Pilot Debrief

CESSNA T210 near Hilltop Lakes, TX — 2009-09-24

Final reportCEN09FA601
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Date
2009-09-24
Location
Hilltop Lakes, TX, USA
Airport
0TE4
Aircraft
CESSNA T210
Registration
N9734Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Go-around

Probable cause

The loss of control of the airplane in dark night light conditions due to the pilot’s spatial disorientation.

NTSB narrative

The pilot was arriving at a private rural airport in dark night conditions. Witnesses estimated that the visibility was 3 to 5 miles in drizzle or light rain with overcast clouds, with the ceiling as low as 500 to 1,000 feet above ground level. The pilot initially attempted to activate the runway lighting via the pilot-activated system; however, the system was inoperable due to a recent lightning strike. An airport resident contacted the pilot on the Unicom radio and informed him that the lights were inoperable. Another resident attempted to illuminate the runway using headlights from an automobile. The pilot said that he was going to attempt to land on runway 34 using a combination of automobile illumination and the airplane’s landing lights. The pilot was west of the airport when he flew eastbound over the airport and entered a right turn for a landing on runway 34. Several witnesses said that the pilot was not aligned with runway 34 and appeared to be too high to land. The witnesses said the airplane was approximately 50 to 150 feet above ground level when the pilot stated on the radio that he was initiating a go-around. The airplane then almost immediately started a descent, struck trees on the right side of the runway, and impacted an unoccupied home. An examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The dark night conditions that surrounded the airport and the airplane’s acceleration due to a go-around would place the pilot susceptible to spatial disorientation. According to the Federal Aviation Administration’s “Instrument Flying Handbook”, FAA-H-8083-15A, in a Somatogravic illusion “A rapid acceleration...can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low, or dive attitude.”

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have aborted the approach earlier due to inoperative runway lights.

NTSB coding

Evidence available

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

Docket documents24

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