ERA15FA144

The pilot's failure to properly execute the instrument approach procedure. Contributing to the accident were the pilot's improper preflight planning and his decision to conduct the flight in instrument meteorological conditions at night into forecast moderate turbulence and with inadequate avionics equipment for the planned flight.

In preparation for the night cross-country flight from southern Florida to Virginia, the private pilot contacted flight service to file instrument flight rules (IFR) flight plans for each of the two planned legs. The pilot was advised that instrument meteorological conditions (IMC), moderate turbulence, and possible low-level wind shear would prevail for the second leg of the trip (the accident flight). Although the pilot indicated to the briefer that he was aware of these conditions, the extent to which he had familiarized himself with the forecast weather could not be determined because there was no record of a complete weather briefing from an official, access-controlled source. The first leg of the flight departed about 2030 and landed uneventfully about 2240. After obtaining fuel, the pilot and his two passengers departed on the accident flight about 2353. The airplane reached the destination airport about 0300. The airport was under low IFR weather conditions, and the pilot requested an RNAV GPS instrument approach, even though the airplane was only equipped with a handheld GPS receiver. During the approach, the air traffic controller twice noted that the pilot was having difficulty maintaining alignment with the final approach course. When asked about this by the controller, the pilot first attributed the issue to problems displaying the instrument approach charts on his GPS receiver and second to the wind correction angle necessary to hold the course. At the conclusion of the unsuccessful approach, the pilot failed to comply with the published missed approach procedure and descended to an estimated 100 ft above ground level (agl) before subsequently climbing. When asked by the controller to fly the published missed approach procedure, the pilot responded that he was unable to do so because he was "off course." With the assistance of air traffic controllers, the pilot diverted to a nearby airport equipped with an instrument landing system (ILS) even though similar weather conditions prevailed. The pilot was provided radar vectors for an ILS approach, but he again had difficulty maintaining the approach's prescribed altitudes and courses, and the controller cancelled the approach clearance. About 0400, during the pilot's second attempted approach to the diversion airport, the airplane descended to within 1 mile of the runway and about 200 ft agl. About that time, the pilot reported that he had the airport in sight, consistent with the airplane descending below the cloud ceiling. A plot of the airplane's GPS-derived ground track and the recorded air traffic control radio transmissions showed that, about the time the pilot reported the airport in sight, the airplane was about 1/4 mile offset from the localizer but tracking toward the runway. However, instead of continuing its track toward the runway, moments later, the airplane made an abrupt, 90-degree right turn before turning left back toward the approach runway several seconds later. During the final 9 seconds of the flight, the airplane descended at a calculated descent rate of 900 ft per minute to ground impact. The airplane's maneuvering and its final descent occurred over a relatively unlit area of water and forest. The diminished lighting conditions likely provided the pilot with limited external cues to draw from in his attempt to maintain control of the airplane and complete the visual portion of the landing approach. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures. A technical performance assessment of the diversion airport's ILS equipment revealed no discrepancies associated with the systems in use by the pilot during the attempted approach. Throughout the approaches to both airports, the pilot repeatedly described the extreme nature of the turbulence and the high wind velocity that the airplane was encountering. Forecast and observed weather were consistent with this assessment. The pilot also described that he was having difficulty maintaining a heading due to precession of the airplane's gyroscopic heading indicator. Detailed examination of the vacuum-system-driven gyroscopic heading indicator revealed no anomalies, and a functional test displayed no abnormal precession. It is most likely that the gyroscopic precession cited by the pilot was directly attributable to the turbulence. The pilot's personal flight logs were not recovered, and neither his recent flight experience nor instrument flight currency could be determined; however, his inability to maintain assigned headings and altitudes and to fly navigational courses indicated that his level of proficiency in flying the airplane in IMC was inadequate for the flight, particularly given the extremely challenging nature of the weather conditions that prevailed on the night of the accident. Additionally, the pilot decided to conduct the flight using a handheld GPS receiver, which was not suitable for IFR navigation and instrument approaches. Although toxicological testing revealed the presence of amphetamine in the pilot's blood and urine, the investigation was unable to determine whether the pilot's use of amphetamine or the effects of any underlying condition contributed to the accident.

SFQ was served by five instrument approach procedures, a localizer approach to runway 4 and four area navigation (GPS) instrument approaches, including the RNAV (GPS) RWY 22 approach. Runway 22 was 5,007 ft long by 100 ft wide and was equipped with high-intensity runway edge and end identifier lights. ORF was served by numerous ILS and RNAV instrument approaches, including the ILS RWY 23 approach. Runway 23 was 9,001 feet long by 150 feet wide and was equipped with high intensity runway edge lights, runway centerline lights, a 1,400-foot-long medium intensity approach lighting system with runway alignment indicator lights, and a precision approach path indicator. The FAA conducted a postaccident technical performance review of the ORF runway 23 instrument approach system components, including the localizer, glide slope, and approach lighting systems. The review revealed that each system was operating within the prescribed tolerances. An autopsy was performed on the pilot by the Office of the Chief Medical Examiner, Norfolk, Virginia. The medical examiner determined that the cause of death was "multiple blunt trauma." Toxicological testing performed by the FAA's Civil Aerospace Medical Institute found no ethanol or carbon monoxide in the samples submitted. The tests were positive for the presence of amphetamine in the pilot's urine and blood. The accident site was located about 2,300 ft northwest of the ORF runway 23 threshold. The immediate area was surrounded by a forest and a lake, and featured relatively little ground lighting when compared with the surrounding residential and industrial areas. The initial impact point was identified as a tree with numerous branches broken from its top at a height of about 80 ft. The tree was located about 20 ft from the shoreline of Lake Whitehurst. A wreckage path extended for about 260 ft on a magnetic heading of 210°. Broken tree branches, paint chips, and small pieces of metal were distributed along the wreckage path. The main wreckage came to rest inverted at the base of a tree oriented roughly 210° magnetic. All major components of the airplane were accounted for at the accident site, and the wreckage did not display any evidence of a pre- or post-impact fire. The outboard 3 feet of both wings were separated from the airplane and were found adjacent to the main wreckage. The left wing displayed a concave depression of its leading edge, outboard of the landing gear, oriented perpendicular to the spar, about 16 inches in diameter. The left fuel tank was ruptured and absent of fuel, and a trace amount of fuel remained in the right fuel tank. The landing gear were extended, and the flaps were retracted. Control continuity was traced though separations consistent with overload from the cockpit controls to each of the flight control surfaces. The State of Virginia, Office of the Chief Medical Examiner reported that both front seat occupants were restrained with lap belts. No shoulder restraints were installed. The emergency locator transmitter remained secured to its mount and was found in the armed position about 36 hours after the accident. Both of the propeller blades displayed aft tip curling and s-bending. One of the blades exhibited chord-wise scratching, and its tip was torn away. A significant quantity of freshly-cut pine needles and tree branches less than 4 inches in length were found inside the engine cowling on top of the engine. Continuity of the powertrain and valvetrain were confirmed through rotation of the propeller by hand, and thumb compression was observed on all cylinders. The spark plug electrodes exhibited normal wear and were dark gray to black in color. A trace amount of liquid consistent in color and odor with 100LL aviation fuel was found within the flow divider and fuel servo inlet screen, and no significant debris or other contamination was noted. The oil inlet screen and fuel filter element were absent of metallic debris, and no other significant contamination was noted. The directional gyro displayed impact-related damage to its external case. The instrument compass card was free to rotate, and the bug setting knob was bent upward with the bug set at 232°. Functional testing of the unit revealed no evidence of any pre-impact mechanical malfunctions or failures, nor did it display signatures indicative of excessive precession. Disassembly of the engine-driven vacuum pump revealed that the rotor, veins, and drive mechanism were intact and undamaged. A handheld GPS receiver was recovered from the wreckage and forwarded to the NTSB Vehicle Recorders Laboratory for data extraction. A track history was recovered from a flash memory card within the device. The track history file contained 71 log files for multiple flights, including the flight that preceded the accident flight (EYW to 28J), as well as the entirety of the accident flight. The weather conditions reported at SFQ, at 0315 (when the pilot was conducting the attempted instrument approach there), included wind from 230° at 10 knots, 2 1/2 statute miles visibility in mist, an overcast ceiling at 300 ft, a temperature of 6° C, a dew point of 5° C, and an altimeter setting of 29.98 inches of mercury. The weather conditions reported at ORF at 0420 included wind from 230° magnetic at 20 knots, gusting to 27 knots, 2 1/2 statute miles visibility in mist, an overcast ceiling at 200 ft, a temperature of 8° C, a dew point of 7° C, and an altimeter setting of 29.92 inches of mercury. A pilot report from an airplane climbing in the vicinity of ORF about 1.5 hours after the accident reported that the overcast cloud layer was between 200 ft and 1,500 ft. The closest upper air sounding was from Wallops Island, Virginia, located 72 miles northeast of the accident site. The sounding for 0700 depicted a lifted condensation level at 700 feet agl, with a relative humidity greater than 90% from this level through 13,000 ft. A defined temperature inversion associated with a front was identified from the surface to 2,000 ft. The freezing level was identified at 10,600 ft. The sounding wind profile indicated a surface wind from 275° at 13 knots, with wind speeds rapidly increasing with height, and little variation in direction. The mean 18,000-foot wind was from 255° at 65 knots. The wind profile supported light low-level wind shear through 2,000 ft and light to moderate turbulence in multiple layers through 18,000 ft. The sounding also indicated that instrument meteorological conditions with strong crosswinds would prevail throughout the altitudes associated with both instrument approaches, with winds at 1,000 ft from 250° at 43 knots, temperature 8.5° C, relative humidity 98%. The GOES-13 infrared satellite image for 0415, covering the accident site, depicted an area of low stratiform clouds extending over the region with a radiative cloud top temperature of +9.8° C. This corresponded to cloud tops near 1,200 ft, based on the Wallops Island upper air sounding. At the time of the accident, there were AIRMETs available warning of ceilings below 1,000 ft and visibility below 3 statute miles in precipitation and mist, moderate turbulence below 12,000 ft, and sustained surface winds greater than 30 knots. According to the US Naval Observatory, moonrise occurred at 1624 on the day preceding the accident, and the moon set at 0544 on the day of the accident. At the time of the accident, the moon was 16 degrees above the horizon, at an azimuth of 267°, and was 98% illuminated. The phase of the moon was a waxing gibbous with a full moon expected on March 5, 2015. The beginning of civil twilight occurred at 0606, and sunrise occurred at 0632. Forecast Conditions A terminal area forecast (TAF) for ORF was issued at 1840. The weather conditions at 2300 were forecast to include surface wind from 220° at 12 knots, visibility 4 statute miles in light rain and mist, and an overcast ceiling at 800 ft. By 0