ERA24FA323

The pilot’s aggressive pitch and power control inputs while executing a missed approach, which resulted in his spatial disorientation and a loss of airplane control.

The pilot received a weather briefing package from a commercial service when he filed his instrument flight rules (IFR) flight plan before departing on the accident flight. The weather briefing information the pilot received included forecasts and AIRMETs for low IFR (LIFR) conditions at the destination airport during the planned time of arrival (LIFR, refers to a cloud ceiling below 500 ft above ground level [agl] and/or visibility less than 1 mile). Reported conditions at the destination airport about 31 minutes before the accident included visibility of 1.5 miles in light rain and mist and an overcast ceiling at 300 ft agl. As the flight neared the destination airport, an air traffic controller provided the pilot with a radar vector, cleared the flight for an instrument landing system (ILS) approach. The ILS approach specified a minimum visibility of 3/4 mile and a decision height of 200 ft agl, or 283 ft mean seal level (msl). A review of flight data parameters downloaded from the airplane’s recoverable data module (RDM) revealed that the airplane’s autopilot was engaged for nearly the entire flight, from shortly after takeoff to about 17 seconds before the accident. The data showed that, after the controller cleared the flight for the approach, the airplane turned to the assigned heading vector, then it turned to a heading consistent with the final approach segment and began a descent toward the runway. When the airplane was about 200 ft msl (or about 117 ft agl) and about 0.4 nautical mile (nm) from the runway threshold with the flaps fully down, the autopilot was disengaged. The airplane’s pitch angle then increased rapidly to about 30° nose-up, its vertical ascent rate reached about 2,350 ft per minute (fpm), its flaps were reduced to 50%, and it climbed to about 450 ft msl, where it remained for about 2 seconds before it began to descend. The airplane then transitioned to an extreme nose-down pitch and extreme left-bank roll while its engine power increased. It briefly rolled back toward wings-level before again entering a left-bank roll, and its descent rate increased to about 4,000 fpm before the data ended. A witness outside at the airport stated that he heard the airplane’s engine noise go to full power, and, when he looked up, he saw the airplane in a sharp left turn before it descended to the ground. He stated that the weather conditions were “brutal” and that he could barely see the airplane at 200 yards away due to the thick fog. A witness who was driving a car near the airport captured video of the airplane in an uncontrolled descent, coming into view as it descended below a low cloud/fog layer. The airframe was largely consumed by a postimpact fire that precluded a detailed examination of flight control continuity; however, all major components of the airplane were identified. Examination of the identified airframe components and the engine revealed no evidence of any preimpact malfunction, and a review of engine data parameters recovered from the RDM revealed that the engine operated normally throughout the flight. The autopsy of the pilot indicated cardiovascular disease that could be associated with increased risk of an impairing or incapacitating cardiovascular event such as heart attack or stroke. Although such an event cannot be excluded by autopsy evidence alone, there is no evidence that such an event occurred. Postmortem toxicology testing detected the opioid codeine, the codeine metabolite morphine, and thebaine. The presence of thebaine is not explained by pharmaceutical codeine use and likely indicates poppyseed consumption. It is possible that the measured codeine and morphine levels might be attributable to poppyseed consumption alone, although the possibility that codeine was also used cannot be excluded. Regardless, the codeine concentration in postmortem heart blood was low, and no morphine was detected in blood. As such, there is no clear evidence that the pilot was impaired by opioid effects at the time of the accident. Overall, there is no clear indication from reviewed evidence that the pilot was significantly impaired by effects of medical conditions or medications, but this possibility cannot be excluded given his identified risk factors for impairment. The pilot’s logbooks were not recovered, so his total or recent experience flying in instrument meteorological conditions (IMC) was not known. Based on the available weather information, it is likely that the airplane was in IMC as the pilot descended on autopilot below the ILS approach decision height. The pilot’s subsequent actions while hand-flying the airplane, which included increasing the airplane’s pitch, reducing the flaps, and increasing engine power, were consistent with the initiation of a missed approach. Although vestibular illusions are commonly experienced by pilots during maneuvering flight in IMC, the accident pilot’s aggressive pitch control inputs while executing the missed approach likely intensified such vestibular illusions, increasing the likelihood of his experiencing spatial disorientation. The airplane’s subsequent extreme nose-down pitch and extreme left roll were consistent with the pilot’s loss of airplane control due to spatial disorientation.

On July 25, 2024, about 1227 eastern daylight time, a Cirrus Design Corp SR22 airplane, N990PT, was destroyed when it was involved in an accident near Trenton, Maine. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to FAA air traffic control information, the flight departed Morristown Municipal Airport (MMU), Morristown, New Jersey, at 1016 destined for Hancock County/Bar Harbor Airport (BHB), Bar Harbor, Maine. A review of an air traffic control recording from the FAA Bangor Approach Control facility revealed that, about 1220, an air traffic controller advised the pilot that the flight was about 5 nm from the final approach fix for the ILS runway 22 approach at BHB, provided the pilot with a radar vector, cleared the flight for the ILS runway 22 approach, and advised the pilot to maintain an altitude of 3,000 ft msl until established on the approach. The controller also advised the pilot that he could cancel his IFR flight plan once on the ground, approved the change to the BHB common traffic advisory frequency, and advised the pilot that, in the event he needed to execute a missed approach, the controller would talk to him on the current frequency. According to the published instrument approach procedure for the ILS runway 22 approach, the decision height was 200 ft agl (283 ft msl), and the minimum visibility was 3/4 mile. The missed approach procedure specified a straight ahead climb to 2,000 ft msl, then a right turn and climb to 4,000 ft msl to the designated missed approach fix. A review of flight track and data parameters recovered from the airplane’s Appareo RDM-300 revealed that the airplane’s autopilot was engaged shortly after takeoff and remained engaged until the final 17 seconds of the flight. After the controller provided the pilot with the approach clearance, the airplane’s flight track turned to the assigned heading then turned to a heading consistent with the final approach course. About 1222, the airplane was descending from about 2,000 ft msl with 50% flaps on a consistent heading toward runway 22; full flaps were applied about 1222:55. The data showed that, about 1226:46, the airplane’s autopilot was disengaged. At the time, the airplane had descended to an altitude of about 200 ft msl while about 0.4-mile from the runway 22 threshold. During the next 8 seconds, the airplane’s pitch angle increased to about 30° nose-up, its vertical ascent rate reached about 2,350 fpm as it climbed on the runway heading, and the flaps were reduced to 50%. By 1226:56, the airplane’s altitude reached about 450 ft msl, where it remained for about 2 seconds. Between 1226:56 and 1227:00, the airplane’s pitch angle rapidly decreased to about 25° nose-down, its left bank angle reached a maximum of about 68° before rolling back toward wings-level, and its engine power increased from about 35% to about 80%; during this time, the airplane reached a vertical descent rate of about 2,800 fpm, and its altitude decreased to about 300 ft msl. By the time the data ended at 1227:03, the airplane again entered a left bank, and its descent rate was about 4,000 fpm. A witness at BHB who was outside working on the approach lighting at the end of runway 22 stated he heard an airplane approaching for landing. He heard the airplane’s engine noise go to full power, and, when he looked up, he saw the airplane in a sharp left turn then “fall to the ground.” He further described that the weather conditions were “brutal” and that he could barely see the airplane at 200 yards away due to the thick fog. Video recorded by a witness in a moving car showed the airplane in an uncontrolled descent, coming into view as it descended below a low cloud/fog layer. It was visible at the approach end of runway 22 in a steep, descending turn to the left before impacting the ground and erupting into a postcrash fire. The pilot’s logbooks were not recovered. During the pilot’s last medical examination dated March 22, 2023, he documented that he had 4,384 hours of total flight experience. He also reported that his medical history included gout. He reported using the medications febuxostat (a prescription medication that may be used in the treatment of gout) and tamsulosin (a prescription medication that may be used to treat symptoms of a large prostate). He was issued a third-class medical certificate with the limitation to use corrective lenses to meet vision standards at all distances. The airplane’s maintenance logbooks were not recovered. BHB was equipped with an Automated Weather Observing System, and the reported conditions at 1156 included visibility of 1.5 miles in light rain and mist, an overcast ceiling at 300 ft agl, temperature of 17°C, and dew point of 17°C. All reported observations between 0956 and 1256 included overcast ceilings between 100 ft and 300 ft agl. The pilot had a ForeFlight account through which he filed his IFR flight plan and requested and received a weather briefing package at 0535. The weather forecast information applicable for the accident location and time included text and graphical AIRMETs for IFR conditions due to precipitation and mist. Graphical Forecasts for Aviation products applicable for the accident location at 1100 and 1400 indicated overcast cloud cover with cloud bases to 300 ft msl and could tops between 12,000 ft and 24,000 ft msl. The TAF for BHB valid at 0535 forecast a ceiling of 300 ft agl for the intended arrival time at the destination airport. A TAF issued at 1100 forecast an overcast ceiling at 100 ft agl for the intended arrival time. The wreckage was located about 600 ft to the left of the approach end of runway 22 on top of the airport perimeter fence. The airplane came to rest in a wooded area and was oriented on a magnetic heading of 040°. The airframe was largely consumed by a postimpact fire. All major components of the airplane were accounted for within the compact wreckage area. The flap actuator jackscrew was found extended 2.75 inches, consistent with a “Flaps 50%” position. The engine was thermally damaged. The fuel pump was removed, and the shaft was intact but stiff to rotate consistent with the effects of the thermal damage. The fuel flow divider was intact, but the diaphragm was destroyed by fire. The fuel injectors were thermally damaged, and injectors for cylinder Nos. 1 and 5 contained some obstructions. The magnetos were thermally damaged, and, when the magneto input drives were rotated by hand, no spark was produced on any leads. The top spark plugs were removed, and all were clean and clear of debris. The engine’s crankshaft rotated smoothly when turned by hand at the propeller, and compression was observed on all cylinders except No. 3. The No. 3 cylinder was impact damaged, and the rocker arm covers were crushed into the push rods. A review of engine parameter data recovered from the airplane’s Appareo RDM-300 revealed that the engine was running normally during the entire flight. According to the Office of Chief Medical Examiner, State of Maine, autopsy report, the cause of death for the pilot was multiple injuries. The pilot’s autopsy identified evidence of hypertensive and atherosclerotic cardiovascular disease, including an enlarged heart with a thickened left ventricle, and 50% narrowing of the left main coronary artery and left anterior descending coronary artery by plaque, with a left-dominant coronary circulation, and focal areas of fibrosis of the heart muscle (scarring of the type that may be seen from old heart attack) in the posterior left ventricle and papillary muscles. Prominent fat streaking of the aorta and focal plaques in the arteries at the base of the brain also were present, as were kidney tissue changes of the type that may be seen with chronic high blood pressure. The aortic valve leaflets were calcified. The liver was cirr