North Myrtle Beach, SC, USA
N2100V
CESSNA 172S
On the day of the accident the pilot decided to practice instrument approaches. Prior to takeoff he advised an air traffic controller that he would like to conduct three approaches, starting with a very-high frequency omnidirectional radio range (VOR) approach. At the completion of the VOR approach, the controller offered the pilot the option of landing or executing a low approach. The pilot elected to execute the low approach and was issued a frequency change, which he acknowledged. During the missed approach, the pilot was then directed by the air traffic controller to proceed direct to the VOR, hold northeast of the VOR, to maintain 3,000 feet above mean sea level (msl), and to advise when he was ready to commence the instrument landing system (ILS) approach. The pilot then transmitted to the controller that he had gotten himself “a little out of whack” and that he was “just trying to straighten it out.” Review of radar data revealed that, at the time the pilot transmitted this information to the controller, the airplane had begun to turn right and continued turning right for about 150 degrees before radar contact was lost. The airplane then struck a tree, a travel trailer, and a pickup truck, fatally injuring the pilot and one occupant of the trailer and seriously injuring the other occupant of the trailer. A postaccident examination of the wreckage did not reveal any evidence of a preimpact failure or malfunction of the airplane, the flight instruments, or engine. Toxicological testing, postmortem examination, and review of medical records also did not reveal any evidence of pilot incapacitation. At the time of the accident, instrument meteorological conditions prevailed in the local area. The ceiling at the airport at the time of the accident was at 600 feet msl, and the minimum descent altitude (MDA) for the VOR approach was 560 feet msl, a difference of only 40 feet. There were no witnesses who observed the airplane during the approach, and the pilot did not report to the air traffic controller the actual altitude of the base of the overcast layer. It is therefore uncertain as to whether the pilot ever entered visual conditions when the airplane approached the MDA prior to executing the missed approach procedure. The environmental conditions that existed during the flight and the pilot's actions and responses indicate that he likely experienced spatial disorientation.
HISTORY OF FLIGHT On January 18, 2011, at 1307 eastern standard time (est), a Cessna 172S, N2100V, was substantially damaged when it collided with a tree, a travel trailer, and a pickup truck, after a loss of control during a missed approach at Grand Strand Airport (CRE), North Myrtle Beach, South Carolina. One occupant of the travel trailer and the certificated private pilot were fatally injured. The other occupant of the travel trailer was seriously injured, and a bystander received minor injuries. Instrument meteorological conditions prevailed, and no flight plan was filed for the local personal flight conducted under Title 14 Code of Federal Regulations (CFR) Part 91. According to voice and radar data provided by the Federal Aviation Administration (FAA), the pilot had requested to do three instrument approaches beginning with a Very High Frequency Omni-Directional Radio-range (VOR) Runway 23 approach. At the completion of the VOR approach air traffic control (ATC) offered the pilot the "option" of landing or executing a low approach. The pilot elected to execute the low approach and was issued a frequency change which he acknowledged. During the missed approach, the pilot was then directed by ATC to proceed direct to the VOR, enter holding northeast of the VOR, to maintain 3,000 feet above mean sea level (msl), and to advise when he was ready to commence the instrument landing system (ILS) approach. The pilot then transmitted to ATC that he had gotten himself "a little out of whack" and he was "just trying to straighten it out". Approximately 1 minute later, radar contact was lost with the airplane and attempts by ATC to make contact by radio were unsuccessful. At approximately the same time that radar contact was lost with the airplane, witnesses in a trailer park located 1.2 miles Southwest of CRE heard an airplane engine. The airplane was then observed to impact a tree, a travel trailer, and then a pickup truck. Multiple explosions occurred and then a large fire ensued. PERSONNEL INFORMATION According to FAA records, the pilot held a private pilot certificate with ratings for airplane single-engine-land and instrument airplane. His instrument rating was issued on April 24, 2009. At the time of its issuance the pilot had accrued 241 hours of flight experience including 45.2 hours of simulated instrument time. His most recent FAA third-class medical certificate was issued on December 17, 2009. On that date, he reported 289 hours of total flight experience of which he accrued 29 hours in the last 6 months. According to pilot records, at the time of the accident, he had accrued 388 total hours of flight experience, and 21 hours of actual instrument flight experience. AIRCRAFT INFORMATION The accident aircraft was a high wing, strut braced, four place, single engine airplane of conventional construction. It was powered by a 180 horsepower, four cylinder, fuel injected engine. The airplane was certificated for flight in instrument meteorological conditions (IMC). All of the flight instruments needed for flight in IMC were contained in a single panel located in front of the pilot. These instruments were designed around the basic "T" configuration. The attitude indicator and directional indicator were located immediately in front of the pilot. They were arranged vertically over the control column with the attitude indicator in the upper portion of the panel and the directional indicator directly below it. Both indicators were air-driven by a vacuum system, which was powered by dual vacuum pumps equipped with check valves, to allow for normal vacuum system operation if one of the vacuum pumps should fail. The airspeed indicator was located to the left of the attitude indicator and, the altimeter was located to the right of the attitude indicator. A multi-function annunciator was also located above the altimeter and provided caution and warning messages for fuel quantity, oil pressure, low vacuum, and low voltage situations. According to FAA and airplane maintenance records, the accident airplane was manufactured in 2004. The airplane’s most recent annual inspection was completed on December 1, 2010. At the time of the inspection, the airplane had accumulated 1,485.8 total hours of operation. AIDS TO NAVIGATION Five instrument approach procedures (IAPs) were published for use at CRE. These included: - ILS OR LOC/DME RWY 23 - RNAV (GPS) RWY 05 - RNAV (GPS) RWY 23 - VOR RWY 05 - VOR RWY 23 The IAPs were published for use from 0401 est. on January 13, 2011, to 0400 est. on February 10, 2011. Examination of cockpit revealed that valid approach plates for these IAPs were on board the airplane. The approach plate for the VOR RWY 23 approach procedure which the pilot had been flying prior to the accident was also discovered to have been removed from the binder which held the approach plates. It was later discovered with some of the cockpit wiring, in a portion of the damaged instrument panel in close proximity to the pilot's seat. The navigation aid used during the VOR runway 23 approach was a VORTAC which is a VOR that also has tactical air navigation (TACAN) equipment installed. It was physically located at CRE. The inbound course for the approach was 238 degrees and the minimum descent altitude was 560 feet msl. In the event of a missed approach, the missed approach procedure was to climb to 2,000 feet msl, then turn left and proceed direct to the CRE VORTAC and hold. METEOROLOGICAL INFORMATION The reported weather at CRE at 1311, included: winds 310 degrees at 4 knots, 4 miles visibility in mist, skies overcast at 600 feet, temperature 7 degrees C, dew point 6 degrees C, and an altimeter setting of 29.85 inches of mercury. AIRPORT INFORMATION According to the Airport Facility Directory, CRE had one runway oriented in a 05/23 configuration. Runway 23 was asphalt, and in good condition. The total length of the runway was 5,997 feet, and its width was 100 feet. It was equipped with precision runway markings, a 2-light precision approach slope indicator which displayed a 2.98 degree glide path, and a medium intensity approach lighting system with runway alignment indicator lights. An obstruction existed on the approach end of runway 23 in the form of a 105 foot tree, 3,582 feet from the end of the runway and 837 feet left of the centerline. A 32:1 slope was required to clear the tree. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that after striking the tree, and the travel trailer, the airplane had pushed the pickup truck across the street from its parking space in front of the trailer. A wreckage path existed which started at the base of the tree and continued out on a 010 degree magnetic heading for approximately 250 feet. Further examination revealed that the wreckage path contained all of the major components of the airplane, pieces of the travel trailer, the pickup truck and multiple fire damaged propane cylinders. A triangular shaped debris field also coexisted with the wreckage path. It initiated at the tree, and then fanned out on both sides of the wreckage path to its widest point which was approximately 248 feet wide. Examination of the tree revealed that a portion of the left wing structure was suspended in the top of the tree as well as portions of the left lift strut. Examination of the travel trailer revealed that after striking the tree, the airplane impacted the roof of the trailer, penetrated the interior, and then traveled out the front. Examination of the wreckage revealed that after pushing the pickup truck across the street, the airplane shed the remainder of its wing structure, and came to rest with the fuselage parallel to the wreckage path, pointed in the opposite direction of travel. Examination of the wreckage revealed no evidence of any preimpact failure of the airplane's structure. Examination of the wings revealed that they were fragmented into multiple pieces which exhibited areas of crush and compression damage. The empennage also exhibited areas of crush and compression damage however, the right horizontal stabilizer, right elevator, vertical stabilizer, and rudder, had remained attached to their fittings. The main landing gear had remained attached to its mounts but, the right main landing wheel assembly was separated from its mounting location at the end of the right main landing gear leg. The nose landing gear assembly was separated from its mounting location. Examination of the flight controls did not exhibit any evidence of preimpact failure or malfunction. The flight and trim control cables, runs, and associated hardware did not reveal any evidence of a preexisting jam. Control continuity was established for all flight controls to the breaks in the cables, which exhibited evidence of tensile overload. Elevator trim actuator extension correlated to a 5 degree tab up position and examination of the internal flap drive mechanism indicated that the wing flaps were in the up position. Examination of the cockpit revealed that the throttle control was in the full throttle position and the mixture control was in the full rich setting. The magneto switch was on "BOTH". The Avionics master switch was in the "ON" position, the navigation lights switch was in the "ON" position, and the pitot heat switch was in the "ON" position. The pilot's combination seatbelt and shoulder harness was latched. Examination of the pitot static system revealed that the pitot tube was separated from its mounting location and was fractured in two. Its drain hole was clear and the pitot tube did not exhibit any evidence of preimpact blockage. The static port was undamaged and exhibited no evidence of blockage. Examination of the flight instruments revealed that the attitude indicator displayed a 30 degree nose down, wings level attitude. Internal examination of the instrument revealed evidence of rotational scoring. The directional indicator displayed a heading of 360 degrees and the heading bug indicated 235 degrees. The altimeter was missing its indicator needles and the Kollsman window displayed an altimeter setting of 29.86 inches of mercury. Examination of the propeller and engine revealed no evidence of any preimpact failures or malfunctions. The propeller was separated from the crankshaft flange and exhibited visible smearing of the fractured surfaces. The propeller blades exhibited twisting, s-bending, leading edge gouging, and chord wise scratching. The engine exhibited impact damage to the crankcase and oil sump. Oil was present in the rocker boxes and oil sump, and the oil sump screen and oil filter were absent of debris. The fuel injector servo was separated from the engine and was fractured across the throttle bore. The throttle plate was in the open position. The fuel regulator section was disassembled and no damage was evident. The fuel flow divider was disassembled and examination of the diaphragm revealed no evidence of damage. The fuel injection nozzle inserts were unobstructed. Both magnetos were damaged however both produced spark at all electrode towers when rotated by hand. All spark plugs were gray in color and appeared normal. Internal examination of both vacuum pumps revealed that their vanes were intact. Crankshaft and valve train continuity was visually confirmed and examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any damage to the piston domes, cylinder walls, or valves. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on behalf of the Horry County Coroner at the Grand Strand Regional Medical Center. The cause of death was extensive trauma with subsequent burning sustained in an airplane crash. Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens were negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs, with the exception of Quinine which was detected in Liver. TESTS AND RESEARCH Review of radar data revealed that at the approximate time the pilot executed the missed approach and the pilot transmitted to ATC that he had gotten himself "a little out of whack" and was "just trying to straighten it out", the airplane began to turn towards the right, and continued turning right for approximately 150 degrees before radar contact was lost. FAA Advisory Circular (AC) 60-4A FAA's Advisory Circular (AC) 60-4A, entitled "Pilot's Spatial Disorientation," states (in part): "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.' The advisory circular goes on to say that, "The disoriented pilot may place the aircraft in a dangerous attitude..." FAA's Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25) The FAA's Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25), also states that under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome. In a classic example, a pilot may believe the airplane is in level flight, when, in reality, it is in a gradual turn. If the airspeed increases, the pilot may experience a postural sensation of a level dive and pull back on the stick, which tightens the turn and creates increasing G-loads. If recovery is not initiated, a steep spiral will develop. This is sometimes called the graveyard spiral, because if the pilot fails to recognize that the airplane is in a spiral and fails to return the airplane to wings-level flight, the airplane will eventually strike the ground. If the horizon becomes visible again, the pilot will have an opportunity to return the airplane to straight-and-level flight, and continued visual contact with the horizon will allow the pilot to maintain straight-and-level flight. However, if contact with the horizon is lost again, the inner ear may fool the pilot into thinking the airplane has started a bank in the other direction, causing the graveyard spiral to begin all over again.
The pilot's loss of airplane control during a missed approach due to spatial disorientation.
Source: NTSB Aviation Accident Database
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