Pilot Debrief

CESSNA 310R near Jacksonville, FL — 2013-12-08

Final reportERA14FA068
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Date
2013-12-08
Location
Jacksonville, FL, USA
Airport
CRG
Aircraft
CESSNA 310R
Registration
N98BT
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot’s failure to maintain airplane control during a missed approach in night instrument meteorological conditions due to spatial disorientation and a lack of instrument proficiency.

NTSB narrative

The pilot filed an instrument flight rules (IFR) flight plan with flight services, and the briefer asked the pilot if he would like weather information. The pilot replied "no," and stated that the weather "looked good"; however, at that time, the weather at the destination airport included visibility of 2 miles and a 400-foot overcast ceiling. The pilot proceeded on the approximate 1-hour night flight to the destination airport in low IFR conditions. During the instrument landing system approach, the pilot flew about 1 mile right of and 900 feet below the final approach fix. The tower controller issued a low altitude alert and instructed the pilot to check his altitude. The pilot acknowledged the instruction and confirmed that the airplane's altitude was 600 feet, which was the altitude indicated on radar. He then flew the airplane left of the final approach course twice before intercepting it a third time, descending to 300 feet, and then reporting that he was going to conduct a missed approach. The published missed approach procedure was to climb to 700 feet and then to make a climbing right turn to 1,900 feet on a 180-degree heading. However, the tower controller instructed the pilot to fly a heading of 280 degrees, and the pilot acknowledged the instruction. The controller did not provide an altitude and was not required to do so. After the pilot acknowledged the instruction, the airplane made a climbing left turn to 900 feet before radar and radio communications were lost. The airplane subsequently descended and collided with a retaining pond near the last recorded radar target. Although the tower controller's issuance of nonstandard missed approach instructions without specifying an altitude might have added to the pilot's workload, radar data show an initial turn consistent with the instructions and an associated climb indicating that the nonstandard instructions were not a factor in the accident. Examinations of the airplane and engine revealed no preimpact mechanical malfunctions that would have precluded normal operation, and there was no evidence of medical impairment that would have affected the pilot's performance. Given the night instrument meteorological conditions (IMC) with restricted visibility and the sustained left turn and climb, it is likely the pilot experienced spatial disorientation. The investigation could not determinate the pilot's overall and recent experience in actual IMC; however, his inability to align the airplane with both the final approach fix's lateral and vertical constraints is consistent with a lack of instrument proficiency.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach earlier based on weather conditions.

NTSB coding

Evidence available

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  • 20 docket documents
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Docket documents20

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