Jacksonville, FL, USA
N98BT
CESSNA 310R
The pilot filed an instrument flight rules (IFR) flight plan with flight services, and the briefer asked the pilot if he would like weather information. The pilot replied "no," and stated that the weather "looked good"; however, at that time, the weather at the destination airport included visibility of 2 miles and a 400-foot overcast ceiling. The pilot proceeded on the approximate 1-hour night flight to the destination airport in low IFR conditions. During the instrument landing system approach, the pilot flew about 1 mile right of and 900 feet below the final approach fix. The tower controller issued a low altitude alert and instructed the pilot to check his altitude. The pilot acknowledged the instruction and confirmed that the airplane's altitude was 600 feet, which was the altitude indicated on radar. He then flew the airplane left of the final approach course twice before intercepting it a third time, descending to 300 feet, and then reporting that he was going to conduct a missed approach. The published missed approach procedure was to climb to 700 feet and then to make a climbing right turn to 1,900 feet on a 180-degree heading. However, the tower controller instructed the pilot to fly a heading of 280 degrees, and the pilot acknowledged the instruction. The controller did not provide an altitude and was not required to do so. After the pilot acknowledged the instruction, the airplane made a climbing left turn to 900 feet before radar and radio communications were lost. The airplane subsequently descended and collided with a retaining pond near the last recorded radar target. Although the tower controller's issuance of nonstandard missed approach instructions without specifying an altitude might have added to the pilot's workload, radar data show an initial turn consistent with the instructions and an associated climb indicating that the nonstandard instructions were not a factor in the accident. Examinations of the airplane and engine revealed no preimpact mechanical malfunctions that would have precluded normal operation, and there was no evidence of medical impairment that would have affected the pilot's performance. Given the night instrument meteorological conditions (IMC) with restricted visibility and the sustained left turn and climb, it is likely the pilot experienced spatial disorientation. The investigation could not determinate the pilot's overall and recent experience in actual IMC; however, his inability to align the airplane with both the final approach fix's lateral and vertical constraints is consistent with a lack of instrument proficiency.
HISTORY OF FLIGHTOn December 8, 2013, about 1821 eastern standard time, a Cessna 310R, N98BT, operated by a private individual, was destroyed when it collided with a pond, during a missed approach at Jacksonville Executive Airport (CRG), Jacksonville, Florida. The private pilot and two passengers were fatally injured. Night instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the planned flight to CRG. The flight originated from St Lucie County International Airport (FPR), Fort Pierce, Florida, about 1715. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to information from the Federal Aviation Administration (FAA), the airplane was in radio and radar contact with Jacksonville International Airport (JAX), Jacksonville, Florida, terminal radar approach control (Jacksonville Approach). At 1806, the controller advised the pilot of updated automated terminal information service (ATIS) information, which included visibility 1.5 miles with mist and ceiling overcast at 400 feet. At that time, the airplane was at 5,000 feet mean sea level and the pilot acknowledged the information. Between 1809 and 1812, the controller cleared the flight to descend to 3,000 feet and then 2,000 feet, which the pilot acknowledged and complied with. At 1814, the controller informed the pilot that his position was 7 miles from the ADERR intersection (final approach fix), instructed him to fly a heading of 350 degrees and to maintain 2,000 feet until established on the localizer, which the pilot acknowledged. At 1815, the pilot was instructed to and changed radio frequency to the CRG tower. The CRG controller cleared the flight to land on runway 32 and provided a pilot report (PIREP) from a flight that landed 30 minutes prior. The PIREP, which included that lights were visible at 300 feet above ground level (agl) and the runway was in sight at 200 feet agl, was acknowledged by the pilot. At 1817, a low altitude alert was generated in the tower and the controller instructed the pilot to check his altitude. The pilot acknowledged the instruction and stated he was at 600 feet, which was the altitude indicated by radar. At 1819, the pilot advised that he was performing a missed approach. The published missed approach procedure was a climb to 700 feet then a climbing right turn to 1,900 feet on a 180-degree heading. The tower controller instructed the pilot to fly a heading of 280 degrees, which would be a left, and the pilot acknowledged. The controller did not provide an altitude and told the pilot to contact Jacksonville Departure, to which the pilot did not reply. No further communications were received from the accident airplane. The crossing altitude for ADERR was 1,900 feet msl. Review of FAA radar data revealed that the airplane passed ADERR about 1 mile right of localizer course and about 1,000 feet msl, which was 900 feet below the published crossing altitude. It then descended and leveled off about 600 feet, while twice proceeding left of localizer course and re-intercepting. During the third intercept, it descended to about 300 feet and then began a climbing left turn to 900 feet msl, before radar contact was lost PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. His most recent FAA third-class medical certificate was issued on August 2, 2013. At that time, he reported a total flight experience of 1,600 hours. The pilot obtained his instrument rating in 2002 and his multiengine rating in 2007. The pilot's logbook was not recovered. Review of an insurance application, dated July 30, 2012, revealed that the pilot reported 1,550 total hours; of which, 800 hours were in multiengine airplanes with 30 of those hours in the same make and model as the accident airplane. The application did not list instrument experience. Review of a flight instructor's logbook revealed that he had provided the pilot a biannual flight review on June 30, 2012; however, no record of an instrument proficiency check or instrument experience was located. AIRCRAFT INFORMATIONThe six-seat, low-wing, retractable-gear airplane, serial number 310R1582, was manufactured in 1979. It was powered by two Continental IO-550, 300-horsepower engines, equipped with McCauley propellers. According to maintenance records, the airplane's most recent annual inspection was completed on June 10, 2013. At that time, the airplane had accumulated 4,161.3 total hours of operation. The engines had accumulated 702.7 hours since major overhaul. According to the hour meter, the airplane had flown 9 hours from the time of the most recent annual inspection, until the accident, including the accident flight. METEOROLOGICAL INFORMATIONAt 1611, the pilot telephoned flight service and filed an IFR flight plan for the accident flight. After filing the flight plan, the flight service specialist asked if he could check any weather for the pilot and the pilot replied no, that the weather "looked good." At that time, the recorded weather at CRG included visibility 2 miles in mist and ceiling 400 feet overcast. The recorded weather at CRG, at 1833, was: wind 060 degrees at 4 knots; visibility 2.5 miles in mist; overcast ceiling at 200 feet; temperature 18 degrees C; dew point 17 degrees C; altimeter 30.20 inches Hg. AIRPORT INFORMATIONThe six-seat, low-wing, retractable-gear airplane, serial number 310R1582, was manufactured in 1979. It was powered by two Continental IO-550, 300-horsepower engines, equipped with McCauley propellers. According to maintenance records, the airplane's most recent annual inspection was completed on June 10, 2013. At that time, the airplane had accumulated 4,161.3 total hours of operation. The engines had accumulated 702.7 hours since major overhaul. According to the hour meter, the airplane had flown 9 hours from the time of the most recent annual inspection, until the accident, including the accident flight. WRECKAGE AND IMPACT INFORMATIONThe wreckage was subsequently located about 1 mile south of CRG, submerged in a pond of a residential development. The wreckage was upright, intact, and oriented about a southerly heading. The leading edges of both wings and the nosecone exhibited impact damage. The main fuel tank and auxiliary fuel tank on each wing were breeched. The right wing fuel selector valve was positioned to the right auxiliary fuel tank. The left wing fuel selector valve was positioned to the left main fuel tank. The right flap remained attached to the right wing and was extended approximately 15 degrees. The right aileron remained partially attached to the right wing. The left flap remained attached to the left wing and was extended approximately 15 degrees. The left aileron remained partially attached to the left wing. The landing gear was retracted. The empennage, horizontal stabilizer, and vertical stabilizer were undamaged. Elevator, elevator trim, rudder, and rudder trim cable continuity were confirmed from their respective flight control surfaces to the aft cabin area where the cables were cut by recovery personnel. Aileron and aileron trim cable continuity were confirmed from their respective flight control surfaces to the wing root area. Measurement of the elevator trim actuator corresponded to a 5-degree tab down (nose up) position. Measurement of the rudder trim actuator corresponded to a 5-degree tab left (nose right) position. Measurement of the aileron trim actuator corresponded to the neutral aileron trim position. The cockpit area was crushed. All four seats were ejected and the lapbelts and shoulder harnesses remained intact. The lapbelts in seat Nos. 1, 2, and 3 were buckled. The pilot's side of the instrument panel was equipped with an electronic flight instrument system (EFIS) with backup attitude indicator. The pilot's attitude indicator and turn and bank coordinator were removed and disassembled for inspection. The disassembly of both instruments revealed that their respective gyros exhibited rotational scoring. The throttle, propeller, and mixture controls were full forward. The altimeter indicated 200 feet with 30.19 displayed in the Kollsman window. The airspeed indicator needle displayed 130 knots. The propeller remained attached to the right engine and all three propeller blades were bent aft. The top and bottom spark plugs were removed. The top spark plug electrodes were intact and gray in color. The bottom spark plug electrodes were intact and oil soaked. The propeller was removed from the right engine and the crankshaft was rotated by hand. Valve train continuity was confirmed and thumb compression was attained on all cylinders. The vacuum pump was disassembled and its vanes were intact. The vacuum pump housing exhibited rotational scoring. The engine driven fuel pump was removed, its drive coupling was intact, and the pump was reinstalled. The fuel screen in the metering unit contained fuel and was absent of debris. Oil was observed throughout the engine. The propeller remained attached to the left engine with two of the propeller blades bent aft and the third blade was loose in the hub. The top and bottom sparkplugs were removed. The top spark plug electrodes were intact and gray in color. The bottom spark plug electrodes were intact and oil soaked. The propeller was removed from the left engine and the crankshaft was rotated by hand. Valve train continuity was confirmed and thumb compression was attained on all cylinders. The vacuum pump was disassembled and its drive shaft was sheared. The vacuum pump vanes were intact and the pump housing exhibited rotational scoring. The engine driven fuel pump was removed, its drive coupling was intact, and it was reinstalled. The fuel screen in the metering unit contained fuel and was absent of debris. Oil was observed throughout the engine. Both engines were successfully test-run at the manufacturer's facility, under the supervision of an FAA inspector, on January 22 and 23, 2013. The EFIS, and a digital engine analyzer were retained and forwarded to the NTSB Vehicle Reorder Laboratory, Washington D.C., for data download. No data was recovered from either unit. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed on the pilot on December 9, 2012, by the State of Florida District 4 Medical Examiner's Office, Jacksonville, Florida. The cause of death was noted as multiple blunt force trauma. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, alcohol, and drugs. AIR TRAFFIC CONTROLReview of FAA air traffic control (ATC) information revealed that when the JAX controller relayed the current ATIS information to the pilot at 1806, a newer special weather observation was recorded at the same time, which indicated an overcast ceiling at 200 feet (verses 400 feet). The updated weather was not communicated to the pilot by the JAX or CRG controller; however, the CRG controller relayed a PIREP, which included that lights were visible at 300 feet agl and the runway was in sight at 200 feet agl. Additionally, although the JAX controller's alternate missed approach instructions did not include an altitude, there was no requirement to do so and the pilot would be expected to climb to the altitude of the published missed approach and then turn to the alternate heading that was provided by the controller. For more information, see the Air Traffic Control Group factual report in the public docket.
The pilot’s failure to maintain airplane control during a missed approach in night instrument meteorological conditions due to spatial disorientation and a lack of instrument proficiency.
Source: NTSB Aviation Accident Database
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