Spatial disorientation kills two

This February 2010 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

Aircraft: Piper Malibu. Injuries: 2 Fatal. Location: Belleville, Illinois. Aircraft damage: Destroyed.

What reportedly happened: The pilot had flown to an airport to receive training in the Malibu. According to the CFI who administered the training, a significant portion of the training time was spent on operation of the Garmin GPS installed in the airplane. According to the CFI, the pilot initially had problems with the pilot interface of the GPS, but upon completion of the training the pilot had met the requirements of the Private Pilot/Instrument Rating Practical Test Standards. The CFI endorsed the pilot’s logbook for an “Instrument Proficiency Check” at the conclusion of the training.

The accident happened when the pilot was attempting to return to his home airport. He was on an IFR flight plan in IMC at night. The airplane was on approach to the destination airport. The pilot contacted the approach control facility and was cleared for an ILS. Twice during the approach, the controller advised the pilot that the airplane was to the right of the approach course. The controller suggested a left turn of 5° to 7°. Once the airplane was back on the inbound course, the controller instructed the pilot to contact a tower controller. The pilot never contacted the tower controller; instead he executed a missed approach and then reestablished contact with the approach controller. The approach controller provided radar vectors for a second attempt at the ILS approach. During the radio communications, the pilot stated that he was having problems with the autopilot, but later stated that the problems had been resolved. During the second approach, the controller again advised the pilot that the airplane was to the right of the approach course and issued the pilot a low altitude alert. The airplane then started a climb and a turn back toward the inbound course. The controller advised the pilot that the airplane would intercept the inbound course at the outer marker for the approach and asked if the pilot would like to abort the approach and try again. The pilot responded that he would continue the approach. There were no further transmissions from the pilot. The airplane crashed into a building about 0.4 nautical miles from the outer marker and burst into flames.

Investigators note the airplane’s turning ground track and the challenging visibility conditions were conducive to the onset of pilot spatial disorientation.

Probable cause: The pilot’s spatial disorientation and subsequent failure to maintain airplane control during the instrument approach.

For more information: NTSB Identification: CEN10FA125


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