of Vero Lake Estates, Indian River County, FL -
 United States of America
|
| Phase: | Initial climb |
| Nature: | Training |
| Departure airport: | Vero Beach Municipal Airport, FL (VRB/KVRB) |
| Pahokee-Palm Beach County Glades Airport, FL (PHK/KPHK) | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
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had the proper endorsements for solo flight, even though her endorsements for the previous day's flight would have been no longer valid.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.
Accident investigation:
 |
|
Sources:
https://flightaware.com/live/flight/SFY429/history/20190305/1730Z/KVRB/KPHK
FAA register: https://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=N556PU
https://flightaware.com/photos/view/1158550-be496ee970e6a33c3c675c19dcdc395851c18428/aircrafttype/P28A
NTSB ERA19FA116
Location
Images:
Photo: NTSB
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 05-Mar-2019 21:10 | Captain Adam | Added |
| 06-Mar-2019 01:14 | Geno | Updated [Time, Nature, Departure airport, Destination airport, Source] |
| 06-Mar-2019 17:08 | Geno | Updated [Registration, Cn, Operator, Source, Narrative] |
| 31-Mar-2019 09:19 | yudongx | Updated [Phase, Source, Narrative] |
| 31-Mar-2021 08:19 | ASN Update Bot | Updated [Time, Other fatalities, Source, Damage, Narrative, Category, Accident report] |
| 31-Mar-2021 11:00 | harro | Updated [Source, Damage, Narrative, Photo] |
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