The commercial pilot and his wife departed on a visual flight rules cross-country flight to their home airport. About 46 nautical miles from the destination airport, the pilot requested an instrument flight rules clearance and was subsequently cleared for an instrument landing system (ILS) approach at the destination airport.
GPS data indicated that the Piper PA 24-260 followed a straight course with minimal variation during its cruise flight in a manner consistent with use of the autopilot. The airplane’s course movements became more erratic when the airplane neared the destination airport in Santa Rosa, California, which suggests that he began to hand-fly the airplane.
A combination of radar data, GPS data, and air traffic control audio showed that the pilot complied with the controller’s instructions.
After he intercepted the glideslope, he maintained a shallow descent rate until the final approach fix. He subsequently crossed the final approach fix 1,000′ above the intercept altitude on a heading track to the right of the localizer.
The tower controller reported multiple deviations over the radio to the pilot, but he did not make appropriate corrections.
Radar data showed the plane enter progressively steeper descent rates after passing the final approach fix, and it began to deviate to the left of the localizer. In the final moments of the flight, the plane turned to the right about 50°, crossed the localizer, and then immediately began a 60° steep left turn at an approximate 1,200-fpm descent rate.
Debris path signatures indicated the airplane was in a high-speed, steep left turn with a nose-down attitude when it hit a field about 1.5 nautical miles south of the runway approach end. Both the pilot and his wife died in the crash.
The proximity of the accident site to the final GPS data point and the similarity between the impact signatures and the track shown by the last few GPS data points indicates that the last data points closely represent the airplane’s final movements before impact.
Examination of the wreckage and of engine analyzer data did not reveal any evidence of preimpact anomalies with the airframe or engine.
Circumferential scoring from the gyros was found on the case of the heading indicator and both attitude indicators, which indicates that these instruments were likely functioning normally at the time of impact.
The pilot obtained weather information from an online service about 24 hours before the flight, however the forecasts he received were not valid at the time of his departure.
In his communication to an Air Route Traffic Control Center (ARTCC) controller, he asked, “what are they doing for approaches?” which indicated that he was aware of possible instrument meteorological conditions (IMC) at the destination airport.
The pilot’s audio transmissions to ARTCC did not indicate that he had received current Airport Terminal Information System weather.
Further, the ARTCC controller did not provide the pilot with the current weather as required by FAA procedure, and the airport tower controller had not been disseminating pilot reports, also required by FAA procedure.
The pilot’s flight instructors commended his aeronautical decision-making skills, however the investigation was unable to confirm if the pilot obtained current weather and if knowledge of the low-visibility weather conditions would have altered his decision to continue the flight despite his desire to return home that night.
Two months before the accident, he completed an instrument proficiency check and made a night flight to fulfill the night currency requirement. Other than these two events, he had no recent instrument or night flight experience.
Further, his flight records did not show any evidence that he had completed a flight in night IMC in nearly three years.
Given his lack of recent experience in night IMC, he was most likely overwhelmed by the complexity of hand-flying the airplane on an ILS approach in night IMC.
Once he crossed the final approach fix, he doubled his descent rate to correct for his high crossing altitude and then deviated from the localizer course line. The airplane’s final movements suggest that he likely lost control of the airplane during the large heading adjustment he made to correct his course and was not able to regain control.
Probable cause: The pilot’s failure to maintain airplane control during an instrument approach in night instrument meteorological conditions, which resulted in a collision with terrain. Contributing to the accident was the pilot’s lack of recent experience in night instrument meteorological conditions.
NTSB Identification: WPR16FA059
This January 2016 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.
Obviously he made the mistake of trying to hand-fly the approach when his autopilot was doing perfectly well before he turned it off and lost control. An ILS approach should not be hand-flown, especially at night.
The mistake was not that he hand flew but that he thought that a day VFR IPC and a night VFR landing currency flight would prepare him for ninth IMC. He also didn’t ‘plan’ the flight—he should have had a current weather brief and known (and mentally practiced) his approach, missed approach, and divert. Did he ever go through the Go/No Go decision or just Go without acknowledging/mitigating the risks?
“The pilot’s flight instructors commended his aeronautical decision-making skills”. Yes, but according to the full narrative report, the IPC instructor also reported that the pilot “struggled in performance, as he kept his airspeed too high during approaches, which resulted in steeper turns”. Also it was indicated that “the pilot had not accumulated any simulated or actual instrument experience between November 6, 2015, and January 2, 2016”, the IPC and accident dates.
Some very good comments on technique and decision making. It looks to me like the pilot had a “mission mindset”, and like Edd Weninger suggests that clouded his ability to call “knock it off”… maybe fly a hold for a few minutes to sort things out, and request vectors or a different approach.
It’s amazing and sad to see accidents like this all the time when the cause boils down to a very simple concept which apparently isn’t taught to instrument students anymore. Pitch equals speed, power equals rate, or trim for speed and set power for the rate of descent. If you learn to do this you can use even a single axis autopilot to “fly the approach” by making turns with the wing leveler, setting speed on the descent with trim and control rate of descent with power. It works because for any configuration and power setting there is ONE trimmed airspeed! Learn this and live on it.
“set power for the rate of descent”. If you have an autopilot which couples to the Glide Slope, the autopilot will slave the elevator to the glide slope thereby managing the rate of descent with pitch. This is also contrary to the FAA recommended manual technique which is to adjust power as needed to maintain desired airspeed. Per the FAA Instrument Flying Handbook pg 9-40 “adjust pitch attitude to maintain the proper rate of descent, and adjust power to maintain proper airspeed”.
Warren, in this case we must assume his autopilot was incapable of flying the vertical component of the approach, otherwise why did he not use it? Many autopilots and wing levelers do not have that capability but they can still be used to track or be vectored to the RNAV final approach or localizer. I’m not going to get into an argument AGAIN about pitch or power controlling speed. The FACT is the FAA has changed it mind on this point in the past and the FACT that a coupled autopilot uses power to control speed does NOT change the FACT that back when ALL approaches were hand flown (with due deference to the expertise of gBiggs) we were taught to trim for airspeed and adjust the rate of descent with power and flaps, if we had had them. It works today the same way it worked then and if you’re not fortunate enough to have a fully coupled autopilot that’s the way you should be doing it today. Learn the trim and power settings that give you the speed you want lest the day your ASI goes tits up you are LOST!
Bart – I don’t think it is that unusual for a pilot to use an autopilot enroute which is simple and where there’s no pressure, then hand-fly the approach where there’s a rapidly changing environment and more demanding buttonology (also with due deference to gbigs, hand-flying proficiency should be the go/no-go item, not the auto-pilot). Sorry about another debate on pitch and power. I did find one of my older FAA Instrument handbooks updated in 1980 – the recommended technique was exactly the same of pitching for vertical speed. Perfectly logical as it fits with the four basic forces diagram found in all handbooks and texts that has always shown that the wing’s vertical force is used to maintain the proper vertical position.
Warren you have to go back before 1980, I was taught to fly instruments using techniques from the 50’s when there were no autopilots, only wing levelers and those only in transport category airplane’s.
Here’s the way it was explained to me. In cruise and straight level flight all forces are equal. Leaving trim and configuration alone if you add power the airplane climbs, at it’s trimmed airspeed. If you reduce power it descends, at its trimmed airspeed. Now if I’m doing an approach which requires me to fly a predetermined angle in the descent why would I change the trim when all I have to do is reduce power? Now at some point in the approach I want to slow down so I trim the nose up change the configuration and add power if necessary to stay on the angle.
It’s important to know the power/pitch/configuration combination that gives you a given airspeed by heart because when your ASI fails, as it will someday, that’s the only way you have of determining your airspeed. But it’s ok, you do it your way and I’ll do it mine and we should both end up in the same place, I just contend mine is easier and safer.
Bart – thanks for the explanation. I agree that technique is very sound if conditions allow and it follows generally the procedure in the C172 manual for an inop elevator where a speed and flap setting are pre-set using trim and throttle, then descent is made only with the throttle. But in rougher weather, it’s probably going to take the stronger authority of the elevator to stay on that thin glideslope or a stable visual descent, so that’s my reason for pushing the current recommendations.
I’ve used this technique in some pretty rough air Warren. Rather than assume it’s better to follow the FAA’s current guidelines why don’t you try it yourself and see how it works. You may be surprised at the results. Back “in the day” a lot of good pilots learned how to stay alive without an autopilot or a magenta line but those lessons are being lost today with dependence on technology rather than skills. I think it’s a shame but I know that on some level it’s just an old guy hanging on to the past. I have the modern tech in my airplane too but I try not to bet my life that it’ll always work.
Bart – I think the inoperative elevator procedure (it’s straight out of the POH) that I’ve practiced quite a few times has given me a very good exposure to using the throttle to control rate of descent. Actually it would be taking that technique to another level, because the procedure is done at normal landing approach speed 65 kts and 20 degrees flaps (less control than ILS approach speed) and all the way to a landing without any use of the elevator (no forward or back pressure whatsoever on the control wheel). It took a while to develop the touch on the throttle and trim to be able to do it safely. I had to save the flare many times with the elevator until I was able to follow the suggested technique to flare and land safely with trim and throttle. To be honest, I know that when there are strong updrafts, downdrafts, and/or gusts, either on an instrument approach or the visual landing approach, I can maintain position on the ILS glide slope or the VASI with the elevator. But based on my experience with using the throttle on the inop elevator procedure, where a cushion of air from the corkscrewing flow down the fuselage is raising or lowering the tail, it can’t possibly work as well, and in fact in twins, where there’s no corkscrewing airflow down the fuselage, will not work at all. Love your comment that it’s important to assume the equipment in the airplane may not work – like I said the pilot’s proficiency with inoperative equipment should be the ultimate go/no-go factor.
Same school as you Bartr and agree 100%
yes, pitch to the glide slope, power to the speed…everything I have flown does this from a Piper 140 to the Boeing 767 to the Airbus 320…
If the AP could couple to the localizer his lateral deviations might have been dampened sufficiently such that he could have brought the vertical deviations under control. As it was he was chasing himself laterally and vertically with increasing diverging deviations. Such an unstable situation warranted a wings level climb and reset. Impossible to salvage such an unstable approach.
This is kind of a shame. He had done recent flight checks which demonstrated he wanted to stay current, so he was no slackard. Perhaps if he had know earlier the Wx at the destination, he might have keyed up and briefed himself sooner and been better prepared. The key point here, was 1000′ high at the FAF. Time to call “knock it off”, call missed, level and climb without a heading change, AP on and asked for vectors.