Loss of situational awareness proves fatal

Aircraft: Cirrus SR22. Injuries: 2 Fatal. Location: Gary, Indiana. Aircraft damage: Destroyed.

What reportedly happened: The pilot was attempting to fly the  RNAV/GPS approach at the destination airport. The air traffic controller did not provide approach clearance until it was inside the final approach fix and 1,000 feet above the FAF crossing altitude.

The controller also issued a late turn to intercept the approach course, and he did not issue a descent clearance because his attention was directed to resolving a separation conflict involving two other aircraft.

According to data recorded by the airplane’s primary flight display, the pilot disconnected the autopilot after receiving the approach clearance, and the airplane then began a rapid descent. About 40 seconds later, the airplane rolled left, tracking left of the approach course.

The airplane’s ground proximity warning alert activated, and the plane rapidly reversed roll and pitch directions consistent with an attempt by the pilot to correct the hazardous flight path.

The airplane continued to roll right and pitch to a nose-high attitude before rapidly transitioning to a nose-down attitude of more than 85°. As the airplane descended below a 900-foot cloud layer, the pilot rolled the airplane to wings level and made a high g-force pull up until ground impact.

Investigators determined that given the pilot’s high workload due to deficient approach control services and possible distraction while operating in instrument meteorological conditions and the subsequent loss of airplane control, it is likely that he experienced spatial disorientation.

Toxicology testing indicated the pilot used cocaine, hydrocodone, and marijuana at some point in the recent past. However, investigators could not determine if the use of the cocaine and hydrocodone affected the pilot’s performance at the time of the accident, and the effect of the marijuana use could not be determined from the available evidence.

Probable cause: The pilot’s loss of control during an instrument approach due to spatial disorientation. Contributing to the accident were deficient approach control services and the pilot’s loss of positional awareness.

NTSB Identification: CEN13FA002

This October 2012 accident report is are provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.