The pilot filed an instrument flight rules (IFR) flight plan with flight services, and the briefer asked if he would like weather information. The pilot replied “no,” and stated that the weather “looked good.”
However, at that time, the weather at the destination airport included visibility of 2 miles and a 400-foot overcast ceiling.
The pilot proceeded on the approximate one-hour night flight in the Cessna 310 to the airport in Jacksonville, Florida, in low IFR conditions.
During the instrument landing system approach, he flew about one mile right of and 900 feet below the final approach fix. The tower controller issued a low altitude alert and instructed the pilot to check his altitude.
The pilot acknowledged the instruction and confirmed the airplane’s altitude was 600 feet, which was the altitude indicated on radar.
He then flew left of the final approach course twice before intercepting it a third time, descending to 300 feet, and then reported that he was going to conduct a missed approach.
The published missed approach procedure was to climb to 700 feet and then to make a climbing right turn to 1,900 feet on a 180° heading. However, the tower controller instructed the pilot to fly a heading of 280°, and the pilot acknowledged the instruction. The controller did not provide an altitude and was not required to do so.
After the pilot acknowledged the instruction, the plane made a climbing left turn to 900 feet before radar and radio communications were lost.
The airplane subsequently descended and hit a retaining pond near the last recorded radar target. All three on board died.
Although the tower controller’s issuance of nonstandard missed approach instructions without specifying an altitude might have added to the pilot’s workload, radar data show an initial turn consistent with the instructions and an associated climb indicating that the nonstandard instructions were not a factor in the accident.
Given the night instrument meteorological conditions (IMC) with restricted visibility and the sustained left turn and climb, it is likely the pilot experienced spatial disorientation.
The investigation could not determinate the pilot’s overall and recent experience in actual IMC, however his inability to align the airplane with both the final approach fix’s lateral and vertical constraints is consistent with a lack of instrument proficiency.
The NTSB determined the probable cause as the pilot’s failure to maintain airplane control during a missed approach in night instrument meteorological conditions due to spatial disorientation and a lack of instrument proficiency.
NTSB Identification: ERA14FA068
This December 2013 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.