Pilot Debrief

BEECH V35A near Seagoville, TX — 2014-12-19

Final reportCEN15FA081
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Date
2014-12-19
Location
Seagoville, TX, USA
Airport
HQZ
Aircraft
BEECH V35A
Registration
N555SF
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s loss of control and subsequent impact with terrain in instrument meteorological conditions.

NTSB narrative

After a 90-minute instrument flight rules flight, the pilot descended toward his home airport and attempted six unsuccessful instrument approaches in instrument meteorological conditions (IMC). The controller terminated three GPS approaches and one instrument landing system approach because the pilot flew through the final approach course; one GPS approach was terminated because the pilot was performing S-turns on final. Sunset occurred during the third approach attempt. After the fourth approach attempt, the controller suggested that the pilot divert to an airport with visual meteorological conditions (VMC), which the pilot declined because of the airplane's low fuel status. During the sixth approach attempt, the pilot stated he was "getting tired of flying this airplane." The controller offered him vectors to a VMC airport, but the pilot declined, stating he wanted to "keep working until we get it." Soon after he made this statement, the airplane turned right toward the final approach course and rapidly descended until terrain impact. The pilot likely either attempted to descend below IMC and/or experienced spatial disorientation, but the investigation was unable to determine the precise reason for the loss of control. The pilot's six unsuccessful approach attempts and his decision not to divert to a VMC airport revealed poor instrument flight skills, poor fuel planning, lack of situational awareness, and poor judgment. A review of medical records revealed that the pilot was using a sedating antihistamine and had several physiological issues, including vision deficits, diabetes, diabetic neuropathy. These conditions may have had an impairing effect on the pilot, but the medical investigation was limited by the degree of damage to the pilot's body and the extent to which they may have affected the pilot at the time of the accident could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have opted for a visual approach earlier instead of continuing GPS attempts.

NTSB coding

Evidence available

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

Docket documents11

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