Pilot Debrief

CIRRUS DESIGN CORP SR22 near Gary, IN — 2012-10-03

Final reportCEN13FA002
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Date
2012-10-03
Location
Gary, IN, USA
Airport
KGYY
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N308PJ
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Approach

Probable cause

The pilot's loss of control during an instrument approach due to spatial disorientation. Contributing to the accident were deficient approach control services and the pilot's loss of positional awareness.

Contributing factors

Contributing to the accident were deficient approach control services and the pilot's loss of positional awareness.

NTSB narrative

The pilot was flying an RNAV/GPS approach when the accident occurred. The air traffic controller did not provide approach clearance to the accident airplane until it was inside the final approach fix (FAF) and 1,000 feet above the FAF crossing altitude. The controller also issued a late turn to intercept the approach course, and he did not issue a descent clearance because his attention was directed to resolving a separation conflict involving two other aircraft. According to data recorded by the airplane's primary flight display, the pilot disconnected the autopilot after receiving the approach clearance, and the airplane then began a rapid descent. About 40 seconds later, the airplane rolled left and tracked left of the approach course. The airplane's ground proximity warning alert activated, and the airplane subsequently rapidly reversed roll and pitch directions consistent with an attempt by the pilot to correct the airplane's hazardous flight path. The airplane continued to roll right and pitch to a nose-high attitude before rapidly transitioning to a nose-down attitude of more than 85 degrees. As the airplane descended below a 900-foot cloud layer, the pilot rolled the airplane to wings level and made a high g-force pullup until ground impact. Given the pilot's high workload due to deficient approach control services and possible distraction while operating in instrument meteorological conditions and the subsequent loss of airplane control, it is likely that the pilot experienced spatial disorientation. Examination of the airframe and engine did not reveal any preimpact failures or malfunctions that would have precluded normal operation. Toxicology testing indicated the pilot used cocaine, hydrocodone, and marijuana at some point in the recent past. However, the use of the cocaine and hydrocodone likely did not affect the pilot's performance at the time of the accident, and the effect of the marijuana use could not be determined from the available evidence.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted the approach when conditions became challenging.

NTSB coding

Evidence available

  • FDR / data
  • ADS-B / radar
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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