ERA16FA100

The pilot's loss of airplane control during a missed approach in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot's inadequate preflight and inflight weather planning which resulted the pilot's selection of an unsuitable alternate airport, and the Civil Air Patrol's inadequate flight release procedures and inadequate oversight of the flight.

The airline transport pilot and non-instrument-rated private pilot were conducting a three-leg Civil Air Patrol (CAP) "compassion flight" to transport a passenger from Florida to Louisiana. The pilots departed the CAP squadron's home base in Alabama and flew to Florida, where they encountered a 2 1/2-hour delay while waiting for the passenger to arrive. After picking up the passenger, they subsequently transported her to her destination in Louisiana. The pilots then departed on the 1-hour return flight in dark night conditions to their home base, where a squadron meeting was scheduled for that evening. All three flights were conducted under instrument flight rules (IFR). During the accident flight, the weather at the destination airport deteriorated from visual meteorological conditions to instrument meteorological conditions, with low cloud ceilings, reduced visibility, and fog; these conditions had been forecasted to develop. The mission pilot should have been aware of both the forecast and actual weather conditions, as he had received an electronic weather briefing, filed an IFR flight plan, and had filed an alternate destination in the event of poor weather at the intended destination. However, the airport the pilot selected as an alternate was located only 10 nautical miles northwest of the destination airport and was affected by the same weather conditions; both airports reported 1/2 statute miles visibility and vertical visibility about 200 ft about the time of the accident. As the flight approached the destination, the pilot elected to divert to the alternate airport and received vectors for an instrument landing system (ILS) precision approach. The investigation was unable to determine why the pilot chose to divert. About 300 ft agl (100 ft above the decision height where the runway environment must be visible), the pilot initiated a missed approach procedure. Radar data showed that, rather than completing the prescribed climb to 2,000 ft on runway heading, the airplane entered a shallow right turn and continued to descend until radar contact was lost. The airplane impacted trees and terrain and was destroyed by a postcrash fire. Examination of the airplane and its systems identified no engine, airframe, or avionics anomalies that would have precluded normal operation. Additionally, no medical factors were identified that could explain the sequence of events. CAP required that all flight activities obtain a flight release before departure. As part of the flight release process, pilots were required to consult with a flight release officer (FRO), who in part ensured the pilot was qualified in the airplane and met currency requirements and input the route of flight into an electronic log system. A CAP member could become qualified as an FRO by completing a one-time online course; they were not required to be rated pilots, FROs were not required to flight follow a flight, and were not responsible for the actual conduct of the flight. The FRO who released the accident flight had a phone conversation with the pilot before the first leg of the trip to cover all three legs. They discussed the pilot's health and readiness to fly, the clouds at altitude that would require the pilot to file an IFR flight plan on each leg and assessed that the operational risk management for the flights was low. While the risk assessment completed on the morning of the accident may have been accurate at that time, the delay encountered in picking up the passenger resulted in a significant change in the circumstances of the flight, introducing the risk factors of deteriorating weather conditions at the destination, a longer duty day, and the pressure to return in time for the squadron meeting. It could not be determined whether the pilot completed a risk assessment specifically for the accident flight taking these factors into account, but even if he had, he was not required to discuss the risk assessment with the FRO or otherwise obtain explicit approval to depart on the accident flight. The pilot's alternate airport choice was likely one of convenience rather than one that was chosen with operational considerations in mind. Additionally, the selected alternate did not meet the legal minimum weather requirements to be filed as an alternate. At the time of departure, the airplane had about 5 hours of fuel onboard, well in excess of IFR-required fuel reserves. This gave the pilot the flexibility of selecting other alternate airports that may have been farther away but were experiencing better weather conditions. A witness at the departure airport stated that, although the pilots had expressed some concern about the weather conditions before departing, they indicated that they wanted to return before conditions deteriorated and so that they could attend their squadron meeting. It is likely that the pilot was affected by "get-there-itis" as he made the decision to continue to his planned destination even though there were choices available that were significantly less risky, such as staying overnight and completing the flight the next morning or diverting to an airport that was not affected by the widespread coastal fog at the destination and alternate airports. The pilot's logbooks were not recovered and his total instrument experience, recency of experience, and experience in the accident airplane could not be determined.. The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion. During this illusion, the vestibular system indicates a climb even though, in fact, the airplane is level. The sensation typically occurs when there are few visual cues (flying away from an airport at night in poor weather) and the airplane is accelerating, such as during a missed approach. Because a somatogravic illusion occurs within the vestibular system and antihistamines may affect the functioning of the vestibular system, it is possible that the pilot's use of doxylamine contributed to the illusion; however, without a blood level to indicate the amount of the drug remaining in the pilot's system, whether it contributed to the accident could not be determined.

Spatial Disorientation According to the FAA's General Aviation Joint Steering Committee, a pilot's sight, supported by other senses, allows a pilot to maintain orientation while flying. However, when visibility is restricted (i.e., no visual reference to the horizon or surface detected), the body's supporting senses can conflict with what is seen. When this spatial disorientation occurs, sensory conflicts and optical illusions often make it difficult for a pilot to tell which way is up. The FAA Airplane Flying Handbook (FAA-H-8083-3) described some hazards associated with flying 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." 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. Somatogravic illusions, those involving the utricle and saccule of the vestibular system, were generally placed into one of three categories, one of which was "the head-up illusion." According to the text, the head-up illusion involves a forward linear acceleration, such as takeoff, where the pilot perceives that the nose of the aircraft is pitching up. The pilot's response to this illusion would be to push the control yoke forward to pitch the nose of the aircraft down. "A night takeoff from a well-light airport into a totally dark sky (black hole) or a catapult takeoff from an aircraft carrier can also lead to this illusion and could result in a crash." FAA Advisory Circular AC 60-22, Aeronautical Decision Making, stated, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'" One of the common behavioral traps identified was "Get-There-Itis." The text stated, "Common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action." Mission Pilot According to the FAA medical case review, the mission pilot reported at his last aviation medical examination high cholesterol and the use of atorvastatin (a cholesterol lowering drug also called Lipitor), as well as regular use of aspirin (an over-the-counter fever and pain medication that can also help prevent heart attacks). The Alabama Department of Forensic Sciences, Mobile, Alabama, performed an autopsy of the mission pilot; the cause of death was multiple blunt force injuries and the manner of death was accident. In addition to his injuries, the autopsy identified severe coronary artery atherosclerosis with multifocal areas of plaque, including an area of 80% stenosis in the proximal portion of the left anterior descending coronary artery. There was no evidence of scarring from a previous heart attack and the remainder of the heart was unremarkable. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing that identified doxylamine in liver and heart tissue and ibuprofen in liver tissue. Doxylamine is a sedating antihistamine available in many over-the-counter products intended to treat allergies, colds, and as a sleep aid. Ibuprofen is an over-the-counter medication used to treat pain and fevers and is not considered impairing. Mission Scanner The Alabama Department of Forensic Sciences, Mobile, Alabama, performed an autopsy the mission scanner the cause of death was multiple blunt force injuries and the manner of death was accident. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma Performed toxicology testing that was negative for carbon monoxide, cyanide, and tested-for drugs, with the exception of amlodipine, a calcium blocker heart medication used in the treatment of hypertension, detected in muscle and liver; diphenhydramine, an over-the-counter (OTC) antihistamine used in the treatment of colds and hay fever, detected in muscle and liver; losartan, used in the treatment of hypertension, detected in liver; and trazodone, a tranquilizer used in the treatment of anxiety disorders, detected in muscle and liver. Synoptic Conditions The National Weather Service (NWS) Surface Analysis Chart for 1800 depicted a stationary front extending east to west across northern Alabama and Mississippi, into southern Arkansas, into northern Texas, where the front joined into a triple point associated with an occluded front with a low-pressure system at 995-hectopascals (hPa). The resultant pressure pattern resulted in southerly winds of warm, moist air from the Gulf of Mexico streaming into the system. The station model for Mobile, Alabama, indicated wind from the south-southeast at 5 knots, visibility unrestricted, scattered clouds, temperature 67°F, dew point 66°F, and a sea level pressure of 1013.0 hPa. Multiple stations east and west of Mobile were indicating visibility restrictions in fog at the time. A review of the Low-level Significant Weather Prognostic Chart also indicated that the 12-hour forecast depicted an extensive area of IFR conditions expected over the Gulf coast region. National Weather Service (NWS) Forecast Discussion The NWS Area Forecast Discussion, issued at 1610, indicated the onset of dense fog along the coast spreading inland from the shore of Alabama to Northwest Florida through the evening and overnight hours. A dense fog advisory was in effect for coastal areas, including Mobile. The aviation section of the forecast indicated mostly IFR to low IFR (LIFR) ceilings and visibilities through the next morning, with widespread low stratus and fog. An updated forecast discussion was issued at 1840 indicated that ceilings and visibilities were expected to drop into the LIFR category overnight. Pilot Reports At 1644, a pilot flying at 15,000 ft msl about 40 sm southeast of the accident site reported coastal fog along the beach. Soundings An upper air sounding from the Slidell, Louisiana, NWS site, located about 85 sm west of the accident site, depicted a moist low-level environment with saturated conditions from 500 ft agl to 6,000 ft with a capping inversion. The freezing level was identified at 14,700 ft. The wind profile indicated calm surface wind with wind from the south-southeast veering to the southwest and west through 18,000 ft. A low-level wind maximum or low-level jet was identified near 5,000 ft at 215° at 25 knots, with winds less than 10 knots below 1,000 ft agl. Destination Airport Observations The automated observation at BFM at 1900 included wind from 160° at 6 knots, visibility 1/2 sm in fog, vertical visibility 200 ft agl, temperature and dew point 18°C, altimeter 29.94 inches of mercury (inHg). Diversion Airport Observations MOB, the flight's diversion airport, was equipped with an ASOS that was augmented by a certified observer. The following observations were reported surrounding the time of the accident: At 1856, wind from 130° at 6 knots, visibility 9 sm, a few clouds at 2,800 feet agl, ceiling broken at 6,000 ft, temperature and dew point 18°C, altimeter 29.93 inHg. At 1909, wind from 130° at 7 knots, visibility 1/2 sm in fog, vertical visibility 200 ft agl, temperature and dew point 18°C, altimeter 29.93 inHg. At 1956, wind from 140° at 7 knots, visibility 1/2 sm in fog,