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Atlas / NTSB / ERA22LA043

NTSB CAROL · Event

Event ERA22LA043

2021-10-31 Orleans, Massachusetts, United States Airport · CQX Fatal 1 aircraft Status: Completed

Aircraft involved

Probable cause & findings

The pilot’s spatial disorientation and subsequent loss of airplane control while maneuvering over water in dark night conditions.

Factual narrative

On October 31, 2021, about 1900 eastern daylight time, a Piper PA-28-236 airplane, N2186U, was presumed destroyed when it was involved in an accident near Orleans, Massachusetts. The private pilot was not located and presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a fuel receipt, the pilot fueled the airplane with 53.8 gallons of 100LL aviation fuel at Freeman Municipal Airport (SER), Seymour, Indiana, at 1203. Automatic Dependent Surveillance-Broadcast (ADS-B) track data provided by the Federal Aviation Administration (FAA) indicated that the airplane departed SER at 1256. At 1623, the airplane landed at Reading Regional Airport/Carl A Spaatz Field (RDG), Reading, Pennsylvania, where it was fueled with 48.6 gallons of 100LL aviation fuel. The airplane departed RDG on the accident flight at 1653.   During the flight, the autopilot-equipped airplane flew at an altitude of about 8,000 ft mean sea level (msl), in a straight line, until it began the descent toward Chatham Municipal Airport (CQX), Chatham, Massachusetts. Continuing its established flight track, the airplane descended to and maintained 1,000 ft msl, and then the flight path turned slightly before the airplane overflew CQX on a 080° heading. The airplane continued past the airport, and the altitude began to vary between 1,100 ft and 750 ft. The airplane turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. At 1849:26, the airplane began a descending right turn from about 1,025 ft msl before track data was lost at 1849:33, at an altitude of 675 ft msl. The following figure provides an overview of the final portion of the accident flight track, CQX, and the location of the debris field. The flight track is depicted in green. The airport is depicted by the pin labeled CQX, and the location of the debris field is depicted by the airplane labeled N2186U. Figure – Flight track information A debris field was located on November 3, 2021, at a water depth of about 80 ft about 2.5 miles from the Cape Cod National Seashore and 7 miles from CQX; however, the airplane was not recovered. The FAA did not provide any air traffic control services to the pilot during the accident flight. According to the airport manager at CQX, the airport lighting system was tested the day of the accident and the day after the accident and was fully functional. According to FAA airman records, the pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued November 12, 2019. At that time, he reported 300 total hours of flight experience, of which 75 hours were within the previous 6 months. The pilot did not hold an instrument rating. The pilot reported no concerns on his recent medical application and no significant issues were identified by the aviation medical examiner. According to FAA airworthiness records, the airplane was powered by a Lycoming O540 series engine equipped with a Hartzell propeller. Review of maintenance records revealed that the airplane’s most recent annual inspection was completed on January 14, 2021, at a total time of 3,336.4 airframe hours and 1,291.6 hours since major overhaul of the engine.   According to astronomical data, on the day of the accident, the sunset was at 1735 and the end of civil twilight was at 1803. Moonrise was at 0150 and moonset was at 1547. The phase of the moon was waning crescent, with 20% of the moon’s visible disk illuminated; however, at the time of the accident, the position of the moon was under the horizon.   The 1852 recorded weather observation at CQX included wind from 230 at 6 knots, 10 miles visibility, clear skies, temperature 13°C, dew point 18°C; and an altimeter setting of 29.63 inches of mercury. The FAA's Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) stated that: Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which combinations of normal motions and forces can create convincing illusions that are difficult to overcome. The Handbook also advised, "unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible." The private pilot departed on a cross-country flight, and after takeoff, the airplane flew in a straight line at an altitude about 8,000 ft mean sea level (msl). It began a descent toward a presumed destination airport in dark night visual meteorological conditions. Continuing on the established track, the airplane descended to and maintained 1,000 ft msl. The flightpath turned slightly before the airplane overflew and continued past the destination airport, turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. During the overwater portion of the flight, the airplane’s altitude varied between 750 ft and 1,100 ft msl. Before track data were lost, the airplane began a descending right turn from about 1,025 ft to 675 ft msl. The debris field located about 2.5 miles offshore and 7 miles from the destination airport. The airplane was not recovered. The uniformity of the flight track and altitude data for most of the flight suggests that the pilot was using the airplane’s autopilot. After overflying the airport, the airplane’s track and altitude variations were consistent with the pilot having disengaged the autopilot to hand-fly the airplane; however, continued flight over the ocean would have resulted in a near absence of cultural lighting and external visual references, requiring the use of instruments to maintain control. The pilot was neither qualified nor proficient to conduct the flight by reference to instruments and would have been vulnerable to the onset of spatial disorientation during the overwater portion of the flight. It is likely that, while maneuvering over the ocean, the pilot became spatially disoriented, resulting in a loss of control and impact with the water. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
  • Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Contributed to outcome
  • Environmental issues-Physical environment-Terrain-Water-Contributed to outcome
  • Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot

Verbatim from NTSB's published report. Source file NTSB_2021_ERA22LA043.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (loss of control, spatial disorientation, maintenance, autopilot). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.

Browse the full corpus — academia portal ↗