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NTSB Accident No. ERA14FA068NTSB Accident No. ERA14FA068

by David Jack Kenny

The most dangerous weather phenomenon isn’t turbulence, icing, or even thunderstorms; it’s ordinary clouds and fog. (Darkness can qualify, too, if the terrain is featureless and the horizon indistinct.) We’ve known since the days of the barnstormers that attempts to fly by visual references end badly when those references disappear. Not every unplanned encounter with IMC ends in an accident—but when one does, the results are predictably tragic.

The invention of gyroscopic attitude instruments, radio navigation aids, and the instrument rating were supposed to address this problem. An acceptably proficient pilot in a properly equipped aircraft doesn’t need to see the ground either to aviate or navigate. But adequate proficiency is essential. The vast majority of instrument flights are completed without incident, but occasionally instrument-rated pilots learn the hard way that their present skills aren’t up to the task at hand. Whether due to a lack of basic proficiency or just a lack of recent practice, accidents on active IFR flight plans in actual IMC are every bit as severe as the VFR variety. If you lose control of the aircraft or wander far enough off course to hit something, it doesn’t much matter whether you hold the rating or not.

At 5:15 p.m. on Dec. 8, 2013, a Cessna 310R departed from the St. Lucie County International Airport in Fort Pierce, Florida, on an IFR clearance to Jacksonville Executive (formerly Craig Municipal). When he'd called to file his flight plan just over an hour earlier, the 1,600-hour private pilot had declined a weather briefing, saying only that the weather “looked good.” At that time, the most recent observation at his destination included an overcast ceiling at 400 feet and two miles’ visibility in mist.

At 6:05 p.m., the pilot checked in with Jacksonville Approach and reported that he was level at 5,000 feet with ATIS Information Oscar. He was told to expect the ILS approach to Runway 32 and cleared to JEVAG, the initial approach fix; 15 seconds later the controller advised him of the updated Information Papa, which included a 400-foot overcast and visibility of a mile and a half in mist. During the next six minutes, he executed clearances to descend to 3,000 and then 2,000 feet.

At 6:14 p.m., the controller advised that the flight was seven miles from ADERR (the final approach fix) and instructed the pilot to fly a heading of 350 and maintain 2,000 feet until established on the localizer. The pilot erroneously read back “cleared to ADERR,” omitting the heading and altitude restriction. A minute later the flight was handed off to the tower controller, who provided a landing clearance for Runway 32 and a pirep from half an hour earlier. A landing Cherokee pilot had reported seeing the airport lights at 300 feet and the runway at 200 feet.

Radar data indicates that the twin Cessna flew through the localizer, and then began turning toward the airport while descending prematurely. It passed abeam the final approach fix about a mile right of course and 900 feet below the glideslope intercept altitude. At 6:17 p.m. the tower controller issued a low-altitude alert; mode C returns showed the airplane at 600 feet, which the pilot confirmed. The airplane then veered left of the approach course twice, descending to just 300 feet, before reintercepting the localizer. Just before 6:20, about two miles from the airport, the pilot transmitted, “We’re gonna go around … we missed it.” The controller assigned a heading of 280 degrees without specifying an altitude and told him to contact Jacksonville Approach. He read back the heading but never completed the frequency change.

The Cessna began a climbing left turn that continued through the assigned vector and onto a southwesterly heading. The last radar return came at an altitude of 900 feet. From there the airplane crashed into a stormwater retention pond in a residential development. The pilot was killed along with both his passengers—his two daughters, aged 20 and 17.

The pilot’s logbooks weren’t recovered, and the NTSB was unable to determine either the extent or currency of his instrument experience. The logbook of the CFI who had provided his last flight review made no mention of an instrument proficiency check, and neither his medical nor insurance applications—from which investigators estimated that his 1,600 hours of flight time included 800 in multiengine airplanes—reported instrument time. FAA records do show that he’d received his instrument rating in 2002, but the NTSB concluded that “his inability to align the airplane with both the final approach fix’s lateral and vertical constraints is consistent with a lack of instrument proficiency.”

We like to say that instrument flight is “as safe as you choose to make it.” That’s true—but an essential element of choosing safety is factoring in a realistic understanding of your own limitations as well as those of your equipment. You’re only as good as you are today, and putting yourself into a situation that requires your skills to be at the sharpest isn’t guaranteed to sharpen them.