ERA15FA099

The pilot's failure to maintain control of the airplane while operating under visual flight rules (VFR) in night, instrument meteorological conditions, likely due to spatial disorientation. Contributing to the outcome was the radar controller's failure to follow published guidance for providing assistance to VFR pilots having difficulty flying in instrument conditions.

The commercial pilot was in the process of purchasing a block of flight time with the intent of building time toward an additional rating. According to the operator, the pilot did not complete the mandatory checkout. However, she possessed the keys to the airplane since she had flown the previous day with an instructor, but he did not approve her for solo flight because he believed she required additional practice landing the airplane with an instructor onboard. On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of the operator. The accident flight was initiated at night, presumably with the intent of operating in the local airport traffic pattern. About 7 minutes into the flight, the pilot likely encountered instrument meteorological conditions (IMC) and requested assistance from air traffic control. An air traffic controller attempted to provide the pilot with radar vectors to a nearby airport; however, the pilot was unable to visually acquire that airport. The controller then observed the airplane on radar at 600 ft and descending and directed the pilot to climb and turn. A short time later, radar and radio contact were lost; the airplane had crashed. The level of damage and fragmentation of the wreckage was consistent with ground impact at a high velocity. The flight was conducted on a dark, moonless night, under an overcast ceiling, and the final portion of the flight was over the ocean. These factors would have reduced the pilot's ability to perceive the natural horizon and increased her risk of spatial disorientation. Although the pilot held an instrument rating and had recently completed an instrument proficiency check, on the night of the accident, she did not demonstrate the skills necessary to control an airplane in IMC. She also did not display the ability to adequately communicate her situation to the controller, nor did she seem to understand or comply with the assistance offered to her. Review of autopsy results and postaccident toxicological testing showed no evidence of any physiologically induced incapacitation or other impairment. During the sequence of events leading up to the accident, the pilot communicated with two air traffic controllers. The pilot described that she was operating in conditions that limited her ability to navigate and potentially affected her ability to control the airplane under visual flight rules (VFR). Although the actions of the controllers did not directly contribute to the pilot's loss of control while attempting to fly under VFR in IMC, the controllers did not act in accordance with Federal Aviation Administration (FAA) guidance that dictates how to assist pilots experiencing this type of emergency. Specifically, the controllers did not ascertain if the pilot was qualified and capable of IFR flight nor did they attempt to locate and direct the pilot toward the nearest areas reporting visual meteorological conditions. Further, a controller assisting the accident controller had the opportunity to solicit a pilot report from another pilot in a nearby airplane to ascertain if that airplane was operating above the reported IMC but did not do so. During postaccident interviews, the air traffic controllers indicated that they had not received FAA-required evidence-based simulation training on emergencies and described the computer-based emergency training that they received as poor quality.

Paragraphs 10-2-8 and 10-2-9 of FAA order 7110.65 address how air traffic controllers should provide radar assistance to aircraft operating under visual flight rules (VFR) in weather difficulty, including techniques that should be used to the extent possible when providing assistance. They state [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 subparagraph 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. 10-2-9. RADAR ASSISTANCE TECHNIQUES Use the following techniques to the extent possible when you provide radar assistance to a pilot not qualified to operate in IFR conditions: a. Avoid radio frequency changes except when necessary to provide a clear communications channel. b. Make turns while the aircraft is in VFR conditions so it will be in a position to fly a straight course while in IFR conditions. c. Have pilot lower gear and slow aircraft to approach speed while in VFR conditions. d. Avoid requiring a climb or descent while in a turn if in IFR conditions. e. Avoid abrupt maneuvers. f. Vector aircraft to VFR conditions. g. The following must be accomplished on a Mode C equipped VFR aircraft which is in emergency but no longer requires the assignment of Code 7700: 1. TERMINAL. Assign a beacon code that will permit terminal minimum safe altitude warning (MSAW) alarm processing. FAA Guidance to Pilots In April 2003, the FAA published Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness. The circular stated in part: "Operating in marginal VFR /IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC. As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR [instrument flight rules] applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT [controlled flight into terrain] accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough." According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions. According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation." Air Traffic Controller Training As part of the investigation into this accident, air traffic controllers were asked about their preparedness to provide assistance to a pilot in an emergency situation. FAA air traffic controllers were required to undergo proficiency training that "maintains and upgrades the knowledge and skills necessary to apply air traffic procedures in a safe and efficient manner." This training included recurrent training and refresher training. Chapter 1 paragraph 5, (a) and (b), of FAA JO 3120.4N, Air Traffic Technical Training, addressed the requirements of recurrent and refresher training and stated [in part]: JO 3120.4N Air Traffic Technical Training a. Recurrent Training. Recurrent training is collaboratively-developed national safety training delivered via electronic means, instructor-led presentations, or any combination thereof. Recurrent training is intended to increase air traffic controller proficiency, enhance awareness of human factors affecting aviation, and promote behaviors essential for the identification, mitigation, and/or management of risk. Topics are derived from data collected through internal and external safety reporting systems and stakeholder input. Recurrent training is conducted via an 8-hour block of training, two rounds delivered yearly. Each round is comprised of approximately 4 hours of training selected from the topics listed below, and 4 hours of training on relevant and timely safety topics, such as but not limited to: Human Factors, Safety Culture, Threat and Error Management, Crew Resource Management, Event Recovery, and learning that promotes the maturity of the Safety Management System. Recurrent training requirements are identified annually NLT October 1st to be delivered the following calendar year. Recurrent training on the following items need not be duplicated in local refresher training: (1) Safety alerts and traffic advisories, to include Minimum Safe Altitude Warning (MSAW) procedures and the relationship between charted minimum