Aviation Investigation Final Report

Location: Luray, Virginia Accident Number: ERA20LA305

Date & Time: August 31, 2020, 19:00 Local Registration: N7323K

Aircraft: Piper PA20 Aircraft Damage: Destroyed

Defining Event: VFR encounter with IMC Injuries: 1 Fatal

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

Throughout the afternoon of the accident flight, the noninstrument-rated pilot had delayed his
departure due to poor weather along his intended route, and despite any meaningful change in
the weather conditions along the route or at the presumed destination, he decided to depart.
Data obtained from the pilot’s electronic flight bag (EFB) application, in addition to a course
change in the airplane’s recorded flight track, indicated that, about 20 minutes into the flight,
the pilot initiated a diversion to a new airport. Although the new airport was reporting visual
flight rules (VFR) conditions, instrument flight rules (IFR) conditions and mountain
obscuration were present along the route of flight. Each of these conditions were forecast
before the pilot’s departure. Review of the weather conditions along the route indicated that
the pilot passed airports with VFR conditions but chose to continue into an area of
deteriorating visibility and cloud ceilings.

As the pilot approached rising terrain toward the new destination, the flight track deviated to
the left and right, followed by a left 360° level turn. The 360° turn was completed in about 1
minute. The airplane then continued in a second left turn, during which its altitude began to
rapidly decrease, and the turn developed into a descending spiral. The final position was
recorded with the airplane about 500 ft above terrain about ¼ mile east of the accident site.
The airplane’s flight track was consistent with the known effects of spatial disorientation and a
subsequent loss of control and impact with terrain.

The wreckage was located 40 hours after the accident in heavily wooded terrain at the bottom
of a steep ravine. The fragmentation of the wreckage indicated that the airplane impacted
terrain in a high speed, uncontrolled descent. A postaccident examination of the airplane did
not reveal any evidence of mechanical malfunctions. The pilot did not file a flight plan, obtain
an official weather briefing, nor was he receiving air traffic control services at the time of the
accident.

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It is likely that the pilot encountered instrument meteorological conditions (IMC), which
included rain, clouds, and low visibility, as he neared the rising terrain and continued flight
into IMC. The pilot did not possess the qualifications to operate in IMC, and the airplane was
not equipped for IFR flight. The investigation found evidence that the pilot likely relied
extensively on an EFB application for GPS navigation. Photos from the pilot’s past flights
showed that he had mounted the EFB in the forward windscreen area and data retrieval from
the EFB application found that the pilot was actively utilizing the EFB while enroute in the
accident flight. It is possible that the pilot was utilizing the application’s attitude
indicator/synthetic vision feature as he entered IMC. The EFB application pilot’s guide stated
that the attitude indicator/synthetic vision feature may only be used for informational
purposes and cannot be used as a primary reference.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

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.

Findings
Personnel issues Qualification/certification - Pilot
Personnel issues Decision making/judgment - Pilot
Personnel issues Spatial disorientation - Pilot
Personnel issues Weather planning - Pilot

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Factual Information

History of Flight
Enroute-cruise VFR encounter with IMC (Defining event)
Enroute-cruise Loss of control in flight
Enroute-cruise Collision with terr/obj (non-CFIT)

On 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.

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 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.

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 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.

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 Pilot Information
Certificate: Private Age: 35,Male
Airplane Rating(s): Single-engine land Seat Occupied: Left
Other Aircraft Rating(s): None Restraint Used: 3-point
Instrument Rating(s): None Second Pilot Present: No
Instructor Rating(s): None Toxicology Performed: Yes
Medical Certification: Class 2 Without Last FAA Medical Exam: July 18, 2018
waivers/limitations
Occupational Pilot: No Last Flight Review or Equivalent: February 8, 2020
Flight Time: (Estimated) 200 hours (Total, all aircraft)

According 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 and Owner/Operator Information

Aircraft Make: Piper Registration: N7323K
Model/Series: PA20 135 Aircraft Category: Airplane
Year of Manufacture: 1950 Amateur Built:
Airworthiness Certificate: Normal Serial Number: 20-268
Landing Gear Type: Tailwheel Seats: 4
Date/Type of Last July 3, 2020 Annual Certified Max Gross Wt.: 1800 lbs
Inspection:
Time Since Last Inspection: 126 Hrs Engines: 1 Reciprocating
Airframe Total Time: 1945 Hrs at time of accident Engine Manufacturer: Lycoming
ELT: C91A installed, not activated Engine Model/Series: O-290-D
Registered Owner: On file Rated Power: 125 Horsepower
Operator: On file Operating Certificate(s) None
Held:

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The 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.

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 Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument (IMC) Condition of Light: Day
Observation Facility, Elevation: LUA,902 ft msl Distance from Accident Site: 9 Nautical Miles
Observation Time: 18:55 Local Direction from Accident Site: 270°
Lowest Cloud Condition: 2300 ft AGL Visibility 7 miles
Lowest Ceiling: Overcast / 2300 ft AGL Visibility (RVR):
Wind Speed/Gusts: 4 knots / Turbulence Type None / None
Forecast/Actual:
Wind Direction: 360° Turbulence Severity N/A / N/A
Forecast/Actual:
Altimeter Setting: 30.01 inches Hg Temperature/Dew Point: 19°C / 19°C
Precipitation and Obscuration: Moderate - None - Rain
Departure Point: Indian Head, MD (2W5 ) Type of Flight Plan Filed: None
Destination: Petersburg, WV (W99) Type of Clearance: None
Departure Time: 18:19 Local Type of Airspace: Class G

Radar 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.

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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.

Wreckage and Impact Information

Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger Aircraft Fire: None
Injuries:
Ground Injuries: Aircraft Explosion: None
Total Injuries: 1 Fatal Latitude, 38.640377,-78.307158
Longitude:

An 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

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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.

Medical and Pathological Information

An 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.

Additional Information

Spatial 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,

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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.

Preventing Similar Accidents

Reduced Visual References Require Vigilance (SA-020)

The Problem

About two-thirds of general aviation accidents that occur in reduced visibility weather
conditions are fatal. The accidents can involve pilot spatial disorientation or controlled flight
into terrain. Even in visual weather conditions, flights at night over areas with limited ground
lighting (which provides few visual ground references) can be challenging.

What can you do?

 Obtain an official preflight weather briefing, and use all appropriate sources of weather
information to make timely in-flight decisions. Other weather sources and in-cockpit
weather equipment can supplement official information.
 Refuse to allow external pressures, such as the desire to save time or money or the fear
of disappointing passengers, to influence you to attempt or continue a flight in
conditions in which you are not comfortable.
 Be honest with yourself about your skill limitations. Plan ahead with cancellation or
diversion alternatives. Brief passengers about the alternatives before the flight.
 Seek training to ensure that you are proficient and fully understand the features and
limitations of the equipment in your aircraft, particularly how to use all features of the
avionics, autopilot systems, and weather information resources.
 Don’t allow a situation to become dangerous before deciding to act. Be honest with air
traffic controllers about your situation, and explain it to them if you need help.
 Remember that, when flying at night, even visual weather conditions can be challenging.
Remote areas with limited ground lighting provide limited visual references cues for
pilots, which can be disorienting or render rising terrain visually imperceptible. When
planning a night VFR flight, use topographic references to familiarize yourself with
surrounding terrain. Consider following instrument procedures if you are instrument

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 rated or avoiding areas with limited ground lighting (such as remote or mountainous
areas) if you are not.
 Manage distractions: Many accidents result when a pilot is distracted momentarily from
the primary task of flying.

See https://www.ntsb.gov/Advocacy/safety-alerts/Documents/SA-020.pdf for additional

resources.

The NTSB presents this information to prevent recurrence of similar accidents. Note that this
should not be considered guidance from the regulator, nor does this supersede existing FAA
Regulations (FARs).

Administrative Information
Investigator In Charge (IIC):
Additional Participating
Persons:
Original Publish Date:
Investigation Class:
Note:
Investigation Docket:
Gerhardt, Adam
David Reese; FAA/ FSDO; Washington, DC
Damian Galbraith ; Piper Aircraft; Vero Beach, FL
Ryan Enders; Lycoming Engines; Williamsport, PA
June 28, 2022
Class 3
The NTSB did not travel to the scene of this accident.
https://data.ntsb.gov/Docket?ProjectID=101906

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with
investigating every civil aviation accident in the United States and significant events in other modes of transportation—
railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents
and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we
conduct transportation safety research studies and offer information and other assistance to family members and
survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions
involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and
we adjudicate appeals of civil penalty actions taken by the FAA.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,
“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are
not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations
section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve
transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition,
statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a
civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). A
factual report that may be admissible under 49 United States Code section 1154(b) is available here.

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