ERA23FA006

The pilot’s loss of situational awareness, which resulted in an unstabilized approach, descent below published minimum altitudes, and collision with terrain.

The pilot and passenger departed on an instrument flight rules (IFR) cross-country flight to the pilot’s home airport at the conclusion of a business trip. Weather radar imagery superimposed over the airplane’s flight track indicated that the airplane was flying toward an area of light intensity echoes associated with light rain to drizzle and instrument meteorological conditions as it approached the area of the destination airport. An AIRMET advisory for these conditions, as well as low-level turbulence, was valid for the accident time. The pilot confirmed to the controller that he had obtained the most recent weather information at the destination and requested the RNAV (GPS) instrument approach procedure. The nearest airport with recorded weather observations, about 11 nautical miles west of the destination airport, reported 2.5 miles visibility, a broken cloud ceiling at 700 ft above ground level (agl), and an overcast ceiling at 1,000 ft agl about the time of the accident. When provided vectors to the final approach course, and when issued his approach clearance, the pilot’s acknowledgements and read-backs of controller instructions were delayed by several seconds and incomplete. Automatic dependent surveillance – broadcast (ADS-B) track data indicated that the airplane flew through, then turned left toward, the final approach course. About 30 seconds after crossing the initial approach fix, about 200 ft below the minimum altitude, the controller issued the pilot a frequency change and provided a phone number through which to cancel his IFR clearance once on the ground. As the airplane proceeded parallel to and east of the final approach course, it continued to descend, and remained consistently hundreds of feet below the minimum published altitude for each respective segment of the approach. The airplane passed the final approach fix 750 ft below the minimum altitude at 58 knots groundspeed. The airplane continued to descend over the next .75 miles at a ground speed about 60 kts before the data ended in the vicinity of the accident site. Several witnesses below the airplane’s flight path reported hearing the airplane, but stated that they could not see the airplane due to the low clouds, rain, and fog at the time of the accident. Their descriptions of the engine sound varied from “not normal” to “didn’t sound healthy” to sounding “…usual, just lower and louder.” Examination of the accident site revealed severed tree trunks with clean, angular cuts, consistent with the engine producing power at the time of impact. Examination of the wreckage, as well as an engine test run, revealed no pre-impact mechanical anomalies that would have precluded normal operation. About 8 months before the accident, the airplane was equipped with dual electronic flight instruments that functioned as the primary attitude indicator and directional gyro. These instruments were integrated with the airplane’s existing autopilot system. Review of the pilot’s logbook indicated that, after receiving about 2 hours of dual instruction, he had flown the airplane about 34 hours since the installation of the avionics, of which 7 hours was recorded as actual IFR. The instrument meteorological conditions the pilot encountered during the approach to the destination airport would have resulted in a loss of outside visual references, requiring the pilot to rely on the flight instruments to maintain his intended course, altitude, and airspeed. The instrument conditions, likely turbulence, and increased workload imposed by beginning the approach phase of the flight presented a situation that was conducive to the development of spatial disorientation and a loss of situational awareness. Given that the pilot maintained a position east of the final approach course for most of the approach and far below the minimum published altitude throughout the approach, it is likely that he had lost situational awareness of the airplane’s position. No information was available to determine the modes or settings of the avionics and/or autopilot during the approach. Whether the pilot’s familiarity with the relatively new avionics and their interface with the autopilot contributed to the accident could not be determined based on the available information.

The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His Federal Aviation Administration (FAA) third-class medical certificate was issued August 2, 2021. Examination of the pilot’s most recent logbook revealed that he had accrued 2,514 total hours of flight experience, of which 977 hours were in the accident airplane make and model. The pilot completed a flight review on February 22, 2021. According to FAA and maintenance records, the airplane was manufactured in 1991 and was powered by a Continental IO-550-B, 300-horsepower engine. The airplane’s most recent annual inspection was completed November 1, 2021, at 3,953.2 total aircraft hours. Airworthiness documentation indicated that dual Garmin GI 275 electronic flight instruments (Attitude/Attitude Direction Indicator) were installed in the airplane on February 4, 2022. (See figure 3.) The FAA Form 337 filed for the installation stated, “Installed Dual Garmin GI275 with internal ADAHARS as Directional Gyro and GI275 with Autopilot interface as Attitude Indicator, and GI275 as Copilot ADI…per STC SA02658SE.” According to a flight instructor who flew with the pilot following installation of the GI275s, the system installed in the accident airplane integrated with the airplane’s S-TEC 55X autopilot. The pilot logged 33.8 hours of experience in the accident airplane between the installation of the Garmin GI 275 displays and the accident flight, of which 7.2 hours was in actual instrument meteorological conditions. He logged 2 hours of dual flight instruction received on February 28, 2022. In the notes section, he annotated “familiarization” with the new avionics, two RNAV approaches flown, and a “go around” performed. There were no further dual-instruction-received entries annotated. Figure 3 – Garmin GI 275 Attitude Indicator [AI/ADI] (Garmin.com) The Maine State Medical Examiner, Augusta, Maine, performed an autopsy of the pilot and determined the cause of death as "blunt force injuries." The FAA Forensic Sciences Laboratory performed toxicological testing on the pilot. Test results were negative for the presence of illegal drugs, contraindicated drugs, and alcohol. Local emergency services personnel located the airplane’s fuselage in hilly, wooded terrain about 1 hour after the accident, and the wreckage was examined at the accident site the following day. The initial impact point was in a tree about 40 ft above the ground. The wreckage path was oriented 050° and was about 150 ft in length; all major components of the airplane were accounted for at the scene. The fuselage came to rest upright with the engine and propeller still attached. The propeller blades displayed similar twisting, bending, and chordwise scratching. The cockpit, cabin area, and nearly all the empennage, were consumed by a post-crash fire. The avionics were destroyed, and no information was available to determine the modes or settings of the avionics and/or autopilot during the approach. The tail section remained largely intact. The wings displayed impact damage consistent with collision with trees and terrain. Flight control cable continuity was confirmed from the cockpit to the flight control surfaces through several breaks consistent with impact and thermal damage. The engine was separated from the airframe. The propeller was rotated by hand and continuity was established through the powertrain to the valvetrain and the accessory section. Compression was attained using the thumb method. The magnetos were secure in their mounts and produced spark at all terminal leads when the crankshaft was rotated. The engine was examined, and a test run was performed at the manufacturer’s facility. The throttle body was not shipped with the engine from the recovery facility, so an exemplar throttle body was attached to the engine for the engine run. The engine-driven fuel pump remained attached to the engine and exhibited thermal damage. The fuel pump was removed, and bench tested for functionality. The pump operated on the test bench and was reinstalled on the engine before the test run was conducted. The damaged propeller was removed, and a club prop was installed for use in the test cell. The following items were removed from the engine to facilitate an engine run: • The alternator was impact damaged, removed, and a plate installed where the alternator attached to the engine. • The engine baffling was removed. • The starter exhibited thermal damage and was removed and replaced by an exemplar unit. • The ignition harness exhibited damage and was replaced with an exemplar unit. • All the air intakes on the engine were impact damaged, these were removed and replaced with exemplar intakes. • The oil filter exhibited thermal damage and was replaced with an exemplar filter. • The exhaust was impact damaged and replaced with straight pipe exhaust. • The propeller governor was removed and replaced with a test cell plate. • The tachometer drive was removed, and the opening covered with a plate. • The vacuum pump was not shipped with the engine and the position on the crankcase was plated over. • The pushrod and pushrod housing for the No. 5 cylinder exhaust valve were impact damaged and replaced with exemplar units. The oil cooler leaked at engine start due to impact damage and was replaced with an exemplar unit. An engine test run was then performed, and the engine accelerated smoothly from idle to a maximum of about 2,550 rpm (maximum-rated output was 2,700 rpm) with the throttle fully open. During the engine test run, the engine idled at about 500 rpm. The engine was then accelerated to 1,800 rpm and ran smoothly at that power setting for about 3 minutes. It was then advanced to about 2,100 rpm, which would be consistent with a power setting used for an instrument approach procedure. The engine ran smoothly at that power setting for about 4 minutes. The engine ran at maximum rpm for about 3 minutes. A magneto check was performed at 2,100 rpm; when switched to only the left magneto, a loss of 124 rpm was observed. When switched to only the right magneto, a loss of 135 rpm was observed. During the test run, the No. 6 cylinder exhaust gas temperature (EGT) was "low," possibly due to an inoperative test cell EGT probe. The cylinder head temperature was on the "low side" of the normal operating range. The fuel flow rate was low at full throttle, which was consistent with the lower rpm achieved at that power setting. The altitude-compensating engine-driven fuel pump was disassembled; the aneroid bellows were punctured by impact damage and therefore fully expanded, which was consistent with the low fuel flow. On October 5, 2022, about 1356 eastern daylight time, a Beech A36, N902AT, was destroyed when it was involved in an accident near Arundel, Maine. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. According to a family member and officer of the pilot’s construction company, the pilot and passenger were returning from a business trip to Presque Isle, Maine. Automatic dependent surveillance - broadcast (ADS-B) data revealed that the airplane departed Presque Isle International Airport (PQI) about 1220 for Biddeford Municipal Airport (B19), Biddeford, Maine, on an instrument flight rules (IFR) flight plan. Weather radar imagery superimposed over the airplane’s flight track indicated that the airplane was flying toward an area of light intensity echoes associated with light rain to drizzle and instrument meteorological conditions as it approached the area of the destination airport. An AIRMET for these conditions and low-level turbulence was valid for the accident time. Air traffic control communication information revealed that, at 1340:03, the controller instructed the pilot to descend and maintain 3,