Pilot Debrief

CESSNA 210D near Altavista, VA — 2011-04-23

Final reportERA11FA258
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Date
2011-04-23
Location
Altavista, VA, USA
Airport
LYH
Aircraft
CESSNA 210D
Registration
N3963Y
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s loss of airplane control due to spatial disorientation. Contributing to the accident was the pilot’s lack of experience in actual night instrument conditions.

Contributing factors

Contributing to the accident was the pilot’s lack of experience in actual night instrument conditions.

NTSB narrative

The pilot was conducting an instrument flight rules flight during night, instrument meteorological conditions. About 15 minutes into the flight, the air traffic controller observed that the pilot was not flying assigned headings. When queried, the pilot responded that he was "…a little disoriented…" The pilot continued to deviate from assigned headings as he was vectored to the airport for the approach. During his first attempt at the instrument landing system (ILS) approach, the pilot executed a missed approach, citing problems with his engine monitor. Following the missed approach, the air traffic controller issued a low altitude alert to the pilot. On his second attempt at an ILS approach, the pilot unknowingly deviated well right of the localizer course and was instructed to climb immediately due to another low altitude alert. The pilot was then vectored to an intersection south of the airport and was offered a global positioning system (GPS) approach. The pilot continued to have difficulty with heading and altitude control, receiving an additional low altitude alert from the air traffic controller. The pilot subsequently informed the controller that he had "complete gyro failure" and needed assistance with heading and altitude monitoring. When asked if he was tracking a navigational aid, the pilot responded that he was "…a little dizzy…" The pilot asked for an altitude check at 5,200 feet mean sea level (msl) and the controller confirmed that altitude on his radar. The controller subsequently issued another altitude alert to the pilot at 1,400 feet msl, and the pilot did not acknowledge the call. At that point, radar and radio contact was lost. Radar, GPS, and witness information confirmed that the airplane collided with the ground during a right, descending spiral. The wreckage was highly fragmented, including the engine. Propeller signatures indicated high engine power at impact. The landing gear and flaps were retracted. Not all of the cockpit instruments could be identified or located due to the impact damage. Data recovered from the engine monitor showed that the engine, vacuum system, and electrical system were operating normally during the flight. The pilot received his instrument rating about six weeks prior to the accident and had not logged any actual instrument time at night. The pilot was an insulin-dependent diabetic and was required to monitor his blood glucose level before and during the flight; however, the investigation was unable to determine if the pilot’s glucose level affected his performance. Although the pilot reported problems with his cockpit instrumentation, physical evidence of an in-flight instrument failure was inconclusive. The environmental conditions that existed during the flight and the pilot's actions and responses indicate that he likely experienced significant spatial disorientation.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have opted for a GPS approach earlier instead of continuing ILS attempts.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • ADS-B / radar
  • Photos
  • 30 docket documents
View NTSB final reportView NTSB docket

Docket documents30

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