ERA13FA088

The failure of the instrument-rated pilot to maintain control of the airplane while in instrument meteorological conditions after reporting a gyro malfunction. Contributing to the accident was the loss of primary gyro flight instruments due to the failure of the vacuum pump, the inadequate assistance provided by FAA ATC personnel, and the inadequate recurrent training of FAA ATC personnel in recognizing and responding to in-flight emergency situations.

The instrument-rated pilot departed with nearly full fuel tanks, obtained his instrument flight rules (IFR) clearance, and proceeded toward the destination airport, which, at the time of the accident, was IFR with a 500-foot ceiling. The pilot was vectored onto final approach for an instrument landing system approach. Radar data showed that the airplane performed s-type turns; the pilot then reported to the local controller that he had "...lost some gyros but I think we are getting it." When the airplane was about 1 mile from the approach end of the runway at 1,300 feet, the local controller cancelled the approach clearance because the airplane was too high and advised the pilot to fly runway heading and climb to 2,000 feet. Radar data indicated that the pilot turned toward an easterly heading without clearance from the controller. The pilot was then instructed to maintain an easterly heading followed by a southwesterly heading (220 degrees) consistent with a downwind leg to fly parallel to runway 4. The pilot turned well past the southwesterly heading to a northwesterly heading, and was asked by the controller if he was having any problem with the airplane such that he was unable to fly assigned headings. The pilot advised the radar controller that he "...currently [had] no gyro I think the best thing for me to climb a little bit and go to my alternate of ah Columbus or some point south." There was an adequate supply of fuel onboard to fly to his alternate airport, which at that time was under visual meteorological conditions with 10 miles visibility and a ceiling at 5,500 feet. As a result of the loss of gyros, the pilot was flying the airplane with a partial panel. The pilot was cleared to climb direct to his alternate airport; however, extensive heading and altitude deviations were noted during this portion of the flight, which was operating in IMC. The radar controller asked the pilot if he was ok to which he replied, "uh no im not okay right now." This verbiage and the fact that extensive altitude and heading deviations occurred were clear indications that an emergency situation existed; however, the controller did not recognize this and did not request the necessary information needed to offer assistance, as outlined in FAA Order 7110.65, 10-2-1. The controller later reported that he believed the gyro comment would have affected only the pilot's ability to maintain heading, thus, he did not believe the loss of gyros while in instrument conditions constituted an emergency. The controller then asked the pilot if he wanted to land at the airport, and he answered, "uh the best thing to"; however, the communication was not finished. It is likely that the pilot was intending to tell the controller again that he wanted to go to his alternate airport. However, because the controller did not recognize the emergency, he continued to vector the pilot to land using an ILS approach. While thbeing vectored, when the airplane was operating in IMC, major heading and altitude changes were noted; however, when the airplane was operating at higher altitudes in VFR conditions, the pilot was able to maintain the airplane's assigned heading and altitude. The steady flight in VFR conditions should have been a cue to the controller that safe flight was possible in visual conditions; thus he should have encouraged the pilot to continue the flight to his alternate airport as the pilot had requested. Instead, the controller vectored the pilot to intercept the localizer, advised that the flight was about 4 miles from the final approach fix, and cleared the pilot to conduct an ILS approach. The pilot managed to fly onto final approach, but while in IMC conditions, rolled to the right and crashed inverted in a wooded area about 7.5 nautical miles from the approach end of the runway. Postaccident examination of the airframe and flights controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the power section of the engine revealed no evidence of preimpact failure or malfunction; one propeller blade exhibited "S"-bending consistent with the engine developing power at impact. No discrepancies were noted with the airport approach systems. Examination of the engine-driven vacuum pump, which operates the primary flight instruments consisting of the attitude indicator and directional gyro revealed fire damage to the shear shaft; however, no evidence of scoring of the interior surface of the housing was noted. Further, inspection of the gyroscopic flight instruments operated by the engine-driven vacuum pump revealed no evidence of rotational scoring; therefore, the engine-driven vacuum pump, which was about 3 years 4 months beyond the suggested replacement interval, was not operating at the moment of impact. This was consistent with the comment from the pilot that he had lost his gyro instruments. Although no determination could be made as to whether the pilot was instrument current, his inability to maintain control of the airplane while flying with a partial panel suggests he was not proficient in doing so; he failed this criteria in April 2002 during his first instrument rating checkride. In August 2004, in response to an NTSB recommendation, the FAA implemented national computer-based training to alert controllers of in-flight emergencies a pilot may encounter and the effect of the emergency. NTSB review of the current version of the CBI revealed it did not contain scenarios related to failures of the vacuum system or gyro flight instruments. Although the training provided to the controllers involved appeared to be inconsistent, it is unlikely that consistent training would have affected the outcome of the accident because specific mention of gyro malfunction was not a covered topic in the CBI training. Although the pilot had not declared an emergency, he had advised ATC personnel that he had lost his gyros, and that he was "not OK." Further, extensive altitude and heading excursions of the aircraft were noted, all of which were clear indicators that an in-flight emergency existed. Had any of the FAA controller personnel understood either by experience or training that the pilot's declarations or altitude and heading changes constituted an emergency, they could have declared an emergency for the pilot and obtained the necessary information required by section 10-2-1 of FAA Order 7110.65U, "Air Traffic Control." Had that occurred, it is likely the pilot would have been vectored to an airport with VFR conditions for an uneventful landing.

HISTORY OF FLIGHT On December 16, 2012, about 1532 eastern standard time, a Piper PA-28-160, N5714W, registered to and operated by a private individual, crashed in a wooded area near Parkton, North Carolina. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Summerville Airport (DYB), Summerville, South Carolina, to Fayetteville Regional Airport/Grannis Field (FAY), Fayetteville, North Carolina. The airplane sustained substantial damage and the private pilot, the sole occupant, was fatally injured. The flight originated from DYB about 1400. The pilot departed VFR and at 1412, he established contact with Charleston air traffic control tower (ATCT) and was issued a discrete IFR transponder code. About 1 minute later the airplane was radar identified, the pilot was issued IFR clearance, and instructed to climb and maintain 5,000 feet which he acknowledged. While proceeding towards the destination airport, air traffic control (ATC) communications were transferred to Shaw Air Force Base Approach, followed by Fayetteville Approach Control. According to a transcription of communications with Fayetteville Air Traffic Control Tower, at 1451:41, the pilot established contact with the radar controller of the East Radar position of Fayetteville ATCT, and advised the controller that the flight was at 5,000 feet mean sea level (msl). The radar controller instructed the pilot to advise when he had automated terminal information service (ATIS) Alpha, and to expect instrument landing system (ILS) runway 4 approach, to which he immediately acknowledged having obtained ATIS information Alpha and to expect ILS runway 4 approach. The controller then provided the altimeter setting to the pilot and he read-back correctly the last 2 digits. At 14:57:20, the radar controller asked the pilot if he could accept direct ZODGI, which is the initial approach fix (IAF) for the ILS to runway 4. While the transcription of communication indicates the pilot's response was unintelligible, NTSB review of the certified voice tape revealed his comment was in the affirmative. The controller issued the pilot a 055 degree heading to join the localizer, and instructed him to report established on the final approach course. The pilot did not respond, so the radar controller repeated the transmission. The pilot apologized and acknowledged the instructions. At 14:59:41, the radar controller issued the pilot a weather advisory for a small area of moderate precipitation at the pilot's one o'clock position and 3 miles, which he acknowledged. At 1504:38, the radar controller instructed the pilot to descend and maintain 2,300 feet and, "…verify established" on the localizer. The pilot acknowledged the altitude assignment, and stated, "…couldn't (unintelligible) isn't quite established yet sir." At 1504:51, the pilot asked if a heading of 055 was good to intercept, and the radar controller replied affirmative. At 1506:07, the controller advised the pilot that the flight was 10 miles from the final approach fix, fly the present heading and to maintain at or above 2,300 feet until established on the localizer, cleared for ILS straight in runway 4 approach. The pilot acknowledged the instructions and advised the controller, "…I think we're established now thanks." Radar data indicates that before reaching ZODGI, the pilot flew slightly east of the final approach course, followed by a left turn flying west of the final approach course. Air traffic control communications were transferred to local control of the FAY ATCT, and at 1507:10, while west of the final approach course but before ZODGI, the pilot established contact with local control and was cleared to land. The local controller also provided the wind direction and velocity information to the pilot but he did not reply. The radar data indicated that as the flight continued towards FAY near ZODGI, the airplane flew in an easterly direction flying east of the final approach course. The airplane was observed on radar turning to the northwest and intercepting the final approach course, then turned again and flew east of the final approach course. At 1509:43, the radar controller contacted the local controller and advised that the airplane appeared to be right of course; at that time the airplane was east of the final approach course. The radar data indicates that the pilot performed S type turns while remaining right of course and at 1510:34, the local controller questioned the pilot if he was receiving the localizer to which he replied, "having a little bit of trouble right now I seem to have lost some gyros but I think we're getting there." The local controller advised the pilot to maintain 2,000 and suggested a heading of 020 to join the localizer, which he acknowledged. At that time, coordination between the local and radar east positions occurred. At 1511:24, the local controller advised the pilot to maintain 1,900 feet until receiving the glideslope, which he acknowledged. Radar data indicates that the flight proceeded towards FAY, and at 1512:15, the pilot was advised that the flight was crossing CINLO, which is the final approach fix. At 1513:30, when the flight was at 1,700 feet msl, about 211 degrees and 2.8 nautical miles from the approach end of runway 4, the local controller asked the pilot if he was receiving the glide slope. The pilot responded, "I'm sorry sir yes sir ah, I would have [unintelligible words] I realize we're coming now." At 1513:37, the local controller asked the pilot if he wanted, "…to come back out for another approach" to which the pilot stated that, "…I think we're doing OK if it looks OK to you." The local controller informed the pilot that he could not tell with the rate of descent and cleared the pilot for a localizer approach to runway 4. The local controller later stated during an interview that he wanted to give the pilot every opportunity to complete the approach and wanted him to worry less about the glideslope so that is the reason that he cleared him for a localizer approach. The pilot acknowledged the clearance with part of his call sign and approximately 37 seconds later, or at 1514:29, the controller cancelled the approach clearance and advised the pilot to climb and maintain 2,000 feet and fly runway heading, which he acknowledged. Radar data indicates that about that time, the airplane was at 1,300 feet and 1.0 nautical mile from the approach end of runway 4. At 1514:40, the local controller informed the pilot that overcast clouds existed at 500 feet, the flight was at 1,200 feet about ½ mile away from the runway, and asked the pilot if he wanted to perform another approach. The pilot responded, "that'll be fine thanks one four whiskey." Coordination between the local and east radar positions occurred. Radar data indicates that beginning about 1514:29, to about 1515:03, the pilot turned right to a nearly due east heading despite the instruction from the controller to maintain runway heading. At 1515:05, the local controller advised the pilot to fly heading 090 degrees climb and maintain 2,000 feet which he correctly read back. The controller then asked the pilot what heading he was flying he reported 081 degrees. The local controller again instructed the pilot to fly heading 090 degrees, climb and maintain 2,000 feet, and to contact Fayetteville Departure Control on frequency 133.0 MHz. Coordination between the local controller and radar east radar controller occurred during which time the local controller stated, "he's having a lot of problems holding a steady heading he's trying a ninety heading right now at two thousand." The transcription does not indicate that the local controller advised the radar controller that the pilot had stated that he lost some of his gyros. The pilot established contact with Fayetteville Approach Con