Pilot Debrief

BEECH A36 near Winslow, AR — 2010-02-06

Final reportCEN10FA114
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Date
2010-02-06
Location
Winslow, AR, USA
Airport
FYV
Aircraft
BEECH A36
Registration
N1085D
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Approach

Probable cause

The instrument-rated pilot's spatial disorientation and subsequent loss of airplane control during flight in instrument meteorological and conditions favorable for structural icing.

NTSB narrative

Before being vectored for an instrument approach to the destination airport, the airplane was in visual meteorological conditions above a layer of clouds where earlier reports indicated icing conditions. During the descent, and as the airplane approached the initial fix for the approach, the airplane entered instrument meteorological conditions. Air traffic control communications and radar data indicated that the airplane flew past the initial fix and through the approach course after the air traffic controller instructed the pilot to intercept the approach course. The airplane turned right toward, and again through the approach course, followed by an additional and larger heading correction to the left and through the approach course. The airplane then flew an increasingly erratic flightpath until it disappeared from radar. The applicable Pilot's Operating Handbook and Federal Aviation Administration-approved Airplane Flight Manual indicated that flight in icing conditions was prohibited. The challenging visibility conditions and the airplane's flight track were conducive to the onset of pilot spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted the approach when conditions worsened.

NTSB coding

Evidence available

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

Docket documents12

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