The instrument-rated private pilot was operating the Piper PA-32-R on an instrument flight rules flight in instrument meteorological conditions (IMC).
As the plane neared the destination airport, the controller cleared the pilot for the instrument landing system (ILS) approach, instructed him to descend to 3,400′ mean sea level (msl), and provided him with a heading to intercept the localizer course.
The pilot acknowledged the clearance and began descending, but did not initiate the turn.
About 30 seconds later, the controller again instructed the pilot to turn to intercept the localizer course. The pilot complied, turned west, and began tracking toward the airport south of the localizer course.
The controller asked the pilot whether the airplane was established on the localizer, to which the pilot replied, “I’m re-establishing.”
Shortly after, the controller asked the pilot if he was receiving the glideslope indication for the approach. He confirmed that he was receiving the glideslope, but stated that he was “off glideslope” and “too high.”
However, at this time, the airplane was 800′ below the minimum altitude for that segment of the approach (3,400′ msl).
The controller issued a low altitude alert, cancelled the approach clearance, and instructed the pilot to turn north and climb. The pilot acknowledged, however the plane turned south and did not climb. The controller again issued the pilot instructions to turn and climb, and the airplane began to turn north and climb before subsequently entering a descent. Shortly thereafter, the pilot stated, “I’m losing it.”
No further transmissions were received from the pilot, and radar contact was lost in the vicinity of the accident site near Castro Valley, California.
The plane hit heavily-wooded terrain about 12 nautical miles southeast of the destination airport, at an elevation about 1,400′. The pilot died in the crash.
Post-accident examination of the airplane revealed heavy fragmentation consistent with a high-energy impact, as well as evidence of a post-impact fire.
Although the extensive damage precluded examination of the primary vacuum pump and functional testing of the autopilot system, it is unlikely these components malfunctioned because before beginning the approach, the pilot experienced no difficulty complying with air traffic control-assigned altitudes and headings, and, throughout the flight, he gave no indication that he was experiencing problems with the flight controls, flight instruments, or autopilot.
Based on weather data and the pilot’s radio communication that he was “in the weather,” the airplane was operating in IMC throughout the approach. When issued instructions to execute a missed approach, the pilot experienced a high workload that involved changes to the airplane’s heading, altitude, and likely, configuration. This was conducive to the development of spatial disorientation.
The pilot likely recognized the onset of spatial disorientation as evidenced by his statement to the controller, “I’m losing it;” however, he was unable to make the appropriate corrective inputs before losing control of the airplane.
Probable cause: The pilot’s loss of control due to spatial disorientation while maneuvering during an instrument approach in instrument meteorological conditions.
NTSB Identification: WPR16FA042
This December 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.
Sounds more like the guy was never in control. It’s too late to setup for an ILS approach once on the ILS itself.