CEN13LA088

The pilot’s spatial disorientation during the instrument approach in night, instrument meteorological conditions, which resulted in the airplane descending below decision height and impacting terrain outside the lateral limits of the localizer. Contributing to the accident was the pilot's lack of recent instrument flight experience.

The commercial pilot was conducting a personal cross-country flight. According to recorded air traffic control (ATC) transmissions and radar track data, the pilot attempted an instrument landing system (ILS) approach to an airport where the reported weather conditions were below published minimums for the approach. The pilot reported that the airplane descended on the glideslope into fog where there was limited to no forward visibility and that he initiated a missed approach at 1,600 ft mean sea level (msl) because he could not see the runway environment. The airplane impacted terrain shortly after the pilot increased engine power to transition into a climb for the missed approach. A review of the pilot's flight logbook established that he had not maintained his instrument currency, as required by federal regulations, during the 6 months preceding the accident. According to radar track data, the airplane made multiple course corrections on both sides of the localizer centerline as it proceeded inbound toward the runway. The airplane eventually flew through the right localizer limit about 1.2 miles from the runway threshold. The airplane continued to fly away from the localizer and descended below the published decision height of 1,480 ft msl. The airplane impacted terrain about 1/2 mile right of the localizer centerline and about 3/4 mile from the runway threshold while in a descending right turn. Postaccident testing revealed that there were no anomalies with the airplane's altimeter that would have prevented its normal operation. Additionally, the pilot had selected a Kollsman window setting that would have minimized any indication errors during the instrument approach. Further avionic testing identified no anomalies with the airplane's primary navigation radio and its associated course deviation indicator. According to ATC documentation, all components of the ILS approach were fully functional at the time of the accident. Further, 12 minutes before the accident, another airplane had completed the same ILS approach to the runway without any reported issues or anomalies. In conclusion, the weather and light conditions at the time of the accident and the pilot's maneuvering during the approach were conducive to the development of spatial disorientation. Therefore, it is likely that the pilot became spatially disoriented during the instrument approach, which resulted in the airplane descending below decision height and impacting terrain outside the lateral limits of the localizer. The pilot's lack of recent instrument flight experience likely contributed to him becoming spatially disoriented during the instrument approach.

The published inbound course for ILS runway 13 approach was 131 degrees magnetic, with a published decision height of 1,480 feet msl (200 feet agl). The crossing altitude for the outer marker (ELLIE) was 2,554 feet msl. The distance between ELLIE and the touchdown zone was 3.8 nautical miles. The touchdown zone elevation was 1,280 feet msl. The published weather minimums for the ILS runway 4 approach were a 200 foot ceiling and 1/2 mile visibility for category A, B, C, and D aircraft. The published missed approach procedure was to climb on runway heading to 2,000 feet, then make a climbing right turn to 3,000 feet direct to the Rochester VHF Omni Directional Radio Range with Distance Measuring Equipment (VOR/DME) and hold. According to air traffic control documentation, all components of the ILS Runway 13 approach were fully functional at the time of the accident. A review of available air traffic control (ATC) information indicated that the accident flight had received normal services and handling. A summary of the voice communications recorded between the accident flight and Rochester ATC is included with the docket materials associated with the investigation. The Rochester International Airport (RST), a public airport located approximately 7 miles southwest of Rochester, Minnesota, was owned and operated by the City of Rochester. The airport field elevation was 1,317 feet msl. The airport had two runways: runway 13/31 (9,033 feet by 150 feet, concrete) and runway 2/20 (7,301 feet by 150 feet, concrete). Runway 13 incorporated medium intensity approach lighting with runway alignment indicator lights, runway touchdown zone and centerline lighting, a 4-light precision approach path indicator, and high intensity runway edge lighting. Runway 13 also was equipped with a runway visibility range (RVR) equipment located at the touchdown zone. According to air traffic control documentation, all runway lighting and the RVR equipment were fully functional at the time of the accident. The altimeter, a United Instruments model 5934P-1, was examined and tested at an avionic repair facility. There was no apparent damage to the as received altimeter. A subsequent bench test revealed no position anomalies with the altimeter, which functioned as designed. A copy of the test card is included with the docket materials associated with the investigation. The Garmin GNS 430W GPS/Nav/Com and its corresponding Garmin GI-106A course deviation indictor (CDI) were examined and tested at an avionic repair facility. The Garmin GNS 430W passed its self-test routine upon the device being powered-up. The active communication frequency was identified as 118.3 (Rochester Tower). The standby communication frequency was identified as 119.8 (Rochester Approach). The primary navigation frequency was identified as 109.10 (ILS Runway 13). The standby navigation frequency was identified as 112.95. The deflection and sensitivity of the CDI was tested while receiving a test signal from the technician bench that was processed by the GNS 430W. The localizer and glideslope indications tested normal for both deflection and sensitivity. Additionally, both localizer and glideslope inoperative flags functioned as designed. The bench testing revealed no anomalies with the Garmin GNS 430W or Garmin GI-106A that would have prevented normal operation. The second CDI, a King Radio Corporation KI-201C, was examined and tested at an avionic repair facility. The KI-201C exhibited VOR course deviations that averaged about 6 degrees left of the calibrated test bench signal. The localizer course deviation was one-dot left of center with a centerline test bench signal; however, the overall course width indicated correctly. The KI-201C was not equipped with a glideslope indicator. The inoperative signal flag functioned properly. At 1754, about 39 minutes before the accident, the airport's automated surface observing system reported the following weather conditions: wind 140 degrees true at 12 knots, visibility 1/4 mile with fog, runway visual range (RVR) variable 1,000 feet to 1,200 feet, vertical visibility 100 feet, temperature 3 degrees Celsius, dew point 2 degrees Celsius, and an altimeter setting of 29.94 inches-of-mercury. The weather report further indicated that the control tower visibility was 1/4 mile. At 1854, about 21 minutes after the accident, the airport's automated surface observing system reported the following weather conditions: wind 140 degrees true at 11 knots, visibility 1/4 mile with fog, RVR 1,200 feet, vertical visibility 100 feet, temperature 4 degrees Celsius, dew point 2 degrees Celsius, and an altimeter setting of 29.93 inches-of-mercury. The weather report further indicated that the control tower visibility was 1/4 mile. The accident airplane was a 1975 Cessna model 172M, serial number (s/n) 17265797. The airplane was an all-metal, single-engine, externally-braced high wing, monoplane. The airplane had a fixed tricycle landing gear, was capable of seating four individuals, and had a certified maximum gross weight of 2,300 pounds. A 150-horsepower Lycoming model O-320-E2D reciprocating engine, s/n RL-45125-27A, provided thrust through a McCauley model 1C160/DTM, s/n 726356, fixed pitch, two-blade, metal propeller. The accident airplane was issued a standard airworthiness certificate on August 28, 1975. The current owner-of-record, Southeastern Minnesota Flying Club, purchased the airplane on February 24, 1985. The airplane's recording tachometer indicated 2,107.4 hours at the accident site. The airframe had a total service time of 13,143.6 hours at the time of the accident. The engine and propeller had accumulated 862.9 hours since their last major overhaul. The last annual inspection was completed on November 14, 2012, at 13,127.4 hours total service time. The static system, altimeter system, automatic pressure altitude reporting system, and transponder were last tested on June 2, 2011. The navigation data cards for the instrument flight rules (IFR) certified Garmin model GNS 430W GPS had been updated on November 14, 2012, and were valid through December 13, 2012. The most recent VOR check, as required by FAA regulation 91.171, was logged on June 13, 2012. A postaccident review of the maintenance records found no history of unresolved airworthiness issues. According to Federal Aviation Administration (FAA) records, the pilot, age 23, held a commercial pilot certificate with single and multi-engine land airplane and instrument airplane ratings. He also held a flight instructor certificate with single-engine land airplane and instrument airplane ratings. His last aviation medical examination was completed on December 7, 2011, when he was issued a first-class medical certificate with a limitation for corrective lenses. A review of available logbook information indicated that the last recorded flight was completed earlier on the day of the accident. As of that logbook entry, the pilot had accumulated 841 hours total flight experience, of which 428 hours were listed as pilot-in-command. He had accumulated 680 hours in single-engine airplanes and 161 hours in multi-engine airplanes. He had accumulated 26.2 hours in actual instrument conditions, 62.7 hours in simulated instrument conditions, and 69 hours at night. The pilot had flown 135 hours in the previous 90 days, 22 hours in the previous 30 days, and 3.2 hours during the 24 hour period before the accident flight. His last recorded flight review was completed on September 16, 2012, in a Piper model PA-28-140 single-engine airplane. A review of available flight logbook information, as completed by a FAA Operations Inspector, revealed that the pilot's most recent instrument proficiency check had been completed on September 10, 2011. During the 6 months before the accident, the pilot had completed 2 instrument approaches that were determined to have been completed in actual instrument meteorological conditions. Add