Aircraft: Piper Cherokee. Injuries: 1 Fatal. Location: Parkton, N.C. Aircraft damage: Substantial.
What reportedly happened: The private pilot, 63, who had logged more than 1,000 hours, took three tries to get his instrument ticket. He failed the checkride twice because he failed the “air traffic control clearances and procedures,” “instrument approach procedures,” and “emergency operations” areas of operations, with special emphasis on partial panel. After additional training he was able to obtain the instrument rating in August 2003.
On the day of the accident, he departed with nearly full fuel tanks, obtained his IFR clearance, and proceeded toward the destination airport. The destination airport was reporting IFR conditions with a 500-foot ceiling.
The pilot was vectored onto final approach for an ILS approach. Radar data showed that the airplane performed s-type turns and the pilot then reported to the local controller that he had “…lost some gyros but I think we are getting it.”
When the airplane was about one mile from the approach end of the runway at 1,300 feet, the local controller cancelled the approach clearance because the airplane was too high and advised the pilot to fly runway heading and climb to 2,000 feet.
Radar data indicated that the pilot turned toward an easterly heading without clearance from the controller. He was then instructed to maintain an easterly heading followed by a turn to 220° consistent with a downwind leg to fly parallel to runway 4.
He turned well past the assigned heading and was asked by the controller if he was having any problem with the airplane since he was unable to fly assigned headings. The pilot advised the radar controller that he had lost the use of the gyros and suggested that he climb and head to the alternate airport. There was an adequate supply of fuel onboard to fly to his alternate airport, which at that time was reporting VFR conditions.
The pilot was cleared to climb direct to his alternate airport, however, ATC noticed extensive heading and altitude deviations during this portion of the flight, which was operating in IMC.
The radar controller asked the pilot if he was ok to which he replied, “uh no I’m not okay right now.” This verbiage and the fact that extensive altitude and heading deviations occurred were clear indications that an emergency situation existed, however, the controller did not recognize this and did not request the necessary information needed to offer assistance, as outlined in FAA Order 7110.65, 10-2-1.
The controller later reported that he believed the gyro comment would have affected only the pilot’s ability to maintain heading, thus, he did not believe the loss of gyros while in instrument conditions constituted an emergency.
The controller then asked the pilot if he wanted to land at the airport, and he answered, “uh the best thing to” and did not finish his sentence. Because the controller did not recognize the emergency, he continued to vector the pilot to land using an ILS approach.
While being vectored in IMC, major heading and altitude changes were noted, however, when the airplane was operating at higher altitudes in VFR conditions, the pilot was able to maintain the airplane’s assigned heading and altitude. The controller vectored the pilot to intercept the localizer, advised that the flight was about four miles from the final approach fix, and cleared the pilot to conduct an ILS approach.
The pilot managed to fly onto final approach, but while in IMC conditions, rolled to the right and crashed inverted in a wooded area about 7.5 nautical miles from the approach end of the runway.
Post-accident examination of the airframe and flights controls for roll, pitch, and yaw revealed no evidence of pre-impact failure or malfunction. Examination of the power section of the engine revealed no evidence of pre-impact failure or malfunction; one propeller blade exhibited “S”-bending consistent with the engine developing power at impact. No discrepancies were noted with the airport approach systems.
Examination of the engine-driven vacuum pump, which operates the primary flight instruments consisting of the attitude indicator and directional gyro revealed fire damage to the shear shaft but there was no evidence of scoring of the interior surface of the housing. Further, inspection of the gyroscopic flight instruments operated by the engine-driven vacuum pump revealed no evidence of rotational scoring.
It was determined that the engine-driven vacuum pump was about three years and four months beyond the suggested replacement interval, and was not operating at the moment of impact. This was consistent with the comment from the pilot that he had lost his gyro instruments.
Although no determination could be made as to whether the pilot was instrument current, his inability to maintain control of the airplane while flying with a partial panel suggests he was not proficient in doing so.
In August 2004, in response to an NTSB recommendation, the FAA implemented national computer-based training to alert controllers of in-flight emergencies a pilot may encounter and the effect of the emergency. NTSB review of the current version of the controller training revealed it did not contain scenarios related to failures of the vacuum system or gyro flight instruments.
Although the training provided to the controllers appeared to be inconsistent, it is unlikely that consistent training would have affected the outcome of the accident because specific mention of gyro malfunction was not a covered topic in the training.
Although the pilot had not declared an emergency, he had advised ATC personnel that he had lost his gyros, and that he was “not OK.” Further, extensive altitude and heading excursions of the aircraft were noted, all of which were clear indicators that an in-flight emergency existed. Had any of the FAA controllers understood either by experience or training that the pilot’s declarations or altitude and heading changes constituted an emergency, they could have declared an emergency for the pilot. Investigators determined that had that occurred, it is likely the pilot would have been vectored to an airport with VFR conditions for an uneventful landing.
Probable cause: The failure of the pilot to maintain control of the airplane while in instrument meteorological conditions after reporting a gyro malfunction. Contributing to the accident was the loss of primary gyro flight instruments due to the failure of the vacuum pump, the inadequate assistance provided by FAA ATC personnel, and the inadequate recurrent training of FAA ATC personnel in recognizing and responding to in-flight emergency situations.
NTSB Identification: ERA13FA088
This December 2012 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.
