ERA18FA167

A loss of control due to spatial disorientation while climbing after departure in instrument meteorological conditions. Contributing to the accident was the pilot's lack of recent instrument experience.

The private pilot, who was not instrument current, and a passenger departed on an instrument flight rules flight into instrument meteorological conditions. After takeoff, the pilot did not climb to the clearance altitude of 2,000 ft mean sea level (msl), instead leveled off about 500 ft msl. The pilot then began a second climb to a maximum altitude of 1,400 ft, then leveled off, followed by a steep right descending turn to about the base of the clouds about 400 ft. The airplane then began a climb to 1,700 ft msl while the airspeed decreased. While flying in a right bank near the published wings-level, 1-g stall speed, the airplane likely exceeded its critical angle of attack, stalled, and entered a descent. A witness reported hearing a loud engine sound from the low-flying airplane, and last observed the airplane in a slight left bank, although the airplane impacted the ground in a nose and right-wing low attitude. Examination of the flight controls, engines, engine systems, and propellers revealed no evidence of preimpact failure or malfunction. While postaccident acceptance testing of autopilot components revealed minor out-of-tolerance conditions, the conditions noted would not have adversely affected proper operation. Although the presence of moisture in the static system could not be ruled out because the static system was destroyed, it is unlikely that was an issue because the ADS-B data for pressure altitude and geometric altitude calculated by the GPS revealed no gross difference. The restricted visibility, maneuvering during the transition from takeoff to cruise flight, and the pilot's lack of instrument proficiency provided conditions conducive to the development of spatial disorientation. The airplane's altitude and track variations were inconsistent with its takeoff and departure clearance and the high velocity impact are consistent with the known effects of spatial disorientation. Therefore, it is likely that the pilot became spatially disoriented while flying in instrument meteorological conditions and lost control of the airplane. Contributing to the loss of control was the pilot's lack of recent instrument experience.

The pilot's most recent flight review and instrument proficiency check (IPC) were performed in the accident airplane on October 7, 2017. Between November 17, 2012, and the last logged flight on June 1, 2018, he recorded about 4.0 hours simulated instrument experience. He recorded three instrument approaches and 1.0 hour of actual instrument flight time in the 6 months before the accident. Further review of the pilot's logbooks revealed that, prior to his last recorded actual instrument flight on June 1, his previous logged actual instrument flight occurred on November 27, 2017. He logged 1.0 hour in actual instrument conditions in the accident airplane, but he did not log any instrument approaches. His next previous instrument experience occurred the same day as the IPC. He logged 1.0 hour actual instrument flight in the accident airplane, but no instrument approaches. According to the flight instructor who performed the pilot's last flight review and IPC, the flight duration for the flight review was about 1.8 hours, and the flight duration for the IPC was about 1.7 hours. Both flights, and about 8.0 hours of ground instruction, were conducted through Bonanza/Baron Pilot Training Inc. The instructor also stated that the pilot executed eight instrument approaches and holding procedures, but did not perform "partial panel," or procedures for the loss of primary flight instruments, contrary to IPC guidance published by the Federal Aviation Administration (FAA). The instructor described the pilot as competent. The pilot's relatives reported that he was in excellent health and exercised daily. They also reported that he was a "by the book" pilot. According to documents provided by Angel Flight East, since November 19, 2013, the pilot had been assigned 18 flights, of which one was cancelled due to a mechanical reason, and one was canceled due to weather. Postmortem examination of the pilot was performed by the Burlington County Medical Examiner's Office, Westampton, New Jersey. The cause of death reported as "multiple injuries." Forensic toxicology of specimens of the pilot was performed by the FAA Forensic Sciences Laboratory and also by NMS Labs, located in Willow Grove, Pennsylvania. According to FAA's toxicology report, cyanide testing was not performed, and the results were negative for carbon monoxide, volatiles, and tested drugs. According to the report by NMS Labs, there were no positive findings reported for any drugs tested. The airplane was equipped with a Bendix/King KFC-200 three-axis autopilot flight control system. The autopilot system installation included an autopilot annunciator panel. Following the accident, the annunciator panel was sent to the NTSB Materials Laboratory for examination, which revealed that only the bulb filament for HDG (heading) was stretched. The airplane's static system provided static air for the rate-of-climb indicator, altimeter, and airspeed indicator. Static air was taken from two static ports, one located on each side of the aft fuselage. The installed emergency static air valve was designed to provide a source of emergency static air from the cockpit, and also to drain the static air plumbing, which was required to be drained as part of the preflight inspection. Review of the maintenance records revealed that a transponder test and the altimeter, pitot-static and altitude system reporting system checks were last performed on August 16, 2016. Further review of the maintenance records revealed that the airplane's most recent annual inspection was completed on February 3, 2018, at an airplane total time of 2,044.1 hours. The engines and propellers were inspected on that same date in accordance with a 100-hour inspection. On that date, both engines and propellers had accrued 392.1 hours and 731.7 hours, respectively, since major overhaul. The last entry in the aircraft maintenance records dated June 1, 2018, reflected the hour meter reading was 2,059.0. The airplane was equipped with a Garmin GNS-530W GPS unit, which was sent to the NTSB Vehicle Recorder's Laboratory to obtain non-volatile memory. A portion of the unit would not power up; therefore, no data were recovered. The airplane was fueled on June 12, 2018, at VAY, with 36.0 gallons of 100 low lead fuel. According to the person who fueled the airplane, he filled the fuel tanks to the tabs; this would have resulted in 166 gallons of usable fuel. On June 13, 2018, about 0907 eastern daylight time, a Beech 58, N218BL, was destroyed when it was involved in an accident near Springfield Township, New Jersey. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The purpose of the flight was to pick up a patient and their spouse for a volunteer medical transport flight from Barnstable Municipal Airport-Boardman/Polando Field (HYA), Hyannis, Massachusetts, to Northeast Philadelphia Airport, (PNE), Philadelphia, Pennsylvania. According to a transcript of communications with the United States Air Force (USAF) McGuire Field (Joint Base McGuire Dix Lakehurst) Airport (WRI) radar approach control, about 0858, an occupant onboard the accident airplane contacted clearance delivery and was issued an amended instrument flight rules (IFR) clearance to HYA, which included the requirement to climb and maintain 2,000 ft after takeoff from South Jersey Regional Airport (VAY), Mount Holly, New Jersey. (It could not be determined if the pilot or the pilot-rated passenger was operating the radios.) At 0859:43, the controller asked if the flight was ready to depart, and an occupant responded that they were. About 0900, a military aircraft about 12 nautical miles east-northeast of VAY reported that the cloud bases were about 300 ft, then about 30 seconds later, reported being on top of the first cloud layer about 2,500 ft mean sea level (msl). The flight was released for departure about 0901, and at 0903:48, VAY security video captured the airplane departing from runway 8. ADS-B data captured the airplane beginning at 0903:56 as the airplane climbed through 150 ft msl. The flight proceeded about runway heading while climbing about 105 knots (best rate of climb), then turned left onto a north-northeasterly heading, climbing to about 500 ft msl. The climb stopped about 0904:24, and the airplane descended and began accelerating. About 0904:32, while flying on a north-northeasterly heading, an occupant advised the controller that the flight was, "…through five hundred for two thousand"; ADS-B data depicted the airplane at 465 ft msl at this time. The flight continued on the north-northeasterly heading until about 0904:56, then turned to the right and proceeded on a northeasterly heading. Although the early portion of the observed ground track was consistent with the departure instructions, the altitude profile was not. At 0905:10, a second climb was initiated, and according to the transcript, at 0905:21, while flying about 1,100 ft msl, the controller asked the pilot what the ceiling base was, and an occupant asked the controller to repeat the question. The controller immediately repeated "say bases," but the occupants did not reply. At 0905:55, the airplane leveled at 1,400 ft msl, contrary to the departure instructions, and about 5 seconds later, the controller asked the pilot to state flight conditions at departure and the reply was "IFR." The airplane at that time was in a level climb attitude, about 150 knots, in a 10° right bank. During the next 20 seconds, the airplane began a right descending turn with the bank angle increasing to greater than 80°. At 0906:25, at an altitude below 500 ft msl, the controller broadcast the call sign of the airplane. The transmission from the airplane was not clear, but sounded like "copy." There were no further transmissions from the airplane despite repeated attempts by the controller. At 0906:27