WPR22FA004

Loss of control due to spatial disorientation.

The pilot was on a cross-country flight, receiving vectors for an instrument approach while in instrument meteorological conditions (IMC). The approach controller instructed the pilot to descend to 2,800 ft mean sea level (msl) until established on the localizer, and subsequently cleared the flight for the instrument landing system (ILS) approach to runway 28R, then circle to land on runway 23. About 1 minute later, the controller told the pilot that it looked like the airplane was drifting right of course and asked him if he was correcting back on course. The pilot responded “correcting, 22G.” About 9 seconds later, the pilot transmitted “SoCal, is 22G, VFR runway 23” to which the controller told the pilot that the airplane was not tracking on the localizer and subsequently canceled the approach clearance and instructed the pilot to climb and maintain 3,000 ft. As the pilot acknowledged the altitude assignment, the controller issued a low altitude alert, and provided the minimum vectoring altitude in the area. The pilot acknowledged the controller’s instructions shortly after. At this time, recorded advanced dependent surveillance-broadcast (ADS-B) data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. Over the course of the following 2 minutes, the controller issued multiple instructions for the pilot to climb to 4,000 ft, which the pilot acknowledged; however, ADS-B data showed that the airplane remained between 2,500 ft and 3,500 ft. The controller queried the pilot about his altitude and the pilot responded, “2,500 ft, 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb and reached a maximum altitude of 3,500 ft before it began a descending right turn. The airplane remained in the right descending turn at a descent rate of about 5,000 ft per minute until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. Recorded weather conditions at the pilot’s intended destination airport about 21 minutes before the accident showed that the cloud ceilings were broken at 2,127 ft msl, overcast at 3,227 ft msl. The closest weather reporting station to the accident site, which was about 1.8 miles south, showed a broken cloud layer at 3,086 ft msl. The airplane had undergone a conversion to modern avionics about 11 months before the accident. No reference to any additional training to the installed avionics was found within the provided pilot records. While the pilot had previous experience with other brands modern avionics, the investigation was unable to determine if the pilot had previous experience or training for the specific model of modern avionics installed in the airplane. The controller had cleared the flight to fly the ILS approach to runway 28R, circle to land on runway 23, and ADS-B track data showed that the airplane was about to be established on the localizer when it started to veer off course to the right, ultimately into an area with minimum vectoring altitudes that required the controller to issue instructions to the pilot to climb. During the divergence from the instrument approach, the airplane was at an altitude above the reported base of the broken cloud layer and below the base of the overcast layer at the destination airport, which most likely placed the airplane in and out of IMC conditions. Ultimately, the airplane climbed back into IMC conditions. It could not be determined if the pilot had inadvertently misconfigured the avionics for the instrument approach. Continuing the instrument approach would have afforded the pilot the opportunity to fly a stabilized approach in protected airspace and safely descend below the cloud layer prior to conducting the circle to land on runway 23. Given the airplane was maneuvering in IMC, it placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including the tightening descending turn, and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe and engines revealed no evidence of any preexisting anomalies that would have precluded normal operation. Therefore, it is likely that the pilot was experiencing the effects of spatial disorientation when the accident occurred.

An autopsy of the pilot was performed by the San Diego County Medical Examiner, San Diego, California, which listed the cause of death as “multiple blunt force injuries.” Autopsy evaluation for natural disease was extremely limited by the severity of injury. Toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. Maintenance records for the airplane showed that on November 6, 2020, the following avionics were installed: Garmin GI275, Garmin GFC600 autopilot, Garmin GTN 650, Garmin GTN 750 Xi, and a Garmin G500 TXi; at the time of installation the airplane had a HOBBS time of 2,629 hours. The most recent maintenance performed on the airplane was an oil change, conducted on August 5, 2021, at a HOBBS time of 2,734.5 hours. One of the pilot’s logbooks, which contained previous flight experience from May 4, 2018, to October 6, 2021, was provided during the investigation. The logbook showed that between November 13, 2018, and October 6, 2021, the pilot had logged 152.2 hours in the accident airplane, of which, 8.2 hours were in instrument meteorological conditions and included 48 instrument approaches. No reference to a circle to land maneuver following an instrument approach was located within the provided logbook. The pilot’s most recent flight review and instrument proficiency check was completed on August 27, 2021. The logbook entry indicated that the flight was 0.7 hours in length, and included 0.7 hours of dual instruction received, 2 instrument approaches, and 3 landings. No reference of specific training regarding the recent Garmin avionics that were recently installed in the accident airplane was observed within the provided logbook. However, a magazine article, dated November 2019, noted that the pilot had owned other airplanes that were equipped with a different brand of advanced avionics than those installed in the accident make/model airplane. On October 11, 2021, about 1214 Pacific daylight time, a Cessna 340A, N7022G, was destroyed when it was involved in an accident near Santee, California. The pilot and one person on the ground were fatally injured, and 2 people on the ground sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of audio recordings from Southern California Terminal Radar Approach Control facilities and recorded ADS-B data revealed that at 1203:58, the controller broadcasted a weather update for Montgomery-Gibbs Executive Airport (MYF), which included a report that visibility was 10 miles, ceiling 1,700 ft broken, overcast at 2,800 ft, and runway 23 was in use. At 1209:20, the controller issued instructions to the pilot to turn right to a 250° heading to join the final approach, which the pilot acknowledged, and ADS-B data showed the airplane at an altitude of 3,900 ft mean sea level (msl). About 28 seconds later, the pilot queried the controller if he was cleared for the ILS Runway 28R approach, with no response from the controller. At 1210:04, the controller told the pilot that he was 4 miles from the PENNY intersection and instructed him to descend to 2,800 ft until established on the localizer and cleared him for the ILS 28R approach before circling to land on runway 23, which the pilot partially read back. The controller reiterated the instruction to descend to 2,800 ft until the flight was established on the localizer, which the pilot acknowledged. At this time, the ADS-B data showed the airplane on a westerly heading at an altitude of 3,900 ft msl. At 1211:19, the controller advised the pilot of traffic at their 2 o’clock position, 3 miles, southbound, at 5,000 ft and descending to 4,000 ft; the traffic reported was a C130 that was restricted above them, and the controller provided a caution about wake turbulence, which the pilot acknowledged while at an altitude of 2,550 ft. Immediately following the pilot’s acknowledgement, the controller queried the pilot that it looked like he was drifting right of course and asked him if he was correcting, to which the pilot responded “I’m correcting, 22G.” At 1211:45, the pilot said “SoCal, is 22G, VFR runway 23” at which time ADS-B data showed the airplane at 2,175 ft msl. The controller told the pilot he was not tracking on the localizer and canceled the approach clearance, followed by issuing instructions to climb and maintain 3,000 ft, followed by the issuance of a low altitude alert; the controller stated that the minimum vectoring altitude in the area was 2,800 ft. The pilot acknowledged the controller’s instructions shortly after. At this time, ADS-B data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. At 1212:12, the controller instructed the pilot to climb and maintain 3,800 and the pilot responded “3,800, 22G.” ADS- B data showed that at this time the airplane was at 3,550 ft msl. About 9 seconds later, the controller issued the pilot instructions to turn right to 090° for vectors to final, to which the pilot responded “090 22G.” At 1212:54, the controller instructed the pilot to turn right to 090° and climb immediately and maintain 4,000 ft. The pilot replied shortly after and acknowledged the controller’s instructions. At this time, ADS-B data showed the airplane at an altitude of 2,500 ft msl, on a north-northeast heading. About 3 seconds after the pilot’s response, the controller told the pilot that it looked like he was descending and that he needed to make sure he was climbing, followed by an acknowledgment from the pilot. At 1213:35, the controller queried the pilot about his altitude; the pilot responded, “2,500 ft., 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb at 1213:39, from 2,550 ft msl. The airplane continued a climb ascent while turning from a northeasterly-easterly heading and reached a maximum altitude of 3,500 ft msl, where it remained for about 4 seconds before it began a descending right turn. The airplane remained in the right descending turn until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. Figure 1: ADS-B data with ATC communication points noted. Multiple witnesses located near the accident site reported hearing or seeing the accident airplane in a right-wing-low descent. One witness, who held a private pilot certificate, reported that he heard the engines for about 3 seconds, and that they sounded like they were at a high-power setting, or “over-revving.” The witness also noted that at the time of the accident there was an overcast cloud layer about 1,900 ft msl. One witness, who was flying a helicopter, reported that while they were inbound for Gillespie Airport (SEE), El Cajon, California, they were informed by the tower controller about an airplane eastbound, 1,100 ft above their altitude. The witness stated they obtained visual contact with the airplane, and saw it make an initial descent of a “few hundred feet” followed by a rapid nose-down descent in a right-wing-low attitude. Examination of the accident site revealed that the airplane impacted a residential street on a heading of about 113° magnetic. The debris path, which consisted of various airplane, vehicle, and residential structure debris, was about 475 ft long and 400 ft wide, oriented on a heading of about 132°. Numerous residential structures exhibited impact related damage and or fire damage. Figure 3: Annotations of wreckage locations. Aerial photo provided by San Diego County Sheriff. The first identified point of contact (FIPC) was a gouge in the asphalt road about 10 inches long and 5 inches wide. Scrape marks extended from about 18 ft from the FIPC to a