Pilot Debrief

PIPER PA46 near Dubuque, IA — 2014-10-14

Final reportCEN15FA008
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Date
2014-10-14
Location
Dubuque, IA, USA
Airport
DBQ
Aircraft
PIPER PA46
Registration
N9126V
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's loss of airplane control while attempting to fly a missed approach procedure in instrument meteorological conditions.

NTSB narrative

The instrument-rated private pilot was returning to his home airport after flying to another location to attend a meeting. At the departure airport, the pilot filed an instrument flight rules flight plan, had it activated, and then departed for his home airport. After reaching his assigned altitude, the pilot requested clearance directly to his destination with air traffic control, and he was cleared as requested. Before arriving at his airport, he requested off frequency to get the NOTAMs and weather conditions for his destination. The weather conditions at the arrival airport included a 200-ft overcast ceiling and 5 miles visibility with light rain and mist. The pilot then requested the instrument landing system (ILS) approach for landing. An air traffic controller issued vectors to the ILS final approach course and cleared the pilot to change off their frequency. Witnesses at the airport reported hearing and seeing the airplane break out of the clouds, fly over the runway about 100 ft above ground level (agl), and then disappear back into the clouds. Two witnesses stated that the engine sounded as if it were at full power and another witness stated that he heard the engine "revving" as if flew overhead. Shortly after the airplane was seen over the airport, it struck a line of 80-ft tall trees about 3,600 ft north-northwest of the airport and subsequently impacted the ground and a large tree near a residence. The published missed approach procedures required the pilot to climb the airplane to an altitude of 2,000 ft mean sea level (msl), or about 900 ft agl, while flying the runway heading. Upon reaching 2,000 ft msl, the pilot was required to begin a left turn to the northwest and then continue climbing to 3,300 ft msl. An examination of the airplane, the engine, and other airplane systems revealed no anomalies that would have precluded the airplane from being able to fully perform in a climb during the missed approach. It is likely that the pilot lost airplane control after initiating a missed approach in instrument meteorological conditions. Although it is possible that the pilot may have experienced spatial disorientation, there was insufficient evidence to conclude that spatial disorientation contributed to the accident.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have executed a go-around instead of continuing the approach.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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