The former Air Force pilot, 75, had logged more than 16,560 hours at the time of the accident. He took off from Fort Lauderdale in the Cessna 340 on an IFR flight plan.Four minutes after takeoff during an assigned climb to 4,000 feet, he advised the departure air traffic controller that the airplane was having “instrument problems” and that he wanted to “stay VFR.”
The controller acknowledged the request. The pilot did not elaborate on what problems he was having.
He subsequently contacted the next sector departure controller, who instructed him to climb to 8,000 feet. He said he would climb after clearing a cloud and reiterated that the airplane was having “instrument problems.”
The controller told the pilot to advise when he could climb the airplane. About 30 seconds later, the pilot told the controller that he was climbing to 8,000 feet, and, shortly thereafter, the controller cleared the airplane to 11,000 feet, which the pilot acknowledged.
Per instruction, the pilot later contacted a center controller, who advised him of moderate-to-heavy precipitation along his route for the next 10 miles and told him that he could deviate either left or right and, when able, proceed direct to an intersection near his destination. The pilot acknowledged the direct-to-intersection instruction, and the controller told him to climb to 13,000 feet, which the pilot acknowledged. He did not advise the center controller about the instrument problems.
The airplane began turning east, eventually completing about an 80° turn toward heavier precipitation. The controller told the pilot to climb to 15,000 feet, but he did not respond. After two more queries, he stated that he was trying to maintain “VFR” and that “I have an instrument failure here.”
The controller told the pilot that a turn toward the east “looks like a very bad idea.” He subsequently advised the pilot to turn to the west but received no further transmissions from the airplane.
Radar indicated that, while the airplane was turning east, it climbed to 9,500 feet but that, during the next 24 seconds, descended to 7,500 feet and, within the following five seconds, it descended to just above ground level. The radar track showed the airplane climbing on a northeast heading to about 1,500 feet during the next 20 seconds, then it disappeared off radar.
The extremely fragmented wreckage and the remains of the aircraft was found in the shallow waters of a wildlife refuge. The pilot was killed.
The investigation could not determine the extent to which the pilot had planned the flight. Although a flight plan was on file, there was no record of the pilot receiving a formal weather briefing. The investigation did not determine when the pilot first lost situational awareness, although the excessive turn to the east toward heavier precipitation raises the possibility that the turn likely wasn’t intentional and that the pilot had already lost situational awareness.
Investigators noted that earlier in the flight, when the pilot reported an instrument problem, the two departure controllers coordinated between their sectors in accordance with air traffic control procedures, allowing him to remain in low and VFR conditions. Although the second controller told the pilot to advise when he was able to climb, the pilot commenced a climb without further comment.
The controller was likely under the impression that the instrument problem had been corrected, therefore, he communicated no information about a potential instrument problem to the center controller. The center controller then advised the pilot of the weather conditions ahead and approved deviations to avoid the weather.
The pilot did not request further weather information or assistance with deviations and only told the center controller that the airplane was having an instrument problem after the controller pointed out that the airplane was heading into worsening weather.
The wreckage was extremely fractured, which precluded thorough examination. However, evidence indicated that all flight control surfaces were accounted for at the accident scene and that the engines were under power at the time of impact.
The airplane was equipped with redundant pilot and copilot flight instruments, redundant instrument air sources, onboard weather radar, and a storm scope. It was noted that the pilot did not advise any of the air traffic controllers about the extent or type of instrument problem, and the investigation could not determine which instruments might have failed or how redundant systems could have been failed at the same time.
Although the pilot stated on several occasions that the airplane was having instrument problems, he opted to continue flight into IMC. By doing so, he eventually lost situational awareness and then control of airplane, but regained both when he acquired visual ground contact. Then, for unknown reasons, he climbed the airplane back into IMC where he again lost situational awareness and airplane control but was then unable to regain them before the airplane impacted the water.
The NTSB determined the probable cause as the pilot’s loss of situational awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed back into instrument meteorological conditions. Contributing to the accident was the pilot’s improper decision to continue flight into IMC with malfunctioning flight instruments.
NTSB Identification: ERA13FA275
This June 2015 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.
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The NTSB Probable Cause nailed this one:
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s loss of situational awareness, which resulted in an inadvertent aerodynamic stall/spin after he climbed the airplane back into instrument meteorological conditions (IMC). Contributing to the accident was the pilot’s improper decision to continue flight into IMC with malfunctioning flight instrument(s).”
Regardless of whether the problem was HF, system, or other the pilot exhibited significant hubris and a huge lack of judgment when he or she opted for continued flight with ‘instrument problems’ on an IFR flight. The key learning point of this accident brief, is not that a GPS was challenging or that other cockpit instrumentation was or was not fully functional. Discussion or speculation on these points are merely distractors from the core failure described in the accident report.
What is not stated in this article, is the potential role of a poorly designed GPS in this accident. The NTSB report clearly identifies that the aircraft was equipped with a G530 and a G430. Both these GPS units are known to have serious human factors “use issues”, and vulnerabilities due to exceedingly poor HF interface design. Even for a highly experienced IFR pilot, as this pilot obviously was, these GA GPSs can be extremely distracting, challenging, and difficult to use (as other GA GPS’s too, up to the latest G1000s), particularly if not flying on a very familiar flight plan, or if getting ATS clearances that require any unusual pilot input or interpretation of information with the GPS units. Any good examiner can usually fail a pilot on using these units on a flight test, regardless of the pilot’s IFR experience, if presenting the pilot with any reasonably probable ATS scenario, albeit out of that pilot’s comfort zone for familiar areas, airports or procedures. The probability of loss of control due to these poorly designed GPSs further increases if any non-normal circumstance is added to the mix. This is likely how another former ex AF C141 pilot also died with his whole family, in a Bonanza, at Scapoose OR a number of years ago, losing control and pulling the wings off, while likely fiddling with his GPS, trying to shoot an approach in the early morning dark hours, in moderately normal smooth air IFR, albeit with 1000 ft ceilings, with another simple instrument failure that otherwise could have readily been accommodated. Hopefully the insurance companies will eventually force changes in the human interfaces in these marginally safe GA GPSs to more closely parallel the vastly better human interfaces used in systems designed for use in modern RNP capable air carrier jets, which are vastly easier, better, quicker, and safer to use than any present GA panel mount GPS. I can confidently say this, after having owned or flown with most of the Garmins, as well as flown most of the KLNs and Avidynes, and Prolines and Epics, since the first Trimbles and Tomorrow’s. In fact, at this point, I’d rather fly a modern production Boeing or Airbus into VNKT at night, with TRW++s nearby, in moderate turbulence, all by myself, with an incapacitated F/O, a failed engine, and a failed hydraulic system, and one complete electrical bus inop, …than fly locally with my Garmin in the easiest of limited IFR, for a nearby $100 hamburger, after having owned and flown with that G430 unit now for over 7 years. Note that a King Air recently crashed also, with a similar suspected GPS human interface issue, as was widely reported in the aviation press and by NTSB.
ManyDecades,
Did your VCR blink “12:00” continuously? The Gx30 boxes are easy to use. So is the KLN90B I have in my Baron. Perhaps you should read the books.
Agree with John.