Pilot Debrief

CESSNA 208B near Muskegon, MI — 2015-03-10

Final reportGAA15CA005
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Date
2015-03-10
Location
Muskegon, MI, USA
Airport
KMKG
Aircraft
CESSNA 208B
Registration
N12155
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The pilot's improper decision to continue the landing when the airplane was not in a safe position to land, resulting in the collision with ground-based approach lighting.

NTSB narrative

The pilot reported that he flew an autopilot coupled approach to minimums in instrument meteorological conditions (IMC). The pilot exited IMC at the decision height, disconnected the autopilot, and the approach lights became visible. The pilot determined he was right of the runway and as he maneuvered to realign the airplane with the runway, he struck elements of the approach light system. A postaccident examination revealed the airplane sustained substantial damage to the horizontal stabilizer. Effective at the time of this accident was a permanent Notice to Airmen (NOTAM) associated with the ILS runway 24 approach prohibiting a coupled autopilot approach from 1150 feet mean seal level to the surface. During a post-accident interview the pilot stated he was unaware of this NOTAM. The NOTAM had been in effect since February 21st, 2014 and the approach chart used did not note this approach restriction. Weather at the time of the accident was reported as winds from 250 degrees at 5 knots, ½ statute mile visibility, 200 feet overcast, temperature 32 degrees Fahrenheit, dew point 32 degrees Fahrenheit, and altimeter 30.04 inches of mercury. The pilot reported no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have checked NOTAMs before conducting the autopilot approach.

NTSB coding

Evidence available

  • Photos
  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5