Safety Pilot: Missed approach mishap

Lack of real-world IFR experience?

October 1, 2012

Bruce Landsberg

An alternative meaning for IFR is “It’s For Real,” reminding us that the cloudy environment is less forgiving than the visual. In January 2011 a 62-year-old pilot was practicing instrument approaches in a 2004 Cessna 172S at Myrtle Beach Airport in South Carolina. The reported weather included light winds, a 600-foot overcast, and four-mile visibility in mist with a one-degree spread on temperature and dew point.

The pilot had completed the first of three planned approaches to Runway 23 and was on the miss when the accident occurred.

The approach is not particularly complex: Minimum descent altitude is 560 feet with three quarters of a mile visibility, with an option to descend to 460 feet with a step-down fix. The missed approach is to climb straight ahead to 2,000 feet followed by a left turn back to the airport to hold at the VOR.

On the missed approach, the pilot was told to proceed direct to the VOR, enter holding northeast at 3,000 feet, and advise when he wanted to start his next approach. According to the NTSB, “The pilot then transmitted…that he had gotten himself ‘a little out of whack’ and he was ‘just trying to straighten it out’…the airplane began to turn towards the right, and continued turning right for approximately 150 degrees before radar contact was lost.”

Witnesses about 1.2 miles southwest of the airport saw the airplane crash into a tree, hit a recreational vehicle, and collide with a pickup truck. The pilot and a woman in the RV died in the ensuing fire.

The pilot held a private certificate with an instrument rating that was issued in April 2009. At the time of issuance he had a total flight time of 241 hours with 45.2 hours of simulated instrument time. At the time of the accident, he had accrued 388 total hours and 21 hours of actual instrument flight experience.

The Cessna 172 had fewer than 1,500 hours flight time and no preimpact malfunction was found. Based on post-accident analysis, it appeared from the attitude indicator that the Cessna impacted in a wings-level, 30-degree nose-down attitude. The throttle was pushed fully forward, the mixture was full rich, and the flaps retracted.

The NTSB’s probable cause was, “The pilot’s loss of airplane control during a missed approach due to spatial disorientation.”

Fortunately, procedural accidents involving an instrument-rated pilot on an IFR flight plan in instrument conditions are rare. It happens a few times a year. However, because of the ground fatality this quickly became national news. The Air Safety Institute conducted a special seminar in Myrtle Beach for the local pilots. Additionally, it was an opportunity to explain to the media and the community some technical aspects of the mishap, as they were known at the time, and to put the accident into context.

The NTSB report was factual, but as with so many of our accidents, it only tells us what happened, not why. On paper, the pilot should have been able to conduct this approach—he met all the requirements. However, the investigators apparently did not look deeply into the pilot’s training or interview those who knew his flight skills. That is an opportunity missed.

Here is where we could have learned more about the instructional background. Even though he wasn’t a total neophyte to IMC, how much experience did he have in relatively low approaches? It’s one thing to fly en route or in the descent to a good-visibility breakout. It’s a bit more complex to level at minimums and then execute a missed approach. Go-arounds and missed approaches are something that require more practice than they are getting now. Everything is in motion and changing direction, which may contribute to vertigo in those who are less than fully trained and prepared.

As just an aside, since much of aviation comes from the nautical world, perhaps pilots should follow similar traditions. Altering boat names is done with great ceremony and sacrifice. It is considered very bad luck to just make the change. The tail number on the Cessna 172 had been reassigned from a Cessna 120 that was destroyed in a crash in 1993. The NTSB report does not mention if the appropriate custom was followed.