WPR14FA127

The pilot’s failure to properly execute the missed approach in instrument conditions. Contributing to the accident were the pilot’s lack of instrument proficiency, as demonstrated by his failure to execute the required procedure turn to align with the final approach course and to configure the airplane for the approach, and his loss of situational awareness and the onset of spatial disorientation during the missed approach.

The commercial pilot was conducting a personal flight. The airplane was en route to the destination airport from the south and was cleared via the initial approach fix for the published GPS approach. The pilot reported that he had the weather at the airport, which was overcast at 3,000 ft above ground level. For all arrivals except from the west, the GPS approach diagram depicts a racetrack procedure turn at the initial approach fix (IAF) to align with the final approach course. The air traffic controller instructed the pilot to cross the IAF and then cleared him for the GPS approach into the airport. The airplane crossed the IAF and made a right turn to parallel the final approach course, which was not the required procedure turn, and the pilot did not slow the airplane's airspeed. The controller terminated radar services. The airplane then made a heading correction to intercept the final approach course but did not descend and continued to maintain its speed. The airplane remained northeast of the final approach course and 2,000 ft above the minimum descent altitude (MDA) all the way to the missed approach point. The pilot did not slow the airplane to an appropriate airspeed for the approach nor configure the airplane for landing. The pilot then announced that he had a missed approach to air traffic control (ATC) and made a left turn toward the depicted holding fix to the north. Instead of proceeding directly to the holding fix, the airplane continued its left turn for about 270 degrees and proceeded away from the fix. The pilot asked ATC for vectors to the holding fix. A controller replied that the airplane was below the minimum vectoring altitude and advised the pilot to proceed to the west toward lower terrain. The pilot stated that he was in instrument meteorological conditions and was picking up ice. Moments later, during the last minute of flight, the airplane entered a series of progressively lower altitude excursions southeast of the airport descending 1,300 ft, then climbing 700 ft, then descending 2,000 ft, then climbing 1,600 ft, and finally descending 1,300 ft and impacting terrain. The fact that the pilot did not execute the procedure turn after crossing the IAF, did not slow the airplane down, did not descend to the MDA, and did not climb to the required altitude or proceed in the direction of the holding fix after the missed approach point all indicate that the pilot had decreased situational awareness. Further, the final series of extreme altitude excursions are consistent with the pilot experiencing spatial disorientation. After the accident, the pilot could not recall the events leading up to the accident. He did state that he normally approached the airport from the west. In that case, a right turn at the IAF to directly align with the final approach course would be the normal procedure. The pilot had an iPad that contained the approach plate for the approach being flown, and the approach had been displayed on the device 30 minutes before the execution of the approach, but it was not displayed any time after that. The pilot stated that he normally used the panel-mounted GPS navigation system in the airplane to conduct instrument approaches and that he was using that system at the time of the accident. Pilot records show that the he had not performed the required six instrument approaches within the 6 calendar months preceding the flight; thus, he was not instrument current to operate as pilot-in-command under instrument flight rules conditions.

FAA-H-8083-15B – Instrument Flying Handbook The Instrument Flying Handbook describes the pilot's responsibility to execute a procedure turn to align with the final approach course unless either the airplane is being radar vectored to the final approach course, or the annotation "NoPT" (no procedure turn) is shown on the approach procedure for the segment being flown. "Holding in Lieu of Procedure Turn A holding pattern in lieu of a procedure turn may be specified for course reversal in some procedures. In such cases, the holding pattern is established over an intermediate fix (IF) or a FAF. The holding pattern distance or time specified in the profile view must be observed. Maximum holding airspeed limitations as set forth for all holding patterns apply. The holding pattern maneuver is completed when the aircraft is established on the inbound course after executing the appropriate entry. If cleared for the approach prior to returning to the holding fix and the aircraft is at the prescribed altitude, additional circuits of the holding pattern are neither necessary nor expected by ATC. If pilots elect to make additional circuits to lose excessive altitude or to become better established on course, it is their responsibility to advise ATC upon receipt of their approach clearance. When holding in lieu of a procedure turn, the holding pattern must be followed, except when RADAR VECTORING to the final approach course is provided or when NoPT is shown on the approach course." Air Traffic Controllers Handbook (JO 7110.65V), Chapter 4, section 8, paragraph e3. "For both RNAV and conventional approaches, intercept angles greater than 90 degrees may be used when a procedure turn, a hold-in-lieu of procedure turn pattern, or arrival holding is depicted and the pilot will execute the procedure. If a procedure turn, hold-in-lieu of procedure turn, or arrival holding pattern is depicted and the angle of intercept is 90 degrees or less, the aircraft must be instructed to conduct a straight-in approach if ATC does not want the pilot to execute a procedure turn or hold-in-lieu of procedure turn." Pilot Instrument Proficiency Requirements Part 61.57 – Recent flight experience – pilot in command "c) Instrument experience. Except as provided in paragraph (e) of this section, a person may act as pilot in command under IFR or weather conditions less than the minimums prescribed for VFR only if: (1) Use of an airplane, powered-lift, helicopter, or airship for maintaining instrument experience. Within the 6 calendar months preceding the month of the flight, that person performed and logged at least the following tasks and iterations in an airplane, powered-lift, helicopter, or airship, as appropriate, for the instrument rating privileges to be maintained in actual weather conditions, or under simulated conditions using a view-limiting device that involves having performed the following-- (i) Six instrument approaches. (ii) Holding procedures and tasks. (iii) Intercepting and tracking courses through the use of navigational electronic systems. (d) Instrument proficiency check. Except as provided in paragraph (e) of this section, a person who has failed to meet the instrument experience requirements of paragraph (c) for more than six calendar months may reestablish instrument currency only by completing an instrument proficiency check. The instrument proficiency check must consist of the areas of operation and instrument tasks required in the instrument rating practical test standards." Personal Electronic Device (iPad 2) An Apple iPad 2, serial number DMPGWPHDDKPH, personal electronic device was located in the cockpit by on-scene personnel. The iPad was retained by the NTSB IIC and sent to the NTSB Vehicle Recorders Laboratory for examination and nonvolatile memory download. Upon arrival at the Vehicle Recorder Laboratory, an exterior examination revealed that the iPad had sustained significant impact damage. An internal inspection was performed and no significant damage was observed to the internal circuitry. The damaged LCD2 and touchscreen digitizer were replaced with surrogate parts and the unit was charged, powered up in a Faraday cage, and placed in Airplane mode. Information stored on the device was captured by exploring aviation related Apps via touchscreen navigation. A download was also accomplished using industry standard forensic software. Several aviation and weather related Apps were found installed on the iPad, including: MyRadar, Aeroweather, AirNav, Duat, FlightAware, Weather, The Weather Channel, AccuWeather, and ForeFlight. Of these, only The Weather Channel and ForeFlight displayed flight related data when manually running the Apps while in Airplane Mode. The weather app displayed a screen showing current conditions at Carnelian Bay, California, with the message that this information had been updated more than 2 hours ago. ForeFlight contained several tabs for navigating through its various functions including: Airports, Maps, File & Brief, and Plates. Under the Airports tab ForeFlight displayed data for KSNA: John Wayne Airport-Orange County, in Santa Ana, California. Under the Maps tab ForeFlight displayed a VFR sectional chart with information specifying a route from KSNA5 to KTRK6 displayed in the summary bar. Under the Plates tab ForeFlight displayed three approach plates - KTRK: GPS RWY 19, KTRK: VOR/DME RNAV or GPS-A, and KSNA: RNAV (GPS) Y RWY 19R. Under the File & Brief tab ForeFlight displayed a message stating 'No flight plans'. The iPad contained approximately seventy images consistent with weather observation and flight planning activities. These images contained satellite and radar weather depictions, approach charts, and en-route maps. These images were all dated March 2, 2014, with time stamps ranging from 0640 PST to 1026 PST. The most recent five images contained thumbnails depicting three different approach plates - the KTRK: GPS RWY 19, the KTRK?: VOR/DME RNAV or GPS-A, and the KSNA: RNAV (GPS) Y RWY 19R. The second most recent image was a ForeFlight display of the VOR/DMA RNAV or GPS-A approach plate. This image was dated March 3, 2014 and time stamped 0943:28 PST. The most recent image depicted a single page from an e-book. This image was dated March 3, 2014, and time stamped 0957:10 PST. The forensic software creates a timeline of iPad activities based on known file creation date and timestamps. The last entry in the iPad timeline before the accident was dated March 3, 2014, and time stamped 0957:14. This entry corresponded with the creation of a log-file containing data consistent with an attempted Kindle7 synchronization event. Spatial Disorientation Advisory Circular 60-4A – Pilots Spatial Disorientation, addresses spatial disorientation as follows. "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is "up." The NWS Surface Analysis Chart for 1000 PST on March 3, 2014, chart depicted a high pressure system to the south of the accident site over the California and Nevada border at 1022-hectopascals (hPa) and another off the southern California coast at 1023-hPa. No frontal boundaries were identified over the region influencing California during the period. The National Center for Atmospheric Research (NCAR) - Research Application Laboratory (