ERA14FA292

The noninstrument-rated pilot's encounter with instrument meteorological conditions and his decision to continue visual flight rules flight in instrument conditions, which resulted in a loss of control due to spatial disorientation.

The noninstrument-rated pilot contacted flight service to inquire whether the conditions for his 15-nm flight, planned for about 1 hour later, would be suitable for visual flight rules (VFR) operations. The pilot received an abbreviated briefing that included only the current conditions at both his departure and destination airports, both of which reported VFR conditions; he subsequently departed on the accident flight about 3 hours later. About 10 minutes after takeoff, after entering the controlled airspace of the destination airport, the pilot contacted air traffic control (ATC) and stated, "I need your help, sir." The controller queried the pilot as to his location, heading, and destination, and the pilot replied with his destination, stating, "I just don't have visibility." The controller asked the pilot whether he was declaring an emergency and advised that the destination airport was under instrument meteorological conditions (IMC); the pilot did not respond. The pilot then stated that he would return to his departure airport and was advised by the controller to "squawk VFR." The pilot acknowledged, and no further communications were received from the accident airplane. Radar data showed that the airplane, about the time of the last radio transmission, entered a descending right turn that continued until ground contact. Such a a flight track is consistent with a somatogyral illusion known as the "graveyard spiral." Given the reported weather conditions in the area about the time of the accident, the pilot's statement that he was experiencing reduced visibility, the fact that the pilot did not hold an instrument rating, and the radar flight track of the airplane, it is likely that the pilot experienced spatial disorientation and a subsequent loss of control as a result of his continued VFR flight into IMC. The extent to which the pilot may have used the airplane's automation, including the autopilot system, could not be determined. Recorded weather data and statements from pilots flying in the area about the time of the accident indicated that, although the departure airport was experiencing visual meteorological conditions, IMC prevailed for much of the area surrounding the destination airport. These conditions had not been forecast until just before the airplane's departure. Had the pilot received the forecast from flight service when he received the current weather, he would only have been informed of low-level scattered clouds at his destination. Despite the discrepancy between the forecast and actual conditions present on the day of the accident, it should have been apparent to the pilot upon takeoff that the cloud ceilings and visibilities were below VFR minimums as the flight progressed. Additionally, the pilot could have obtained the automated weather report at the destination airport via radio shortly after departure, which would have informed him that the airport was experiencing IMC. However, the pilot's communication with ATC suggested that he was not aware of the weather conditions at his destination. If the pilot had declared an emergency and stated that he was not capable of instrument flight rules flight, he would have been provided priority handling and greater assistance from ATC. Although he did indicate that he was experiencing reduced visibility conditions, he did not declare an emergency and did not provide any specific information about the conditions he was experiencing or his limitations as a noninstrument-rated pilot. In the absence of this information, the controller likely assumed that the pilot was able to maintain VFR flight and return to the departure airport as stated without any further assistance.

The FAA Aeronautical Information Manual, Chapter 5, "Air Traffic Procedures," Section 5; Pilot/Controller Roles and Responsibilities, stated in part: b. The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to the safe operation of that aircraft. In an emergency requiring immediate action, the pilot-in-command may deviate from any rule in the General Subpart A and Flight Rules Subpart B in accordance with 14 CFR Section 91.3. c. The air traffic controller is responsible to give first priority to the separation of aircraft and to the issuance of radar safety alerts, second priority to services that are required, but do not involve separation of aircraft and third priority to additional services to the extent possible. d. In order to maintain a safe and efficient air traffic system, it is necessary that each party fulfill their responsibilities to the fullest. Chapter 6, "Emergency Procedures," Section 2, Emergency Services Available to Pilots, stated in part: If continued flight in VFR conditions is not possible, the noninstrument rated pilot should so advise the controller indicating the lack of an instrument rating, declare a distress condition… Section 3, Distress and Urgency Procedures, stated in part: a. A pilot who encounters a distress or urgency condition can obtain assistance simply by contacting the air traffic facility or other agency in whose area of responsibility the aircraft is operating, stating the nature of the difficulty, pilot's intentions and assistance desired. d. Distress communications have absolute priority over all other communications, and the word MAYDAY commands radio silence on the frequency in use. FAA Order 7110.65 (Air Traffic Control) provided guidance and instruction to controllers for determining emergencies and obtaining information for handling an emergency. Paragraph 10-2-8 stated in part: 10-2-8. RADAR ASSISTANCE TO VFR AIRCRAFT IN WEATHER DIFFICULTY a. If a VFR aircraft requests radar assistance when it encounters or is about to encounter IFR weather conditions, ask the pilot if he/she is qualified for and capable of conducting IFR flight. b. If the pilot states he/she is qualified for and capable of IFR flight, request him/her to file an IFR flight plan and then issue clearance to destination airport, as appropriate. c. If the pilot states he/she is not qualified for or not capable of conducting IFR flight, or if he/she refuses to file an IFR flight plan, take whichever of the following actions is appropriate: 1. Inform the pilot of airports where VFR conditions are reported, provide other available pertinent weather information, and ask if he/she will elect to conduct VFR flight to such an airport. 2. If the action in subpara 1 above is not feasible or the pilot declines to conduct VFR flight to another airport, provide radar assistance if the pilot: (a) Declares an emergency. (b) Refuses to declare an emergency and you have determined the exact nature of the radar services the pilot desires. 3. If the aircraft has already encountered IFR conditions, inform the pilot of the appropriate terrain/obstacle clearance minimum altitude. If the aircraft is below appropriate terrain/obstacle clearance minimum altitude and sufficiently accurate position information has been received or radar identification is established, furnish a heading or radial on which to climb to reach appropriate terrain/obstacle clearance minimum altitude. Spatial Disorientation The Airplane Flying Handbook (FAA-H-8083-3A) stated, "…the VFR pilot is, in effect, in IMC anytime he or she is inadvertently, or intentionally for an indeterminate period of time, unable to navigate or establish geographical position by visual reference to landmarks on the surface. These situations must be accepted by the pilot involved as a genuine emergency, requiring appropriate action…If the natural horizon were to suddenly disappear, the untrained instrument pilot would be subject to vertigo, spatial disorientation, and inevitable control loss." The FAA Pilot's Handbook of Aeronautical Knowledge, chapter 16, "Aeromedical Factors," stated, "Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which normal motions and forces create convincing illusions that are difficult to overcome…Unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible. A pilot can reduce susceptibility to disorienting illusions through training and awareness, and learning to rely totally on flight instruments." The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility conditions. Somatogyral illusions, those involving the semicircular canals of the vestibular system, were generally placed into one of four categories, one of which was the "graveyard spiral." According to the text, the graveyard spiral, "…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground." All figures in this report are available in the public docket for this accident, which can be found at: http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=89451 Information provided by Lockheed Martin Flight Service revealed that the pilot placed a phone call to the flight service station at 0630 the morning of the accident and received an abbreviated briefing. The pilot indicated that he would be departing FRG for ISP at 0730, and inquired whether the conditions were "good VFR [visual flight rules]." The briefer advised the pilot of a presidential temporary flight restriction for the area that would be effective later that day, and asked when the pilot would be returning to FRG. The pilot replied that he would return to FRG by 0900. The briefer then provided local notice to airmen (NOTAM) information and advised the pilot of the current cloud ceilings and visibilities at FRG and ISP, which included 9 miles visibility and few clouds at 7,000 feet, and 10 miles visibility, few clouds at 6,500 feet, scattered clouds at 9,000 feet, and an overcast ceiling at 26,000 feet, respectively. The briefer did not provide, nor did the pilot request, forecast conditions for either airport. Official recordings of air traffic control communications provided by the Federal Aviation Administration (FAA) revealed that the pilot contacted FRG ground control at 0840, and was cleared for takeoff from runway 14 at 0850. At 0854, the pilot requested a frequency change and s