CEN24LA144

The pilot’s spatial disorientation and subsequent loss of control while maneuvering outside established instrument approach procedures in instrument meteorological conditions, which resulted in an impact with terrain. Contributing to the accident was the local control controller’s failure to issue appropriate missed approach instructions due to inadequate procedural knowledge.

The instrument-rated pilot was repositioning the airplane to a maintenance facility for a pitot-static test required to complete instrument flight rules (IFR) certification. The pilot initially filed a visual flight rules (VFR) flight plan but later filed an IFR flight plan instead. The airplane departed and proceeded toward the destination airport. The destination airport local control (LC) controller advised the departure radar east (DRE) controller that the destination airport was instrument meteorological conditions (IMC) and the RNAV runway 14 approach was in use. The DRE controller then instructed the pilot to advise when he had the updated weather information for the destination airport and advised him to expect the RNAV runway 14 approach. The pilot responded that he had the updated weather information, and he acknowledged the RNAV runway 14 approach was in use. As the pilot approached the airport, the LC controller cleared the pilot to land on runway 14. According to air traffic control (ATC) surveillance data, the airplane tracked west of the final approach course. The pilot advised that he needed to perform a 360° turn and reported the field in sight, which the LC controller acknowledged. The LC controller then coordinated with the DRE controller and advised that the pilot was performing a 360° turn to realign with the approach. The DRE controller then asked the LC controller if the pilot was going to return to the approach. The LC controller stated that the pilot was doing a “quick 360.” The DRE controller advised the LC controller that he was going to vector an uninvolved airplane that had been following the accident airplane and would re-sequence it for the approach. The DRE controller asked the LC controller to let him know when the accident airplane landed, and the LC controller acknowledged. The LC controller advised the pilot that there was another airplane inbound for the approach behind him and instructed the pilot to advise when he was reestablished on final approach. The pilot acknowledged and stated he would report reestablished. The pilot then completed two clockwise 360° turns and, midway through a third turn, ATC surveillance data stopped approximately 0.8 nautical miles (nm) southwest of the runway 14 threshold. Two pedestrians who were walking together on a public walking trail sustained serious injuries when the airplane impacted wooded terrain. During the impact sequence, the wings and the empennage separated from the fuselage and the airplane was destroyed. Examination of the airframe, engine, and propeller found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The flaps were found at the fully extended position. The pitch trim was found in the full nose-down position. The airplane had not had an altimeter test, a pitot static test, or a transponder test performed within the 24 months before the accident, as required for operation under IFR in controlled airspace. A review of the pilot’s logbook showed that he had not met the required instrument experience requirements within the preceding 6 months. There was no record of the pilot obtaining an instrument proficiency check within the preceding 12 months. The owner of the maintenance facility the pilot was departing from reported that the pilot experienced difficulties operating and understanding the onboard navigation system, but that he knew of no issues with the systems. The pilot’s toxicology testing identified diphenhydramine. The quantity of the pilot’s specimen was not sufficient for quantitative testing. The specimen tested was also drawn at the same time as the pilot was receiving a large amount of donated blood products. Therefore, whether the diphenhydramine detected resulted from the pilot’s use or from transfused blood products could not be determined, and its contribution to the accident could not be established. During the post-accident evaluation, the pilot was found to have an intracranial vascular abnormality, or cavernous malformation. Cavernous malformations are common vascular brain lesions in adults. These lesions are increasingly identified due to more frequent use of brain imaging. Without symptoms such as seizures or headaches, the risk of serious effects is low. In this case, the pilot reportedly had no symptoms and was unaware of the lesion’s presence. It is unlikely that the cavernous malformation contributed to the accident. Neither post-accident drug nor alcohol testing were ordered nor conducted with the LC controller. Based on the available evidence, the pilot, who was not instrument current, initiated an IFR flight in an airplane that was not in compliance with required IFR equipment and inspection requirements. During the instrument approach, the pilot likely did not properly configure the onboard navigation system, resulting in the airplane tracking off course. When the pilot initiated a 360° turn during the instrument approach, the LC controller did not issue missed approach instructions in accordance with the tower’s standard operating procedures. Had the appropriate missed approach instructions been provided by the LC controller, the airplane likely would have been resequenced for another approach, rather than continuing the 360° turns. The presence of known IMC at the destination airport at the time of the accident was conducive to the development of spatial disorientation, and the airplane’s flight track is consistent with the known effects of spatial disorientation. The pilot’s 360° turns may have been appropriate in visual meteorological conditions (VMC); however, in IMC, they likely resulted in spatial disorientation and a subsequent loss of control.

Pilot The pilot worked as a franchise business owner. A review of the pilot’s logbook found that he had a flight review conducted with a flight instructor on May 17, 2022. The pilot also held a high-performance airplane endorsement for pilot-in-command privileges, issued by a flight instructor on August 14, 2015. For the 12 months preceding the accident, the pilot’s logbook recorded four instrument approaches and four separate instrument holding procedures. All these tasks were performed under simulated instrument conditions (using a view-limiting device). During the 6 months preceding the accident, the pilot’s logbook did not record any instrument flights. The most recent instrument flight conducted by the pilot prior to the accident occurred on May 24, 2023. There was no record that the pilot had completed an instrument proficiency check within the 12 months preceding the accident. LC Controller A review of records showed that the LC controller was employed by Midwest ATC and reported directly to the MIE FCT in March 2008. He had been certified on the LC position since April 2008 and was current and proficient in accordance with facility standards on the day of the accident. He was 54 years old and held a current second-class FAA medical certificate at the time of the accident. His most recent ATC physical was conducted on August 2, 2023. A review of FAA registration records showed that the pilot purchased the airplane on July 9, 2015. The airplane was equipped with a Garmin GTN 750 unit and a J.P. Instruments EDM-700 unit. According to the owner of the BMG Jet Center, the pilot appeared to have difficulty understanding the operation of both units, as well as interpreting the information they displayed. He reported knowing of no issues with either unit. A review of the airplane’s maintenance records found that the most recent altimeter, pitot-static system, and transponder tests were performed on December 28, 2021. Pilot According to the post-accident pre-hospital and hospital records, the pilot required prolonged extrication from the airplane wreckage by emergency medical services (EMS) after the accident. The pilot was administered ketamine and etomidate by EMS before arrival at the hospital. On arrival at the hospital, the pilot received a massive transfusion of donated blood products and was administered lidocaine. The pilot was hospitalized for the management of serious injuries. During his hospitalization, he underwent imaging, including brain imaging, which identified skull and brain injuries and also incidentally revealed a developmental venous anomaly, or cavernous malformation, in the lateral left parietal lobe. Given the poor prognosis for his injuries, the pilot was discharged to hospice care and died on April 20, 2024. No autopsy was performed by the coroner’s office. The FAA Forensic Sciences Laboratory performed toxicological testing on a specimen collected from the pilot at 1125 on the day of the accident. Diphenhydramine, ketamine, norketamine, etomidate, lidocaine, losartan, tamsulosin, atorvastatin, naproxen, and acetaminophen were detected in blood. LC Controller The LC controller had a medical waiver documented in his FAA medical records. He reported taking prescribed regular maintenance medications as directed, including the day of the accident. He was required to wear corrective lenses while performing ATC duties and reported that he was wearing his prescribed contact lenses at the time of the accident. Neither post-accident drug nor alcohol testing were ordered nor conducted by the FAA and Midwest ATC with the LC controller. On April 1, 2024, about 1027 eastern daylight time, a Piper PA-28-236 airplane, N8438B, was destroyed when it was involved in an accident near Muncie, Indiana. The pilot sustained fatal injuries and two pedestrians on the ground sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The purpose of the flight was to transport the airplane, a Piper Dakota, from Monroe County Airport (BMG), Bloomington, Indiana, to Muncie Delaware County Airport (MIE). The pilot intended to transport the airplane to MIE to have a pitot-static test performed to meet the requirements for IFR operations. A review of ForeFlight records indicated that a VFR flight plan was filed with an estimated enroute time of 40 minutes. The flight plan was subsequently amended to an IFR flight plan. A review of air traffic control (ATC) surveillance data showed that, about 0937, the airplane departed BMG and climbed to an initial cruise altitude of 5,000 ft. About 0944, the pilot checked in with the Indianapolis Airport Traffic Control Tower and reported the airplane was level at 5,000 ft. The departure radar east (DRE) controller provided the pilot with the current altimeter setting. The pilot acknowledged and requested a climb to 7,000 ft, stating that he was still in the clouds at 5,000 ft. The controller approved the climb to 7,000 ft. The pilot acknowledged with a correct readback. About 0950, the pilot attempted to contact the DRE controller to provide a pilot weather report (PIREP). About 0951, the DRE controller responded, and the pilot reported the cloud bases were at 2,400 ft and the cloud tops were at 7,000 ft. The controller acknowledged and asked if the pilot had experienced any icing conditions. The pilot responded “negative.” About 0955, the MIE local control (LC) controller called the DRE controller and reported that the airport was in instrument meteorological conditions (IMC), the RNAV (known as Area Navigation) runway 14 approach was in use, and the current automatic terminal information service (ATIS) code was Echo. Subsequently, the DRE controller instructed the pilot to advise when he had the updated weather at MIE and advised him to expect the RNAV runway 14 approach. The pilot responded that he had ATIS information Echo and he acknowledged the RNAV runway 14 approach was in use. About 1002, the DRE controller instructed the pilot to change to frequency 120.65. The pilot did not acknowledge. About 1003, the DRE controller attempted to contact the pilot. The pilot reported he was in receipt of ATIS information Echo. The controller acknowledged and instructed the pilot to change to frequency 120.65. After initially reading back the frequency incorrectly, the controller corrected the pilot, and the pilot acknowledged and contacted the controller on the correct frequency. The controller then instructed the pilot to turn left direct to JOGBA (the intermediate fix/initial approach fix). The pilot acknowledged with a correct readback. About 1011, the DRE controller instructed the pilot to descend and maintain 4,000 ft. The pilot acknowledged with a correct readback. About 1013, the DRE controller called the MIE federal contract tower (FCT; the contract ATC services were provided by Midwest ATC) and provided the inbound information for the airplane. The LC controller acknowledged. About 1016, the DRE controller instructed the pilot to turn right heading 050° and advised him to expect vectors inside JOGBA. The pilot acknowledged with a correct readback. About 1017, the DRE controller instructed the pilot to descend and maintain 3,000 ft. The pilot acknowledged with a correct readback. About 1018, the DRE controller advised the pilot that he was four miles from HIXAG (the final approach fix). The DRE controller instructed the pilot to turn right to 120°, maintain 3,000 ft until established on the final approach course, and then cleared him for the RNAV runway 14 approach into MIE. The pilot acknowledged with a correct readback. About 1020, the DRE controller restated the approach clearance to the pilot, advised that radar services were terminated, and instructed the pilot to contact the MIE tower. The pilot acknowledged with a correct readback. The pilot contacted the LC controller and advised he had been cle