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Failure to follow instructions proves fatal

By NTSB · December 5, 2010 ·

This December 2008 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: Cessna 206 Injuries: 1 Fatal. Location: Kalkaska, Mich. Aircraft damage: Destroyed.

What reportedly happened: The pilot received an instrument rating about 10 months before the accident and had accumulated about eight hours of actual instrument flight time since receiving the instrument rating. He departed on a cross-country flight from Minnesota to New York. There was no indication that he had met the recent flight experience required by regulations to act as pilot in command in instrument flight conditions.

The airplane was equipped with the Garmin G1000 integrated avionics suite. The navigation capabilities of the G1000 system included en route and approach certified GPS navigation and VHF navigation. The avionics system included a database which, among other information, included airport information, Navaid information, airspace information and instrument approach, departure and fix information.

While en route and in VFR conditions above the clouds, the pilot elected to divert to a nearby airport due to adverse weather conditions. He received an IFR clearance, radar vectors, and instrument approach information from air traffic control. However, he was unable to complete the approach due to trouble receiving the localizer signal for the ILS approach. He requested that he be able to continue with only glide slope information and the controller informed the pilot that his current altitude of 2,700 feet MSL was the minimum altitude that ATC could authorize. The pilot informed ATC that he was going to descend and ATC reported that radar contact was lost. Over the next four minutes, the controller instructed the pilot to climb several times. The pilot did not comply with these requests and radar data indicated that the airplane circled several times about 1.5 miles east of the airport during this time period. After several requests the pilot agreed to climb and accepted vectors for another approach. Transcripts indicated that the pilot was able to successfully tune his navigation equipment for the GPS approach to the airport. While the airplane was being vectored for another approach, the controller instructed the pilot to climb and the pilot responded “I’m off,” which was the last transmission received. Radar data showed that the airplane remained airborne and maneuvered east of the airport for 36 minutes after the last radio transmission from the pilot. Witnesses on the ground reported seeing the airplane circling before it hit trees, the ground, and a residence.

The autopsy on the pilot revealed evidence of multiple previous and one very recent, possibly ongoing, heart attack. There were no indications that the pilot had been symptomatic with or was aware of his heart disease. The circumstances of the accident do not suggest incapacitation, and the pilot did not indicate any symptoms in discussions with air traffic controllers. It could not be determined whether distraction or impairment due to the pilot’s heart disease may have played a role in this accident.

Probable cause: The failure to maintain clearance from trees and terrain during the IFR flight. Contributing to the accident was the pilot’s failure to comply with instrument flight procedures and his lack of recent instrument flight experience.

For more information: NTSB.gov

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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