Pilot Debrief

BEECHCRAFT B36TC near Amarillo, TX — 2013-11-11

Final reportCEN14FA047
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Date
2013-11-11
Location
Amarillo, TX, USA
Airport
AMA
Aircraft
BEECHCRAFT B36TC
Registration
N4245D
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The noninstrument-rated pilot’s improper decision to fly a night instrument approach in instrument meteorological conditions, which resulted in the pilot’s spatial disorientation and loss of control of the airplane during an attempted missed approach.

NTSB narrative

The noninstrument-rated private pilot filed an instrument flight plan to an airport that was reporting night instrument meteorological conditions (IMC), which included ¼-mile visibility, fog, sky obscuration, and 100-foot vertical visibility. Radar track data showed that, upon arrival at the airport, the pilot flew the instrument lighting system approach and then attempted to execute a missed approach. During the missed approach, radar contact was lost and the airplane impacted the terrain. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot's toxicology report indicated that gabapentin and duloxetine were found in the pilot's system, and both are disqualifying drugs for flight. The pilot did not report either of these disqualifying medications on his last medical certification examination. While both medications are sedating, a witness reported that the pilot was alert and energetic before the flight and showed no signs of sedation. Witness reports and findings from the wreckage examination are consistent with a loss of control event, and, based on the degraded visual reference conditions present about the time of the accident, it is likely that the pilot experienced spatial disorientation. Although it could not be determined what effect the use of the medications had on the pilot's performance during the high-workload IMC flight, their use could increase the chance of experiencing and responding inappropriately to spatial disorientation.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to divert to alternate airport instead of attempting approach.

NTSB coding

Evidence available

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

Docket documentsshowing 50 of 51

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