Pilot Debrief

BEECH 58P near Birmingham, AL — 2011-01-06

Final reportERA11FA107
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Date
2011-01-06
Location
Birmingham, AL, USA
Airport
BHM
Aircraft
BEECH 58P
Registration
N48TS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain control of the airplane during an instrument approach due to spatial disorientation.

NTSB narrative

During the approximately 5 hour and 25 minute night instrument cross-country flight in a multi-engine airplane, the pilot elected not to stop at his planned fuel stop. Upon reaching the destination airport, the weather conditions included an overcast ceiling at 300 feet and 2 miles visibility in drizzle, which were worse than the forecast conditions of overcast ceiling at 1,000 feet and 6 miles visibility. The pilot diverted to his planned alternate airport and attempted an instrument landing system approach. Given the lack of a fuel stop, the pilot may have felt personal pressure to land the airplane as soon as possible. The airplane initially intercepted the localizer for the approach, but did not intercept the glideslope. The airplane then proceeded left of course, above the glideslope, followed by a continued left deviation and descent below the glideslope. The tower controller asked the pilot if he was still on the localizer course and the pilot replied that he was not. The tower controller then provided heading and altitude instructions in an attempt to guide the pilot onto a missed approach. The pilot acknowledged the heading instruction, but failed to turn to the assigned heading or climb to the assigned altitude. The airplane subsequently impacted a residential area about 1/2 mile from the runway. The pilot's logbook was not recovered and a determination of his flight experience in actual instrument conditions could not be made. According to a flight instructor, the pilot had owned the accident airplane for about 6 months and had 80 to 90 hours in the make and model. The pilot completed an instrument proficiency check with the instructor about 1 month prior to the accident. The instruction included many instrument approaches and missed approach procedures. Additionally, the flight instructor concentrated on attitude flying, which was not the pilot's strongest skill. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. If neither horizon nor surface references exist, the attitude of an airplane must be determined by artificial means from the flight instruments. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen; when this happens, a pilot is particularly vulnerable to disorientation. Postmortem toxicology testing noted findings consistent with marijuana use; however, no blood was available for toxicological testing and it was not possible to reliably estimate when the marijuana may have most recently been used or whether the pilot may have been impaired by such use.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot failed to follow ATC instructions to turn and climb during approach.

NTSB coding

Evidence available

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

Docket documents19

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