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Spatial disorientation fatal for four

By NTSB · June 2, 2020 ·

The commercial pilot was conducting a personal, cross-country flight. Upon arrival at the destination airport, air traffic control (ATC) cleared the pilot for a GPS approach.

The controller instructed the pilot to change to the airport common traffic advisory frequency after passing the initial approach fix. The pilot acknowledged, after which point no further communications were received.

The available ATC data depicted the Cessna 182 tracking the final approach course until radar contact was lost less than two miles from the runway due to routine radar coverage limitations. Radar contact with the airplane was not regained.

Low instrument meteorological conditions prevailed, and the cloud ceiling was below the minimum descent altitude for the approach.

A witness heard the airplane immediately before the accident and described the sound as similar to an airplane performing aerobatic maneuvers. She subsequently observed a “fireball” through an opening in the tree line behind her home in Monroe, Wisconsin, and immediately heard an explosion. All four people on board the airplane died in the crash.

The accident site was about 1/2 mile north of the runway departure threshold.

Post-accident airframe and engine examinations did not reveal any anomalies consistent with a preimpact failure or malfunction.

The investigation was unable to determine whether the autopilot was engaged during the flight. However, the precise flight track and course intercepts depicted by the position data are consistent with extended portions of the flight, including the initial portion of the approach, being flown by the autopilot.

While the published missed approach procedure included a left turn, the location of the accident site in relation to the runway indicated that a right turn was executed during the missed approach. This revealed that the pilot was not using the course guidance from the autopilot and was either using the autopilot in heading mode or was flying the airplane manually.

Based on the witness description of an airplane performing aerobatics, it is likely that the pilot was flying the airplane manually.

Furthermore, it is probable that the airplane remained in instrument meteorological conditions during the approach and missed approach phases of the flight. Therefore, it is likely that the pilot became spatially disoriented during the missed approach, which resulted in a loss of airplane control and impact with the trees and terrain.

Probable cause: Spatial disorientation resulting in a loss of control during the missed approach conducted in instrument meteorological conditions. Contributing to the accident was the pilot’s decision to execute an instrument approach in weather conditions that were below the approach minimums.

NTSB Identification: CEN18FA216

This June 2018 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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Comments

  1. scott says

    September 21, 2020 at 5:10 am

    Sometimes shooting a below minimums approach reveals 8000ft of visual runway.

  2. JOHN SWALLOW says

    June 3, 2020 at 8:16 pm

    Whether it was legal or not has no bearing on the outcome. In training (simulator and actual), you routinely shoot approaches where the weather is below minimums; if nothing is seen, you go someplace else. Where I reside, there was a time where you could not shoot an approach to a destination that was below limits unless you already had a clearance to another airport. In other words, training only. Now, had you crashed on that approach, it would have had nothing to do with the fact that you executed the procedure, only that you somehow lost control. The approach had nothing to do with it.

    The way I see it anyway… (;>0)

  3. Lynn F. says

    June 3, 2020 at 10:35 am

    Quite often AWOS weather can differ from pilot observed weather at the MAP due to a number of factors. Nothing wrong with taking a look as long as control of the aircraft is maintained. The pilot must always expect to miss the approach, and not be surprised when the landing area is not seen. There should be no hesitation to go missed. Weather was not the cause, lack of proficiency was.

  4. JOHN SWALLOW says

    June 3, 2020 at 7:19 am

    Concur with Mike M. Nothing wrong with shooting an approach where you don’t have a hope in hell of breaking out. Losing control was the problem…

    • Mark says

      June 3, 2020 at 6:56 pm

      Disagree. Flying an approach with 3 passengers onboard to an airport below minimums is an unacceptable risk, in my opinion. There is a reason it is not allowed under Part 135 and 121 operations.

      • Peter Heck says

        June 4, 2020 at 7:21 am

        I wonder what the thinking behind that regulation is. Is it the possibility of striking something on the ground? Or is it the temptation to bust the MDA? At any rate, that’s not what happened in this case.

  5. Captain says

    June 3, 2020 at 6:37 am

    Sad

  6. Andy T says

    June 3, 2020 at 6:02 am

    “The controller provided alternate missed approach instructions: fly heading 090° and climb and maintain 4,000 ft.”

    I guess that’s the reason she turned right. Says so right in the full narrative.

  7. gbigs says

    June 3, 2020 at 5:47 am

    “Low instrument meteorological conditions prevailed, and the cloud ceiling was below the minimum descent altitude for the approach.” Says it all.

    • Mike M. says

      June 3, 2020 at 6:17 am

      I think you’ve missed understanding the cause cited in the report. There was nothing wrong with trying the approach. In fact, he did try it, then started the missed approach, which was the correct thing to do. He crashed due to spacial disorientation, not because the ceiling was below minimums.

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