CEN15FA008

The pilot's loss of airplane control while attempting to fly a missed approach procedure in instrument meteorological conditions.

The instrument-rated private pilot was returning to his home airport after flying to another location to attend a meeting. At the departure airport, the pilot filed an instrument flight rules flight plan, had it activated, and then departed for his home airport. After reaching his assigned altitude, the pilot requested clearance directly to his destination with air traffic control, and he was cleared as requested. Before arriving at his airport, he requested off frequency to get the NOTAMs and weather conditions for his destination. The weather conditions at the arrival airport included a 200-ft overcast ceiling and 5 miles visibility with light rain and mist. The pilot then requested the instrument landing system (ILS) approach for landing. An air traffic controller issued vectors to the ILS final approach course and cleared the pilot to change off their frequency. Witnesses at the airport reported hearing and seeing the airplane break out of the clouds, fly over the runway about 100 ft above ground level (agl), and then disappear back into the clouds. Two witnesses stated that the engine sounded as if it were at full power and another witness stated that he heard the engine "revving" as if flew overhead. Shortly after the airplane was seen over the airport, it struck a line of 80-ft tall trees about 3,600 ft north-northwest of the airport and subsequently impacted the ground and a large tree near a residence. The published missed approach procedures required the pilot to climb the airplane to an altitude of 2,000 ft mean sea level (msl), or about 900 ft agl, while flying the runway heading. Upon reaching 2,000 ft msl, the pilot was required to begin a left turn to the northwest and then continue climbing to 3,300 ft msl. An examination of the airplane, the engine, and other airplane systems revealed no anomalies that would have precluded the airplane from being able to fully perform in a climb during the missed approach. It is likely that the pilot lost airplane control after initiating a missed approach in instrument meteorological conditions. Although it is possible that the pilot may have experienced spatial disorientation, there was insufficient evidence to conclude that spatial disorientation contributed to the accident.

The Dubuque Regional Airport, is located 7 miles southwest of the city of Dubuque, Iowa. The field elevation is 1,076 ft mean sea level (msl). Its principal runways are 13-31, and runway 18-36. Runway 18-36 is 6,327 feet long and 150 feet wide. Its surface is grooved concrete and has a medium intensity approach lighting system with runway alignment indicator lights. The airport is publically owned by the City of Dubuque. The airport has an Air Traffic Control Tower that is manned between the hours of 0600 and 2200. After 2200, pilots use the Common Traffic Advisory Frequency (CTAF) of 119.5 MHz to advise other aircraft of their position in relation to the airport. A VORTAC radial distance navigation station is located on the field near the airport center. The airport has several instrument approaches to the two principal runways. Runway 36 has a VOR approach, RNAV (GPS) approach, and an ILS/LOC (Localizer) approach associated with it. The ILS/LOC approach to Runway 36 begins at the outer marker, GOLDN (golden), at or above 3,000 ft msl. The weather required to fly the approach is a minimum ceiling of 200 feet agl and 1/4 mile visibility. The full approach is a procedure turn, with the maneuvering side to the east of the 177-degree radial off the DBQ VORTAC. The glideslope intercept is also located at GOLDN, 5 nautical miles (nm) from the end of the runway. Pilots establish themselves on the 357-degree inbound course, intercept the ILS glideslope at 2,700 ft, and fly it down to a decision height of 1,247 feet, about 240 feet above the ground. If they fail to see the runway environment, they execute the missed approach procedure, which is to climb to 2,000 ft msl on the runway heading of 360 degrees. At 2,000 ft, the pilot turns left to a heading of 310 degrees and continues climbing to 3,300 ft, proceeding to CASSY, the missed approach fix, which is off the DBQ VORTAC 322-degree radial at 25 nm. The pilot would also contact the departure frequency for further clearance. The airplane's engine was disassembled and examined at Continental Motors, Incorporated, Mobile, Alabama, on June 15 and 16, 2016. The examination showed no anomalies that would have resulted in the engine not producing full power when needed. The results of an autopsy performed on the pilot on October 14, 2014 by the Iowa Office of the State Medical Examiner, Ankeny, Iowa, showed the cause of death to be blunt force trauma and thermal injuries sustained in the accident. The FAA's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot. Test results were negative for all tests conducted. The accident site was located in a residential area about 3,600 ft north-northwest of the DBQ airport. The initial impact was a line of trees at a GPS location of N4225.245 / W090.43.223 and an elevation of 1,088 ft. The trees were about 80 ft tall and pieces of the airplane's propeller were located in the area of the tree line along with several tree branches and branch pieces. The branch pieces examined exhibited 45-degree cuts at the ends. Paint chips were visible in the cut surfaces of the branch pieces. A 14-inch long piece of propeller blade portion to include the tip was located about 200 yards south of the tree line. It showed leading edge chips and gouges consistent with striking a hard object. The airplane wreckage continued north from the tree line along a 360-degree heading. The initial debris field began at a large L-shaped ground impact scar. Dirt and airplane parts were dispersed north from the impact scar. The north extending debris field contained pieces of broken Plexiglas, the elevator assembly, right horizontal stabilizer, and a portion of top right inboard wing skin. Additional pieces of the airplane's propeller were also found along the debris path and exhibited impact damage consistent with a tree strike. The right outboard wing section was lying forward and to the left, in line with the initial tree strike. The debris trail continued for about 120 ft to where the fuselage came to rest on the northeast side of a large tree that it had struck. Impact marks were visible on the tree trunk. The airplane's fuselage was oriented on amagnetic heading of about 235 degrees. The airplane's left wing was folded over the fuselage. The fuselage forward cabin section was broken open and consumed by ground impact and a post impact ground fire. The firewall assembly was found separated. The rudder pedal assemblies were in place on the firewall. The control yoke assemblies were bent and fractured. Both control wheels were separated from their respective control yokes. The left and right instrument panels were bent and broken aft. Most of the engine and flight instruments, and radio/navigation units were broken out of their mounts, crushed, and charred by fire. The circuit breaker panels were broken aft, charred, and consumed by fire. The engine power, mixture, and propeller levers were in the full forward position and were separated from their engine and propeller governor connections. They moved freely when manipulated. The electrical switch panels were broken aft and downward and charred by fire. The wing flaps switch was found in the up position. The landing gear select switch and alternate air lever were broken. The aft cabin door was broken aft and showed thermal damage. The forward baggage door was separated and crushed. Both the cabin and baggage doors bayonets were found in the locked position. The fuel selector valve and stabilator and rudder trim indicators were broken aft and fractured. All cabin seats and seat restraint systems were broken aft and consumed by fire. The airplane's windscreen and cabin windows were broken and fragmented. The nose landing gear was broken aft and separated from the wheel well compartment. The aft tail section was separated from the forward fuselage section at the pressure bulkhead. It contained the autopilot trim gyro and the Emergency Locator Transmitter (ELT). The ELT did not activate. The airplane's vertical stabilizer was separated from its fuselage mounting location. It was found lying in the debris field adjacent to the main fuselage wreckage. It showed aft bending and crushing from impact forces. The rudder was laying on the ground adjacent to the vertical stabilizer. It was broken at the vertical stabilizer hinge points and showed impact aft bending and crush damage from impact forces. The airplane's horizontal stabilizers were separated from the aft fuselage tail cone. They were lying in the initial impact area in the debris field. They showed impact damage consistent with tree and ground impact. The elevator assembly was noted to be lying adjacent to the horizontal stabilizers. The trim tabs were still attached. The trim control rods were separated. The airplane's left wing had separated from the fuselage at the wing root and subsequently fractured into several sections. The inboard section was lying against the fuselage and the outboard section rested in the nearby debris field. The inboard section exhibited severe fire damage. The inboard section of the wing spar was melted and consumed. The fuel tank was breached. The fuel tank cap was in place and in the locked position. The deice boot was charred and consumed by the post impact ground fire. The cables to the left aileron were stretched and unraveled indicative of a tension overload separation. The pitot mast was bent aft. The wing's leading edge was crushed aft along its entire span. The left main landing gear was located in its wheel well and was found in the down position. The flap actuator rod was bent and the flap control rod was separated. The left flap and left aileron were separated from their hinge points and both exhibited impact damage. The aileron's balance weight was noted to be in place. Left aileron control continuity was confirmed through the cable separation to the control yoke mixer unit. The right wing