ERA15FA340

The pilot's loss of airplane control due to spatial disorientation, which resulted in an aerodynamic stall/spin. Contributing to the accident was deficient Federal Aviation Administration air traffic control training on recognition and handling of emergencies, which led to incorrect controller actions that likely aggravated the pilot's spatial disorientation.

The private pilot had recently purchased the airplane and it was more complex than the airplane he had flown previously. The accident airplane was also equipped with an upgraded avionics suite. The pilot had practiced loading and flying instrument approaches with the new avionics during recent flights with a flight instructor and another pilot onboard, and the flights were conducted in visual meteorological conditions (VMC). The pilot's most recent logbook was not available for review, so his instrument currency, as well as his recent and type of flight experience could not be verified.   Review of the flight from departure to entry into the arrival airport's airspace revealed no unusual events or problems, and it was conducted in VMC. However, once the pilot began the higher workload phase of flight preparing to execute the instrument landing system (ILS) approach in actual instrument meteorological conditions, he began to exhibit some uncertainty and confusion. The first approach controller had to confirm the runway assignment three times and the pilot's assigned altitude once. After contacting a second approach controller, who vectored the flight to the ILS, the pilot had difficulty becoming established on the localizer, eventually causing the controller to cancel the approach clearance and issue vectors for a second attempt at the approach. The instructions issued by the second approach controller were not complicated, but the pilot had difficulty flying assigned headings and altitudes. The controller also did not immediately detect some of the unusual maneuvers conducted by the pilot or recognize that he was perhaps suffering from spatial disorientation until the pilot explicitly said so. Instead of simply issuing a single heading and having the pilot climb a few hundred feet back into VMC, the controller asked the pilot if he was able to accept "no-gyro" vectors. The pilot accepted the offer, and the controller then issued turn instructions that required turns in both directions. This excessive maneuvering possibly exacerbated the pilot's spatial disorientation. The controller then directed the pilot to climb in an attempt to get him into VMC, but shortly thereafter, the airplane entered an aerodynamic stall/ spin and impacted terrain. When interviewed, the controller was unable to explain the basics of no-gyro vectoring and was unable to demonstrate the ability to effectively provide the service.   Facility management provided four summaries of training scenarios that included unusual or emergency situations, but none included no-gyro vectors or focused on identification of emergencies. Overall, the recognition of and response to emergencies did not appear to be a strong training item, which is not limited to this facility. The FAA training did not properly prepare the controllers involved in this accident to recognize and effectively respond to disorientation scenarios.   Examination of the airframe, engine, and flight instruments revealed no mechanical deficiencies that would have precluded normal operation at the time of impact.

**This report was modified on August 31, 2016. Please see the docket for this accident to view the original report.** HISTORY OF FLIGHT On September 7, 2015, about 1203 eastern daylight time, N36HT, a Beech A36, was destroyed when it impacted terrain near Kernersville, North Carolina. The private pilot and the two passengers were fatally injured. The airplane was registered to Central Penn Aviation Academy Inc., Paxinos, Pennsylvania and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the flight that departed Sarasota-Bradenton International Airport (SRQ), Sarasota, Florida, about 0819, under the provisions of a 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions (IMC) prevailed at the time of the accident. According to radar and voice communication data provided by the Federal Aviation Administration (FAA), the airplane was being radar vectored by air traffic control for the ILS RWY 5R instrument approach to the Piedmont Triad International Airport (GSO), Greensboro, North Carolina, following a previous unsuccessful ILS approach to the same runway. The pilot contacted GSO approach at 1132:54 and reported that he was descending through 5,700 ft. A controller replied that automated terminal information system (ATIS) information Delta was current, the altimeter setting was 30.19, and the pilot should expect to land on runway 5R. The pilot read back the runway assignment, and then asked if he should expect a visual approach. The controller stated that the pilot should expect the ILS approach, and asked the pilot to report when he had received information Delta. The pilot confirmed that he had information Delta, and then asked if the assigned runway was 5L. The controller reconfirmed the original assignment, runway 5R. At 1133:51, the pilot asked the controller to confirm that he was cleared to descend to 5,000 ft. The controller responded that if 5,000 was the altitude assigned by the previous controller, it was correct, and also noted that he had not issued any other altitude instructions. The pilot acknowledged. At 1135:14, the pilot again asked the controller to confirm whether he should expect runway 5R or 5L.The controller responded, "The right side – R I G H T." The pilot read back, "Five right 36HT." At 1140:44, the controller instructed the pilot of N36HT to fly heading 360 for sequencing into GSO, and the pilot acknowledged. At 1143:26, the controller instructed the pilot to contact another controller on frequency 124.35. The pilot contacted the controller at 1144:00 while the airplane was level at 5,000 ft. The controller provided the GSO altimeter setting, 30.19. At 1145:24, the controller cleared the pilot to descend to 3,000 ft. At 1148:01, the controller advised the pilot of potentially conflicting traffic ahead, type and altitude unknown. The pilot responded, "Roger – 36HT is about to go IMC." The airplane was descending through 3,600 ft at the time. At 1148:38, the controller advised the pilot that traffic was no longer a factor and instructed him to turn right heading 010 degrees. The pilot correctly read back the heading. At 1149:04, the pilot reported level at 3,000 ft, and then asked if the controller wanted him to remain at 3,000 ft. The controller responded, "Affirmative." At 1150:35, the controller transmitted, "N36HT niner miles from Pagan, turn right heading 020, maintain 3,000 until established on the localizer, cleared ILS runway 5R approach. The pilot responded, "Turning right heading 020 for Pagan." The controller restated the altitude restriction and the approach clearance, and the pilot correctly read it back. At 1152:48, the pilot asked, "How do you like this route of flight?" The controller responded, "You look just a little bit right of course for the ILS, turn left heading 0…make that 360 for the ILS, report established." The pilot then asked, "Turning left or turning right for 360?" The controller replied, "left to 360," and the pilot acknowledged. At 1153:59, the controller asked the pilot, "…are you established? [on the localizer]" The pilot responded, "Established if I could have vectors to final, please." The controller then asked, "…Are you established on the localizer?" The pilot stated, "I believe I am, 36HT." The controller continued, "Now you look like you just actually went through the localizer." The pilot replied, "Roger – request a vector for final for 36HT." The controller issued an instruction to another airplane, then at 1154:30 transmitted, "N36HT cancel your clearance, maintain 3,000, turn left heading 320 for sequencing." The pilot read back, "Left 320." At 1156:42, the controller instructed the pilot to turn left heading 230 degrees for vectors to the ILS runway 5R approach. The pilot correctly read back the instruction. At 1157:30, the controller asked the pilot to verify that he was flying heading 230. The pilot replied, "Negative, and 36HT is close to..." The transmission ended incomplete. The controller then took a coordination call from another facility. During that call, the pilot called again in a strained tone, stating, "N36HT request vectors," and the controller also noticed that the airplane's altitude was below 3,000 ft. He ended the call and at 1157:57 responded to the pilot, "Bonanza 36HT you need to be level at 3,000, altitude shows you 2,500, Greensboro altimeter 30.19." The pilot responded, "6HT climbing to three." The controller asked the pilot to verify that he was on a 230 heading. The pilot did not respond. At 1158:40, the controller asked the pilot to verify the airplane was at 2,900 ft. The pilot did so. At 1159:16, the controller asked the pilot to verify the airplane's heading. The pilot responded that the airplane was heading 166. The pilot continued, "We need a descent, we are almost disoriented, N36HT…2,700." In the background of the transmission, a female voice said, "Turn something off." At 1159:43, the controller instructed the pilot to start a left turn and 16 seconds later told him to maintain 2,500 ft. The pilot did not acknowledge the turn, but radar data indicated the pilot initiated a left turn. At 1200:16, the controller instructed the pilot to start a right turn. The pilot responded, "Right turn, 36HT leveling off 2,500." At 1200:47, the controller transmitted a low altitude alert to N36HT along with the altimeter setting, and asked the pilot to say altitude. The pilot did not acknowledge the transmission, and radar data showed that during the next minute the airplane initially turned right but then entered and completed a 360-degree left turn. At 1201:25, the controller transmitted, "N36HT climb and maintain 4,000, I can see if I get you back up into the uh above the clouds." At 1201:35, the controller continued, "N36HT Greensboro approach you up? Last altitude showed 2,100." At 1201:41, the pilot transmitted "N36HT" in an agitated voice. The controller replied, "N36HT just climb and maintain 4,000, I'll block altitude for you." At 1202:06, the controller asked the pilot of N36HT, "… if he was able to take the climb", and continued, "Last tops were reported at 3,500, if I can get you up to 4,000 maybe you can square it back off." At 1202:18 a short sound was heard, possibly from the pilot. At 1202:39, the controller advised the pilot that his altitude was 2,100 ft. At 1202:44, an unidentified transmission of what sounded like breathing was heard on the frequency. At 1202:54, the pilot asked, "Is there a nearby field for 36 ho-." The controller responded, "…the nearest airport is Greensboro airport, off your left wing and off your current heading 7 miles. Right now showing 1000 overcast for the ceiling." At 1203:21, the controller asked the pilot for his altitude. At 1203:34, screams were heard on the frequency. There were no further communications with the pilot. Sev