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Spatial disorientation kills four

By NTSB · December 26, 2014 ·

Aircraft: Piper Matrix. Injuries: 4 Fatal. Location: Greensburg, Ind. Aircraft damage: Destroyed.

What reportedly happened: The instrument-rated private pilot was executing a non-precision instrument approach procedure at night in deteriorating weather conditions. According to GPS track data, he executed the approach as published, but descended below the missed approach point’s minimum altitude before executing a climbing right turn.

The turn was not consistent with the published missed approach procedure. The airplane then began a series of left and right climbing and descending turns to various altitudes. The last few seconds of recorded data showed the airplane entered a descending left turn.

Two witnesses heard the airplane fly overhead at a low altitude but could not see it because of fog.

A friend of the pilot flew the same route in a similarly equipped airplane and arrived about 30 minutes before the Matrix. He said he performed the same approach to the missed approach point but never broke out of the clouds, so he executed a missed approach and diverted to an alternate airport.

FAA Flight Training Handbook Advisory Circular 61-21A cautions that pilots are particularly vulnerable to spatial disorientation during periods of low visibility due to conflicts between what they see and what their supporting senses, such as the inner ear and muscle sense, communicate.

The Matrix’s maneuvering flightpath, as recorded by the GPS track data, in night instrument meteorological conditions is consistent with the pilot’s loss of airplane control due to spatial disorientation.

Probable cause: The pilot’s failure to maintain airplane control while maneuvering in night instrument meteorological conditions due to spatial disorientation.

NTSB Identification: CEN13FA085

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.

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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