Pilot Debrief

CESSNA 172M near Rochester, MN — 2012-12-03

Final reportCEN13LA088
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Date
2012-12-03
Location
Rochester, MN, USA
Airport
RST
Aircraft
CESSNA 172M
Registration
N9853Q
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot’s spatial disorientation during the instrument approach in night, instrument meteorological conditions, which resulted in the airplane descending below decision height and impacting terrain outside the lateral limits of the localizer. Contributing to the accident was the pilot's lack of recent instrument flight experience.

Contributing factors

Contributing to the accident was the pilot's lack of recent instrument flight experience.

NTSB narrative

The commercial pilot was conducting a personal cross-country flight. According to recorded air traffic control (ATC) transmissions and radar track data, the pilot attempted an instrument landing system (ILS) approach to an airport where the reported weather conditions were below published minimums for the approach. The pilot reported that the airplane descended on the glideslope into fog where there was limited to no forward visibility and that he initiated a missed approach at 1,600 ft mean sea level (msl) because he could not see the runway environment. The airplane impacted terrain shortly after the pilot increased engine power to transition into a climb for the missed approach. A review of the pilot's flight logbook established that he had not maintained his instrument currency, as required by federal regulations, during the 6 months preceding the accident. According to radar track data, the airplane made multiple course corrections on both sides of the localizer centerline as it proceeded inbound toward the runway. The airplane eventually flew through the right localizer limit about 1.2 miles from the runway threshold. The airplane continued to fly away from the localizer and descended below the published decision height of 1,480 ft msl. The airplane impacted terrain about 1/2 mile right of the localizer centerline and about 3/4 mile from the runway threshold while in a descending right turn. Postaccident testing revealed that there were no anomalies with the airplane's altimeter that would have prevented its normal operation. Additionally, the pilot had selected a Kollsman window setting that would have minimized any indication errors during the instrument approach. Further avionic testing identified no anomalies with the airplane's primary navigation radio and its associated course deviation indicator. According to ATC documentation, all components of the ILS approach were fully functional at the time of the accident. Further, 12 minutes before the accident, another airplane had completed the same ILS approach to the runway without any reported issues or anomalies. In conclusion, the weather and light conditions at the time of the accident and the pilot's maneuvering during the approach were conducive to the development of spatial disorientation. Therefore, it is likely that the pilot became spatially disoriented during the instrument approach, which resulted in the airplane descending below decision height and impacting terrain outside the lateral limits of the localizer. The pilot's lack of recent instrument flight experience likely contributed to him becoming spatially disoriented during the instrument approach.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have diverted to AUM instead of attempting ILS approach to RST.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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