A newly minted instrument rating couldn’t keep this pilot out of the weeds. Did a medical condition contribute?


License to learn” is the description often given to a freshly earned certificate or rating. The phrase describes a pilot’s new ability to get into conditions for which he or she has been trained but lack experience. Most of the time, we don’t read about what happened on a pilot’s first few forays with a new piece of paper. It’s a good idea if the first few flights during which we exercise our new certification are over familiar territory in relative benign conditions. The aircraft should be in good condition, as should the pilot.

But that’s apparently not what happened in the events leading up to this month’s Accident Probe. Although the pilot had a fresh instrument rating and a handful of hours at night, he had no experience in night IMC. He also had a medical condition that may have contributed to the flight’s outcome.

On April 22, 2011, at about 2146 Eastern time, a Cessna 210D Centurion was substantially damaged following a collision with terrain at Altavista, Va. The solo, instrument-rated private pilot was fatally injured. Night instrument conditions prevailed; an IFR flight plan was in effect. The flight originated from the Winchester (Va.) Regional Airport about 1956.

The pilot’s first airborne check in with the Potomac Terminal Approach Control (Tracon) was at 1958. By 2013, a controller with Washington Center commented to Potomac Tracon, “…he was on like a two seventy heading and I asked him where he was going and he told me direct Lynchburg so I would keep an eye on him.” At 2020, the pilot radioed ATC he was, “just a little disoriented here.” That proved to be an understatement.

Almost an hour later, at 2115, and after receiving vectors for the ILS Runway 4 approach at Lynchburg, Va., the flight executed a missed approach. That approach was aborted by ATC, which showed the airplane “well right of course.” At 2124, the first of at least two low-altitude alerts was issued. At 2136, the pilot reported “complete gyro failure” and requested assistance. Controllers began providing no-gyro vectors.

By 2144, ATC informed the pilot that Washington Center and Greensboro Approach were looking for airports with more favorable weather conditions, and that any approach into Lynchburg was available. At 2146, ATC issued another low-altitude alert, directing an immediate climb to 2800 feet. There was no response; radar and radio contact were lost.

Recorded data revealed the last radar return depicted the Cessna at 1100 feet msl. The radar track was consistent with a right, descending spiral. A review of the last 15 minutes of radar data revealed that, prior to the last descending spiral, the airplane was continuously turning to the left and right, varying in altitude between 5900 and 1600 feet.

A witness reported the airplane initially made two circles over her house, and the engine was popping and sputtering. She then heard the airplane going toward the airport, and thought it had landed. The airplane then returned at a higher altitude. She heard the engine cut out, and then cut back on. The airplane made a “weird whining sound,” and a few seconds later she heard a “boom” and knew the airplane had crashed.
The airplane collided with terrain after severing an 11-inch-thick tree trunk about 50 feet from the ground. The fuselage and empennage came to rest against a shear vertical rock face. The wreckage path was oriented on a heading of about 040 degrees. There was no evidence of fire and all flight control surfaces were accounted for at the accident site.

Flight control continuity could not be determined. However, flight control cables exhibited stretching and overload breaks consistent with impact forces. Both wings and the horizontal stabilizers were separated from the fuselage; the vertical stabilizer remained attached. The flaps and landing gear were retracted.

Damage to the airframe and engine was extensive. The top and bottom spark plugs in three cylinders exhibited normal operation signatures but neither cylinder compression nor valve-train continuity could be evaluated. The mixture control screen was free and clear of debris or contaminates, as was the fuel manifold screen. Both propeller blades exhibited damage consistent with the engine producing power at impact.

An engine/systems monitor was installed and working during the accident flight. Its retrieved data did not indicate any anomalies with the engine, vacuum system or electrical system. The turn and bank indicator’s gyro was disassembled, revealing light rotational marks on the exterior of the non-rotating stator and on the interior of the rotor consistent with normal operation.

The pilot had obtained his instrument rating approximately seven weeks earlier. Within 10 days of the accident flight, he had recorded about 295 hours total flight time in his logbook, including 22.9 hours of night time. However, he had no logged experience in night, instrument conditions. Observed weather at Lynchburg included winds from 030 degrees at three knots, an overcast ceiling at 600 feet and three miles’ visibility in mist.

The pilot’s FAA medical records reveal he was granted a special-issuance certificate due to insulin-dependent diabetes. As a condition of that certificate, he was required to use a glucose-measuring device before, during and after any flight. No evidence of such a device was present at the accident site. Toxicology testing for carbon monoxide was not performed because of unsuitable specimens.

Probable Cause
The NTSB determined the probable cause(s) of this accident to include: “The pilot’s loss of airplane control due to spatial disorientation. Contributing to the accident was the pilot’s lack of experience in actual night instrument conditions.”

Clearly, this pilot experienced significant difficulties controlling his airplane. Although he reported failed flight instruments to ATC, no evidence of such a failure was found. It’s more likely his disorientation resulted from a medical condition, perhaps associated with his diabetes. Although hypoxia is unlikely, given the altitudes at which he was flying, it’s unfortunate tests for carbon monoxide poisoning could not be performed.

But whatever the source of his disorientation, the outcome likely would have been different if he had chosen different conditions in which to make one of his first flights after earning the instrument rating.




Please enter your comment!
Please enter your name here