Pilot Debrief

BEECH F33 near Columbia, SC — 2021-01-13

Final reportERA21LA101
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Date
2021-01-13
Location
Columbia, SC, USA
Airport
CUB
Aircraft
BEECH F33
Registration
N266DC
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's in-flight loss of airplane control due to spatial disorientation during a missed approach in instrument meteorological conditions.

NTSB narrative

The instrument-rated commercial pilot departed on a visual flight rules flight plan but requested and received an instrument flight rules clearance while en route to the destination airport. During the flight, the air traffic controller instructed the pilot to advise when he had obtained the reported weather conditions at the destination airport and asked the pilot about the type of instrument approach he was requesting to the destination. The pilot requested an area navigation (RNAV) approach, and the controller acknowledged; however, the controller did not confirm if the pilot had the weather conditions at the destination airport, nor did he provide that information to him. The pilot then asked the controller for the approach minimums at the destination airport and if any pilot reports (PIREPs) had been received. The controller responded that he received an unsolicited PIREP 45 minutes earlier from a pilot who had attempted to land at the same destination airport, but was unable to do so. About that time, and continuing through the time of the accident, the reported weather conditions at the airport included 1/4-mile visibility in fog and 200 ft vertical visibility. The accident pilot continued the approach, subsequently declared a missed approach, and the controller responded with heading and climb instructions. The pilot asked if the change in heading involved a left turn, and the controller confirmed that it did. The pilot read back the instructions correctly and then asked about the weather at a nearby airport. The controller provided the pilot with the weather conditions; however, the pilot did not respond, and radar contact was lost shortly thereafter. Flight track data indicate that, throughout the approach, the airplane remained about 3/4 mile left of course until the airplane was about 1 1/4 mile from the approach end of the runway. At that time, the airplane made a right turn, descended to an altitude of 325 ft mean sea level, then made a climbing left turn to 800 ft mean sea level before descending and impacting terrain in a residential neighborhood. A postcrash fire ensued. The witness descriptions of the engine sounds as the airplane maneuvered during the final moments of the flight, as well as the tip curling and chordwise scratching observed on the propeller blades after the accident, indicated that the engine was producing power at the time of the accident. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. Given the instrument meteorological conditions at the time of the accident, which included restricted visibility, and the pilot’s maneuvering off of the instrument approach course both laterally and vertically, it is likely that the pilot became spatially disoriented during the approach, which led to a loss of airplane control and a subsequent spiraling descent.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot did not request or receive current weather information before approach.

NTSB coding

Evidence available

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

Docket documents21

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