Greensboro, NC, USA
N569JL
BEECH 58
The pilot was flying the third of four scheduled flights for the day and was returning with a passenger to the passenger’s originating airport. The flight was operating in instrument meteorological conditions on an instrument flight rules flight plan. About 45 minutes into the flight, as the airplane neared the destination airport, the pilot advised air traffic control that she would need to enter a holding pattern and wait for the weather conditions at the destination airport to improve. The controller advised the pilot of several other airports with better weather conditions that were between 25 and 40 miles from her destination. The pilot declined the alternatives, and, about 9 minutes after entering the holding pattern, advised the controller that she would like to divert to an airport not far from her original destination, if the weather conditions there were "good." The controller immediately provided the pilot with radar vectors toward the requested diversion airport. The original destination and diversion airports were located about 13 nautical miles (nm) apart, and similar weather conditions prevailed at both airports, including low ceilings and visibilities in mist and fog. After vectoring the flight toward the diversion airport, the controller advised the pilot of the weather conditions. After a brief discussion regarding other flights that recently completed instrument approaches and successfully landed at the diversion airport, the pilot elected to continue to that airport despite the reported weather conditions. The controller provided vectors to the pilot for an instrument landing system approach and informed her that the runway visual range was 4,000 feet, which was above the 1,800-foot required landing minimum for the approach. Radar data indicated that the flight subsequently intercepted, briefly passed through, and then re-intercepted the final approach course before descending and crossing the final approach fix about 200 feet below the published intercept altitude. The flight continued its descent below the glideslope until reaching a point about 3 nm from the runway and 400 feet above the ground, at which time the pilot initiated a missed approach. The airplane climbed to about 700 feet above the ground and then again began to descend. The last radar return showed the airplane about 600 feet above the ground. The airplane impacted the ground about 1,800 feet beyond the last radar return indicating that, during the final seconds of the flight, the airplane entered a steep descent with an average angle of about 18 degrees. The wreckage was located about 2 nm from the runway. The debris path, which was about 600 feet in length and oriented with the runway heading, and the fragmentation of the wreckage indicated that the airplane was traveling at a relatively high airspeed when it impacted the ground. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation, and there was no indication that the airplane struck any objects before it impacted the trees identified as the initial point of the debris path. Analysis of the radar data for the approach portion of the flight showed that the accident airplane trailed another airplane on the instrument landing system approach by an average of 1.5 minutes and about 5 nautical miles. A wake vortex analysis based on the radar-observed positions of both airplanes showed that the accident airplane remained below the calculated wake vortices generated by the airplane ahead until that airplane landed. Additionally, analysis of the accident airplane’s calculated pitch, roll, and heading did not indicate that the airplane encountered a wake vortex. The airplane’s calculated bank angle remained below 10 degrees for at least the final 3 minutes of the flight, and the largest calculated bank angle observed was 6 degrees left after the pilot advised air traffic control that she was initiating a missed approach. The published missed approach procedure included a climbing left turn. Analysis of the last 9 seconds of radar data indicated that the airplane’s groundspeed increased from 109 to 129 knots, while its altitude remained within a 100-foot range. This abrupt increase in speed likely resulted from increased thrust as the pilot initiated the missed approach and increased engine power. During this time, the pilot was vulnerable to a vestibular illusion associated with forward acceleration known as a somatogravic illusion, which causes a false sensation of increased pitch, particularly when flying in low visibility conditions. Further analysis of the airplane’s radar data-based performance showed that the maximum pitch attitude attained during the missed approach was about 13 degrees nose up; however, calculations indicated that the pilot’s maximum vestibular/kinesthetic perception of the airplane’s nose-up pitch may initially have been closer to 19 degrees, which would have prompted her to lower the airplane’s nose. If the pilot lowered the nose in response to a perceived increase in pitch, the airplane would have accelerated even more rapidly, exacerbating the somatogravic illusion and causing the pilot to lower the nose even further. (Analysis showed that the pilot’s perception of the airplane’s pitch likely remained above actual pitch for the remainder of the flight, as perceived pitch decreased from about 19 to 6 degrees nose up.) As a result, the airplane’s final flight path would have approximated a parabolic trajectory. This is consistent with the accident airplane’s transition from a climb to a steep descent.Furthermore, the pilot had only about 13 seconds between the start of the airplane’s final descent and terrain impact; this would have reduced the likelihood of a successful recovery, given that studies have shown that pilots can require 21 to 36 seconds to transition to stable instrument flight after spatial orientation is lost. Therefore, it is likely that the pilot experienced spatial disorientation due to a somatogravic illusion and placed the airplane in a nose-low attitude as a result. A review of company records revealed that, in the 6 months before the accident, the pilot performed six instrument approaches, two of which were performed on the morning of the accident flight. In addition, the pilot had conducted a total of seven instrument approaches in the accident airplane type. These numbers suggest that the pilot had only minimal instrument flying proficiency. However, it is difficult to determine the pilot’s level of instrument flying proficiency based solely on recency of experience and the number of instrument approaches conducted in the accident airplane type. Furthermore, even highly experienced, proficient pilots occasionally experience brief episodes of spatial disorientation. The influence of the pilot’s instrument flying proficiency on the pilot’s spatial disorientation could not be determined. Available information indicated that the pilot had a rest opportunity of 7 hours 44 minutes the night before the accident, which was close to her reported sleep need of 8 hours per night. In addition, although the pilot had been on duty for 13 hours by the time of the accident, she received a 5-hour break at an intermediate stop before she began preparing for the accident flight. It is possible she used some of this time to obtain additional rest. Furthermore, the accident occurred at a time of day that is normally associated with high levels of alertness. Thus, the available evidence does not support a conclusion that the pilot’s performance was degraded by fatigue. No blood sample was available for toxicological testing, but tissue specimens were used for ethanol and drug assays. No ethanol was found in any tissue. Sertraline was detected in the liver. Since blood levels for butalbital (detected in the liver and kidney) and promethazine (detected in the kidney) (both of which can cause sedation and impair mental and/or physical ability) were not available, it was not possible to assess the pilot’s level of impairment at the time of the accident. Based on the tissue levels of butalbital, promethazine and sertraline, it was likely that, at some point the day before, or the day of, the accident flight, the pilot ingested these medications. Whether actual blood levels of butalbital and/or promethazine were great enough to interfere with the pilot’s aeronautical decision-making or flying skills at the time of the accident could not be determined.
HISTORY OF FLIGHT On March 30, 2011, at 1746 eastern daylight time, a Beech 58, N569JL, operated by Jet Logistics, Inc., was substantially damaged when it impacted trees and a residence while conducting an instrument approach to Piedmont-Triad International Airport (GSO), Greensboro, North Carolina. The certificated airline transport pilot and passenger were fatally injured. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight, which departed Wilmington International Airport (ILM), Wilmington, North Carolina, and was destined for Smith Reynolds Airport (INT), Winston Salem, North Carolina. The non-scheduled passenger flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. Personnel records provided by the operator indicated that, on the day preceding the accident, the pilot reported for duty at 1030 after having been off duty for several days. The pilot acted as second-in-command of a Beech 90 during a two-leg trip, and reported off duty at 1830. Review of data provided by a third-party flight planning and weather briefing service showed that, at 2053, the pilot obtained a weather briefing encompassing the series of airports she was scheduled to fly to the following day. On the day of the accident flight, the pilot was scheduled to fly a multi-leg trip originating from the operator's base at Raleigh-Durham International Airport (RDU), Raleigh/Durham, North Carolina. The pilot was then scheduled to reposition the airplane in order to pick up a passenger at INT, and then proceed to ILM. The pilot would then reverse the circuit, eventually returning to RDU at the conclusion of the day. That morning, the pilot queried the weather and flight planning service several times between 0437 and 0443. According to a receipt recovered from the wreckage, the pilot obtained catering refreshments at 0534. At 0644, the pilot advised the operator via electronic messaging that she was departing from RDU, en route to INT. The airplane arrived at INT at 0739, and the pilot obtained a weather briefing for the next scheduled leg of the flight, and at 0840, advised the operator she was departing INT for ILM. The flight subsequently arrived at ILM about 1000. Between 1454 and 1551, the pilot submitted numerous weather queries for the return portion of the flight via an internet flight planning service, including requesting weather from numerous other airports in the vicinity of the destination. At 1552, the pilot contacted a fellow company pilot asking for assistance with finding a legal alternate airport for the upcoming flight from ILM to INT. The pilots discussed possible alternatives, including GSO. At 1611, the pilot advised the operator that she was departing ILM en route to INT. According to air traffic control (ATC) radar and voice data provided by the Federal Aviation Administration (FAA), the pilot requested and was given an IFR clearance about 1600. The flight departed ILM about 1622, and during the departure, the pilot advised the air traffic controller that the base of the overcast ceiling was 600 feet. The pilot was then cleared on course, and after speaking with several different ATC facilities en route to INT, contacted GSO approach at 1704. Upon receiving updated weather conditions at INT from the controller, the pilot advised that she would need to be placed into a holding pattern, due to the ceilings at INT being below 200 feet. At 1708, the pilot was cleared to hold at the INGON intersection, which was the published missed approach holding point for the instrument landing system (ILS) approach to runway 33 at INT. At 1711, the GSO approach controller advised the pilot that the weather conditions at Statesville, Burlington, and Mount Airy, North Carolina, located between 25 and 40 nautical miles from INT, included cloud ceilings of at least 300 feet. The pilot advised the controller, "…that's hopeful but yeah we want to go to Wilmington…" Shortly thereafter, the GSO approach controller contacted the INT tower controller and advised that the pilot would be entering a holding pattern at INGON, and requested to be notified when the weather at INT had improved. The pilot reported entering the holding pattern at INGON at 1725. About 5 minutes later, a new approach controller came on duty and was briefed by the outgoing controller. During the briefing, the outgoing controller stated that most of the arrivals were being conducted to runway 5L as the runway visual range (RVR) on runway 5R was lower. He further stated that the most recent cloud base report was from an airplane that had departed about 30 minutes prior, and had reported that the clouds were at 50 feet. Additionally, two other aircraft had arrived at the airport and, "nobody's going around yet." The outgoing controller then also provided a briefing on each of the flights in the area, and stated that the accident airplane was holding at INGON with the pilot waiting for the ceilings at INT to improve, and that he expected the INT tower controller to advise when that happened. At 1734, the pilot contacted the GSO approach controller and stated that after discussing the issue with her passenger, proceeding to GSO would be an acceptable alternative if the weather conditions were "good." The controller immediately cleared the pilot to GSO via radar vectors. At 1735, the controller advised the pilot that the ceiling at GSO was overcast at 100 feet, to which the pilot responded, "That's not going to help much..." Two minutes later, at 1737, the controller asked the pilot her intentions. The pilot responded that if no other aircraft were arriving at GSO, she would return to the previous holding pattern. The controller responded, "Everybody's getting into Greensboro, nobody's gone around yet," to which the pilot replied, "Alright, let's do it." The controller then began vectoring the pilot for the ILS approach to runway 5L at GSO [see the AIRPORT INFORMATION section of this report for a detailed description of the ILS RWY 5L instrument approach procedure]. At 1740, the pilot was cleared to descend to 3,000 feet and was given a radar vector to intercept the localizer for runway 5L. After passing through the localizer course from the northwest about 1 minute later, the pilot turned the airplane and re-intercepted the localizer course from the southeast. The controller contacted the pilot to advise and provide assistance if necessary, and the pilot declined. After establishing the airplane on the localizer and being cleared for the approach, the pilot descended the airplane to the published minimum altitude of 2,500 feet for the intermediate segment of the approach. The controller advised the pilot to contact the GSO tower controller, at 1743. Upon contacting the tower controller, the pilot was advised that the RVR for runway 5L was 4,000 feet and that she was number two to land behind an Embraer 145 that was 1 mile from the runway threshold. At 1744:33, about 0.5 nautical miles from the final approach fix, the airplane began descending from 2,500 feet, and crossed the fix about 200 feet below the published intercept altitude. Over the next 2 nautical miles, and over the course of about 2 minutes, the airplane descended to 1,300 feet, and remained below the calculated glideslope for the final 8 nautical miles of the approach. Upon reaching 1,300 feet msl, the airplane was about 400 feet above ground level and about 3 nautical miles from the runway 5L threshold. The airplane then began climbing at 1745:42, and about that time, the GSO tower controller issued a low altitude alert to the pilot. The pilot responded, "we're goin' around." The controller subsequently advised the pilot to fly the runway heading, and to climb to 4,000 feet, and the pilot acknowledged the instructions. No further transmissions were received from the pilot. After reaching 1,600 feet at 1745:52, the airplane descended to 1,500 feet at 1745:56, about the time the pilot concluded her final radio transmission. No further radar targets were observed. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for multi-engine land, and a private pilot certificate with a rating for airplane single engine land. According to the pilot's FAA Airman File, she obtained her private pilot certificate in 1984, her instrument rating in 2000, and her commercial pilot certificate in 2001. The pilot was issued second-in-command (SIC) type ratings in the LR-45 and BE-400 in 2007, and a pilot-in-command (PIC) type rating in the BE-400/MU-300 when she was issued her airline transport pilot certificate in 2008. The pilot was issued a LR-JET SIC type rating in October 2010. Review of company records revealed that the pilot was hired by the operator in March 2010, and at that time had reported 2,590 total hours of flight experience, 770 hours of which were acting as PIC. The operator provided training to the pilot in the accident airplane, and she was found proficient to act as PIC on March 30, 2010. The operator provided the pilot with 6 hours of flight training in preparation for her LR-JET SIC type rating. During three simulator sessions while acting as second-in-command, the pilot satisfactorily completed precision, non-precision, circling, and missed approach procedures. During this training session, the operator also certified that the pilot completed the required 6-month instrument proficiency check in accordance with CFR 135.297, on October 26, 2010. According to company records, as of the date of the accident flight the pilot had accumulated 2,884 total hours of flight experience, 856 hours of which were acting as a PIC. The pilot also logged 117 total hours of flight experience in the accident airplane make and model, 95 hours of which were acting as a PIC. Between the time of the pilot's most recent instrument proficiency check in October and the day prior to the accident flight, she had logged 4 instrument approaches (1 approach in a LR-55, and 3 approaches in the accident airplane), and 5 hours of instrument flight experience in the accident airplane. Review of FAA ATC voice communications showed that the pilot also completed two ILS approaches during her earlier flights to INT and ILM on the day of the accident. AIRCRAFT INFORMATION The airplane was manufactured in 1975, and was equipped with two 285-horsepower Teledyne Continental Motors IO-520 reciprocating engines. According to company records, the airplane's most recent annual inspection was conducted on November 8, 2010. The airplane was equipped with a Garmin GNS 530W multi-function navigation and communication system. According to the Garmin 500 W Series Pilot's Guide and Reference, the unit featured a non-certified terrain awareness system, or an optional certified Terrain Awareness and Warning System (TAWS). The accident airplane was not equipped with a certified TAWS installation, nor was it required to be. The non-certified Terrain feature displayed terrain and obstructions relative to the altitude of the airplane, and displayed alerts that were advisory in nature. The unit utilized terrain and obstacle databases to display a 2-dimensional picture of the surrounding terrain and could use position and altitude information to predict the airplane's flight path with relation to that terrain, in order to provide the pilot with an advanced alert of a predicted dangerous terrain condition. While this system was installed in the accident airplane, the use of the non-certified terrain awareness system was not authorized by the operator’s Operations Specifications. One of the available warnings was the Premature Descent Alert (PDA), which would issue an alert to the pilot when the system detected that the airplane was significantly below the normal approach path to the runway. The advisory envelope would provide alerts from between 0.5 and 15 miles of the runway threshold, at altitudes that decreased as the airplane approached the runway. Interpretation of the PDA Threshold chart published in the guide showed that alerts would have been issued if the airplane descended to the following altitudes above the ground with respect to the airplane's distance from the runway threshold: 350 feet and 5 nautical miles; 325 feet and 4 nautical miles; 275 feet and 3 nautical miles; 225 feet 2 nautical miles, 125 feet and 1 nautical mile. A review of the airplane’s radar height profile for the final portion of the instrument approach showed that the airplane never descended below a height that would have activated a PDA. The terrain system provided an inhibit mode, designed to deactivate the PDA and the Forward Looking Terrain Avoidance visual alerts when they were deemed unnecessary by the pilot. The guide warned that pilots should use discretion when inhibiting the terrain system and always remember to enable the system when appropriate. When inhibited, terrain was available to be viewed by accessing the appropriate navigation page on the unit, but alert messages were not generated. Units configured with standard terrain advisories would restore the previously inhibit state (on/off) at startup, while TAWS-configured units would always start with alerts uninhibited. The airplane was also equipped with a Garmin GDL 69 remote sensor that was capable of receiving broadcast weather data from the XM Satellite Radio service. The Garmin 530W was capable of serving as the display and control unit, and could display both graphic and textual weather information on the installed Garmin 530W. No information regarding the pilot’s use of either the non-certified terrain awareness system or the satellite-delivered weather information was available for review. METEOROLOGICAL INFORMATION The National Weather Service (NWS) Surface Analysis Chart for 1700 depicted the accident site between two major weather systems; the first located to the southeast through south and the second developing system to the west. The first system was associated with a low pressure system off the South Carolina coast with a stationary front extending northeast and southwest from the low extending off the southeast Atlantic coast and through southern Georgia to another low pressure system and a frontal wave. The second system was located west of the accident site associated with a low pressure system over eastern Tennessee with a developing cold front extending southwestward across western North Carolina, Georgia, into Alabama, with a trough of low pressure extending northward from the low into Virginia and West Virginia. The station models depicted light to heavy rain over eastern North Carolina and Virginia, and light to moderate rain over western Virginia, North Carolina, South Carolina, and eastern Tennessee along and ahead of the developing cold front. Numerous stations across the region also reported fog or mist, with overcast or obscured skies. The station model for Greensboro indicated wind from the northeast at approximately 5 knots, drizzle, and overcast skies. The NWS Radar Mosaic for 1745 depicted a large area of rain showers and thunderstorms over eastern North Carolina with scattered light rain showers and drizzle over the Greensboro area. Since no significant weather echoes appeared in the Greensboro area, no further weather radar information was documented. The 1745 weather observation at GSO included winds from 050 degrees at 8 knots, tower visibility 1/4 statute-mile visibility in light drizzle and fog, an overcast ceiling at 100 feet, temperature 6 degrees C, dew point 5 degrees C, and an altimeter setting of 29.84 inches of mercury. A surface visibility of 1/2-mile and trace precipitation of less than 0.01 inches was also noted. The 1745 weather observation at INT included winds from 050 degrees at 5 knots, visibility 1 statute mile in mist, an overcast ceiling at 100 feet, temperature and dewpoint 6 degrees C, and an altimeter setting of 29.84 inches of mercury. The NWS GSO upper air sounding was examined for cloud and stability information. The sounding indicated saturated conditions from 409 feet to approximately 10,500 feet, where the sounding had a relative humidity greater than 90 percent. A d
The pilot’s spatial disorientation due to a somatogravic illusion while conducting a missed approach in instrument meteorological conditions, which resulted in the airplane’s descent into objects and terrain.
Source: NTSB Aviation Accident Database
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