ERA11FA258

The pilot’s loss of airplane control due to spatial disorientation. Contributing to the accident was the pilot’s lack of experience in actual night instrument conditions.

The pilot was conducting an instrument flight rules flight during night, instrument meteorological conditions. About 15 minutes into the flight, the air traffic controller observed that the pilot was not flying assigned headings. When queried, the pilot responded that he was "…a little disoriented…" The pilot continued to deviate from assigned headings as he was vectored to the airport for the approach. During his first attempt at the instrument landing system (ILS) approach, the pilot executed a missed approach, citing problems with his engine monitor. Following the missed approach, the air traffic controller issued a low altitude alert to the pilot. On his second attempt at an ILS approach, the pilot unknowingly deviated well right of the localizer course and was instructed to climb immediately due to another low altitude alert. The pilot was then vectored to an intersection south of the airport and was offered a global positioning system (GPS) approach. The pilot continued to have difficulty with heading and altitude control, receiving an additional low altitude alert from the air traffic controller. The pilot subsequently informed the controller that he had "complete gyro failure" and needed assistance with heading and altitude monitoring. When asked if he was tracking a navigational aid, the pilot responded that he was "…a little dizzy…" The pilot asked for an altitude check at 5,200 feet mean sea level (msl) and the controller confirmed that altitude on his radar. The controller subsequently issued another altitude alert to the pilot at 1,400 feet msl, and the pilot did not acknowledge the call. At that point, radar and radio contact was lost. Radar, GPS, and witness information confirmed that the airplane collided with the ground during a right, descending spiral. The wreckage was highly fragmented, including the engine. Propeller signatures indicated high engine power at impact. The landing gear and flaps were retracted. Not all of the cockpit instruments could be identified or located due to the impact damage. Data recovered from the engine monitor showed that the engine, vacuum system, and electrical system were operating normally during the flight. The pilot received his instrument rating about six weeks prior to the accident and had not logged any actual instrument time at night. The pilot was an insulin-dependent diabetic and was required to monitor his blood glucose level before and during the flight; however, the investigation was unable to determine if the pilot’s glucose level affected his performance. Although the pilot reported problems with his cockpit instrumentation, physical evidence of an in-flight instrument failure was inconclusive. The environmental conditions that existed during the flight and the pilot's actions and responses indicate that he likely experienced significant spatial disorientation.

HISTORY OF FLIGHT On April 22, 2011, about 2146 eastern daylight time, a Cessna 210D, N3963Y, was substantially damaged following a collision with terrain at Altavista, Virginia. The certificated private pilot was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night, instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from Winchester Regional Airport, Winchester, Virginia, about 1956. Examination of voice recordings with air traffic control revealed the following. At 1952:12, the pilot informed Potomac Clearance Delivery that he was ready for takeoff. At 1958:22, the pilot checked in with Potomac Terminal Approach Control (TRACON) and was instructed to climb to 8,000 feet. At 2013:30, a controller with Washington Air Route Traffic Control Center (ARTCC) commented to Potomac TRACON, "but he was on like a two seventy heading and I asked him where he was going and he told me direct Lynchburg so I would keep an eye on him." At 2020:59, the pilot stated to Potomac TRACON, "uh Potomac six three yankee just a little disoriented here." The pilot was then offered vectors toward Lynchburg, which he accepted. For the next 15 minutes, the pilot received vectors from Potomac TRACON. Potomac TRACON also provided vectors around moderate precipitation in the area. At 2042:41, the pilot checked in with Lynchburg West radar at 8,000 feet and received vectors for the Instrument Landing System (ILS) approach to runway 4 at Lynchburg Regional Airport (LYH). At 2059:33, the Lynchburg West controller stated to LYH tower, "yeah this is a heads up ah six three yankee is ah transitioning through ah your airspace in your departure corridor I gave him like ah one ninety heading I guess that didn't work for him." At 2112:30, the pilot was handed off to LYH tower for the ILS approach to runway 4. At 2115:51, LYH tower informed Lynchburg West that the pilot of N3963Y was executing a missed approach and that the pilot cited problems with his "engine monitor." At 2116:26, the pilot requested another ILS approach to runway 4. At 2121:30, after the pilot had been instructed to climb and maintain 3,000 feet, Lynchburg West informed him, "…six three yankee low altitude alert ah the mva [minimum vectoring altitude] in your area is two thousand eight hundred I show you at two thousand two hundred sir." The pilot responded, "that's affirmative I'm just trying to get the vors [VHF Omnidirectional Receivers] in here six three yankee." At 2122:40, Lynchburg West asked the pilot if he would like a Global Positioning System (GPS) approach and the pilot replied that he would prefer another ILS approach. At 2123:24, Lynchburg West called LYH tower and informed the controller that he was keeping the pilot on his frequency and would not be handing him off to tower. LYH issued a landing clearance and responded, "…you can keep him." At 2123:59, as the pilot attempted the ILS approach for a second time, Lynchburg West queried the pilot, "…are you on the localizer now sir?" The pilot responded that he was, and Lynchburg West stated, at 2124:05, "november six three ah yankee I'm showing you well right of course ah sir advise you climb immediately maintain three thousand." The pilot acknowledged and Lynchburg West stated, at 2124:17, "november six three yankee ah low altitude alert once again climb immediately maintain three thousand." The pilot acknowledged the climb to 3,000 feet. At 2125, Lynchburg West confirmed that the airplane was equipped with a GPS and offered clearance to KILBE intersection to fly the GPS approach to runway 4. The pilot acknowledged the transmission by stating, "…that'd be okay six three yankee." At 2127:47, Lynchburg West told the pilot, "…I'll let you play with your altitude as much as you need um just try to stay at least above two thousand eight hundred." The pilot acknowledged the transmission. At 2130:57, Lynchburg West cleared the pilot for the GPS approach to runway 4. The pilot reported, at 2132:49, "…I'm gonna need to make a three sixty right here I'm still having some trouble with my engine monitors." At 2134:20, the pilot was informed of another low altitude alert and was instructed to climb immediately to 2,800 feet or above and the pilot informed Lynchburg West that he was climbing. At 2136:08, the pilot stated, "ah Roanoke I've got ah complete gyro failure it looks like I need some help with ah both heading and ah altitude monitoring." At 2136:58, Lynchburg West began to provide no-gyro vectors to the pilot. Lynchburg West asked the pilot if he was tracking the LYH VOR, and the pilot responded, "um I'm a little dizzy thanks." At 2138:38, the pilot stated to Lynchburg West, "I'm currently showing about five thousand two hundred elevation." The controller replied, "that altitude checks." At 2141:28, Lynchburg West made the following remarks to Washington ARTCC, "um november six three yankee um is the call sign of that aircraft Centurion um the pilot is very disoriented um he reported some equipment problems um he apparently ah he reports he lost he lost his altitude readout and his um gyros um so he's trying to work out um all that but I really do feel like um this pilot is disoriented more than anything else um the last altitude check I had with him was okay um I gave him instructions for no no gyro vectors he was not really picking up on that…" At 2142:35, the pilot stated, "ah can you give me a course heading six three yankee?" Lynchburg West responded, "…I show you tracking roughly about a one two zero heading." At 2144:23, Lynchburg West informed the pilot that Washington Center and Greensboro Approach were looking for airports with more favorable weather conditions. The pilot was also informed that any approach into LYH was at the pilot's disposal, including no-gyro vectors. At 2144:58, the pilot responded with his last recorded transmission, "ah roger that I'm gonna turn ah right to ah one eight zero start tracking outbound see if I can't ah get back in line with the ah ah approach and see if you can give me ah a no gyro approach as well." At 2146:17, Lynchburg West made the following transmission, "november six three ah yankee I show your altitude at one thousand four hundred climb immediately at or above two thousand eight hundred." No response was received from the pilot. An examination of recorded radar data revealed that the last radar return was at 2146:14, at an altitude of 1,100 feet mean sea level (msl). The recorded radar track was consistent with a right, descending spiral. A review of the last 15 minutes of recorded data revealed that, prior to the last descending spiral, the airplane was continuously turning to the left and right, and varied in altitude between 5,900 feet and 1,600 feet msl. A witness who lived near the accident site reported that the airplane flew over his house at high speed, in a descending, right hand turn, until it crashed. He estimated the bank angle to be about 80 degrees. He stated that the engine sounded normal when it flew over his house. He reported that the weather conditions at the time were "very dark and foggy." Three witnesses were interviewed who were located about two nautical miles west of the accident site at the time of the accident. One of these witnesses reported that he was outside and saw an airplane fly over very low. The airplane was so low that the lights on the bottom of the airplane were visible. The airplane "porpoised" up and down about four times. The engine sound increased as the airplane dove, then decreased as it climbed. The airplane went away and returned a few seconds later, not porpoising the second time. The engine noise was then "steady." He reported the weather conditions at the time to be foggy, with rain. A second witness in th