Pilot Debrief

BEECH 95-B55 near Hartwell, GA — 2022-09-10

Final reportERA22FA405
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Date
2022-09-10
Location
Hartwell, GA, USA
Aircraft
BEECH 95-B55
Registration
N3670D
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s spatial disorientation and subsequent loss of airplane control following a perceived undetermined problem with the airplane’s gyroscopic instrumentation.

NTSB narrative

The pilot elected to fly an RNAV approach in instrument meteorological conditions (IMC) at the destination airport. The pilot executed a missed approach, after which he requested another RNAV approach. Air traffic control (ATC) issued instructions to join the approach course; however, the pilot began to descend and maneuver, and was unable to join the final approach course. The controller asked if he needed assistance to which the pilot responded negative and that he needed to “get reset.” The pilot was issued an altitude and heading, but he turned to a heading 180° from the heading issued. When queried, the pilot responded that he was having trouble with his gyros. The controller offered the ILS approach and the pilot accepted. The controller issued vectors for the approach and the pilot complied. The pilot was cleared for the approach but did not intercept the localizer. The controller instructed the pilot to stop his turn and maintain altitude. No further communications were received from the pilot. According to ADS-B flight track data, the airplane entered a right turn after being cleared for the ILS. The airplane completed two right turns and descended before climbing and entering a left turn. The last track data was observed as the airplane was in a descent. The wreckage descended to impact with a lake south of the airport. Examination of the engine-driven vacuum pumps, which operate the primary flight instruments consisting of the attitude indicator and directional gyro, revealed they were intact and no preimpact anomalies were noted; however, no evidence of scoring on the interior surface of the housings was noted. The attitude indicator, directional gyro, and the horizontal situation indicator (HSI) were impact damaged, which precluded functional testing; however, no pre-impact defects or rotational scoring were noted. The pilot’s logbook was not located; therefore, the pilot’s experience operating in IMC conditions could not be documented. Because the investigation was unable to establish the operational status of the directional gyroscope and HSI, it could not be determined what issue the pilot was dealing with when he replied that he needed to “get reset.” The pilot was able to follow the controller’s instruction following the missed approach, but was unable to initiate a second approach. It is likely that the pilot was task saturated with a perceived instrumentation issue. Based on his communications with air traffic control and the airplane’s flight track, the pilot’s ability to control the airplane continually degraded. The airplane’s erratic maneuvers are consistent with the pilot experiencing spatial disorientation resulting in a loss of control in flight and inability to recover the airplane.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have requested assistance earlier during approach difficulties.

NTSB coding

Evidence available

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

Docket documents9

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