Pilot Debrief

PIPER PA 46 350P near Truckee, CA — 2014-03-03

Final reportWPR14FA127
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Date
2014-03-03
Location
Truckee, CA, USA
Airport
KTRK
Aircraft
PIPER PA 46 350P
Registration
N9281F
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s failure to properly execute the missed approach in instrument conditions. Contributing to the accident were the pilot’s lack of instrument proficiency, as demonstrated by his failure to execute the required procedure turn to align with the final approach course and to configure the airplane for the approach, and his loss of situational awareness and the onset of spatial disorientation during the missed approach.

Contributing factors

Contributing to the accident were the pilot's lack of instrument proficiency, as demonstrated by his failure to execute the required procedure turn to align with the final approach course and to configure the airplane for the approach, and his loss of situational awareness and the onset of spatial disorientation during the missed approach.

NTSB narrative

The commercial pilot was conducting a personal flight. The airplane was en route to the destination airport from the south and was cleared via the initial approach fix for the published GPS approach. The pilot reported that he had the weather at the airport, which was overcast at 3,000 ft above ground level. For all arrivals except from the west, the GPS approach diagram depicts a racetrack procedure turn at the initial approach fix (IAF) to align with the final approach course. The air traffic controller instructed the pilot to cross the IAF and then cleared him for the GPS approach into the airport. The airplane crossed the IAF and made a right turn to parallel the final approach course, which was not the required procedure turn, and the pilot did not slow the airplane's airspeed. The controller terminated radar services. The airplane then made a heading correction to intercept the final approach course but did not descend and continued to maintain its speed. The airplane remained northeast of the final approach course and 2,000 ft above the minimum descent altitude (MDA) all the way to the missed approach point. The pilot did not slow the airplane to an appropriate airspeed for the approach nor configure the airplane for landing. The pilot then announced that he had a missed approach to air traffic control (ATC) and made a left turn toward the depicted holding fix to the north. Instead of proceeding directly to the holding fix, the airplane continued its left turn for about 270 degrees and proceeded away from the fix. The pilot asked ATC for vectors to the holding fix. A controller replied that the airplane was below the minimum vectoring altitude and advised the pilot to proceed to the west toward lower terrain. The pilot stated that he was in instrument meteorological conditions and was picking up ice. Moments later, during the last minute of flight, the airplane entered a series of progressively lower altitude excursions southeast of the airport descending 1,300 ft, then climbing 700 ft, then descending 2,000 ft, then climbing 1,600 ft, and finally descending 1,300 ft and impacting terrain. The fact that the pilot did not execute the procedure turn after crossing the IAF, did not slow the airplane down, did not descend to the MDA, and did not climb to the required altitude or proceed in the direction of the holding fix after the missed approach point all indicate that the pilot had decreased situational awareness. Further, the final series of extreme altitude excursions are consistent with the pilot experiencing spatial disorientation. After the accident, the pilot could not recall the events leading up to the accident. He did state that he normally approached the airport from the west. In that case, a right turn at the IAF to directly align with the final approach course would be the normal procedure. The pilot had an iPad that contained the approach plate for the approach being flown, and the approach had been displayed on the device 30 minutes before the execution of the approach, but it was not displayed any time after that. The pilot stated that he normally used the panel-mounted GPS navigation system in the airplane to conduct instrument approaches and that he was using that system at the time of the accident. Pilot records show that the he had not performed the required six instrument approaches within the 6 calendar months preceding the flight; thus, he was not instrument current to operate as pilot-in-command under instrument flight rules conditions.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot did not execute the missed approach procedure as required.

NTSB coding

Evidence available

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

Docket documents16

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