Pilot Debrief

PIPER PA32R near Castro Valley, CA — 2015-12-22

Final reportWPR16FA042
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Date
2015-12-22
Location
Castro Valley, CA, USA
Airport
OAK
Aircraft
PIPER PA32R
Registration
N323PA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's loss of control due to spatial disorientation while maneuvering during an instrument approach in instrument meteorological conditions.

NTSB narrative

The instrument-rated private pilot was operating the airplane on an instrument flight rules flight in instrument meteorological conditions (IMC). As the airplane neared the destination airport, the controller cleared the pilot for the instrument landing system (ILS) approach, instructed him to descend to 3,400 ft mean sea level (msl), and provided him with a heading to intercept the localizer course. The pilot acknowledged the clearance and began descending the airplane, but did not initiate the turn. About 30 seconds later, the controller again instructed the pilot to turn to intercept the localizer course. The pilot complied, turned west, and began tracking toward the airport south of the localizer course. The controller asked the pilot whether the airplane was established on the localizer, to which the pilot replied, "I'm re-establishing." Shortly thereafter, the controller asked the pilot if he was receiving the glideslope indication for the approach. The pilot confirmed that he was receiving the glideslope, but stated that he was "off glideslope" and "too high." However, at this time, the airplane was 800 ft below the minimum altitude for that segment of the approach (3,400 ft msl). The controller issued a low altitude alert, cancelled the approach clearance, and instructed the pilot to turn north and climb. The pilot acknowledged; however, the airplane turned south and did not climb. The controller again issued the pilot instructions to turn and climb, and the airplane began to turn north and climb before subsequently entering a descent. Shortly thereafter, the pilot stated, "I'm losing it." No further transmissions were received from the pilot, and radar contact was lost in the vicinity of the accident site. The airplane impacted heavily-wooded terrain about 12 nautical miles southeast of the destination airport, at an elevation about 1,400 ft. Postaccident examination of the airplane revealed heavy fragmentation consistent with a high-energy impact as well as evidence of a postimpact fire. Examination of the airframe, flight controls, and the engine revealed no evidence of any preimpact mechanical failures or anomalies. Although the extensive damage precluded examination of the primary vacuum pump and functional testing of the autopilot system, it is unlikely these components malfunctioned because before beginning the approach, the pilot experienced no difficulty complying with air traffic control-assigned altitudes and headings, and, throughout the flight, he gave no indication that he was experiencing problems with the flight controls, flight instruments, or autopilot. Based on weather data and the pilot's radio communication that he was "in the weather," the airplane was operating in IMC throughout the approach. When issued instructions to execute a missed approach, the pilot experienced a high workload that involved changes to the airplane's heading, altitude, and likely, configuration; this situation was conducive to the development of spatial disorientation. The pilot likely recognized the onset of spatial disorientation as evidenced by his statement to the controller, "I'm losing it;" however, the pilot was unable to make the appropriate corrective inputs before losing control of the airplane.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot did not initiate right turn to intercept localizer as instructed.

NTSB coding

Evidence available

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

Docket documents9

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