Accident Details
Probable Cause and Findings
The pilot’s spatial disorientation due to a somatogravic illusion while conducting a missed approach in instrument meteorological conditions, which resulted in the airplane’s descent into objects and terrain.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On March 30, 2011, at 1746 eastern daylight time, a Beech 58, N569JL, operated by Jet Logistics, Inc., was substantially damaged when it impacted trees and a residence while conducting an instrument approach to Piedmont-Triad International Airport (GSO), Greensboro, North Carolina. The certificated airline transport pilot and passenger were fatally injured. Instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight, which departed Wilmington International Airport (ILM), Wilmington, North Carolina, and was destined for Smith Reynolds Airport (INT), Winston Salem, North Carolina. The non-scheduled passenger flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135.
Personnel records provided by the operator indicated that, on the day preceding the accident, the pilot reported for duty at 1030 after having been off duty for several days. The pilot acted as second-in-command of a Beech 90 during a two-leg trip, and reported off duty at 1830. Review of data provided by a third-party flight planning and weather briefing service showed that, at 2053, the pilot obtained a weather briefing encompassing the series of airports she was scheduled to fly to the following day.
On the day of the accident flight, the pilot was scheduled to fly a multi-leg trip originating from the operator's base at Raleigh-Durham International Airport (RDU), Raleigh/Durham, North Carolina. The pilot was then scheduled to reposition the airplane in order to pick up a passenger at INT, and then proceed to ILM. The pilot would then reverse the circuit, eventually returning to RDU at the conclusion of the day.
That morning, the pilot queried the weather and flight planning service several times between 0437 and 0443. According to a receipt recovered from the wreckage, the pilot obtained catering refreshments at 0534. At 0644, the pilot advised the operator via electronic messaging that she was departing from RDU, en route to INT.
The airplane arrived at INT at 0739, and the pilot obtained a weather briefing for the next scheduled leg of the flight, and at 0840, advised the operator she was departing INT for ILM.
The flight subsequently arrived at ILM about 1000. Between 1454 and 1551, the pilot submitted numerous weather queries for the return portion of the flight via an internet flight planning service, including requesting weather from numerous other airports in the vicinity of the destination. At 1552, the pilot contacted a fellow company pilot asking for assistance with finding a legal alternate airport for the upcoming flight from ILM to INT. The pilots discussed possible alternatives, including GSO. At 1611, the pilot advised the operator that she was departing ILM en route to INT.
According to air traffic control (ATC) radar and voice data provided by the Federal Aviation Administration (FAA), the pilot requested and was given an IFR clearance about 1600. The flight departed ILM about 1622, and during the departure, the pilot advised the air traffic controller that the base of the overcast ceiling was 600 feet. The pilot was then cleared on course, and after speaking with several different ATC facilities en route to INT, contacted GSO approach at 1704. Upon receiving updated weather conditions at INT from the controller, the pilot advised that she would need to be placed into a holding pattern, due to the ceilings at INT being below 200 feet. At 1708, the pilot was cleared to hold at the INGON intersection, which was the published missed approach holding point for the instrument landing system (ILS) approach to runway 33 at INT.
At 1711, the GSO approach controller advised the pilot that the weather conditions at Statesville, Burlington, and Mount Airy, North Carolina, located between 25 and 40 nautical miles from INT, included cloud ceilings of at least 300 feet. The pilot advised the controller, "…that's hopeful but yeah we want to go to Wilmington…" Shortly thereafter, the GSO approach controller contacted the INT tower controller and advised that the pilot would be entering a holding pattern at INGON, and requested to be notified when the weather at INT had improved. The pilot reported entering the holding pattern at INGON at 1725. About 5 minutes later, a new approach controller came on duty and was briefed by the outgoing controller. During the briefing, the outgoing controller stated that most of the arrivals were being conducted to runway 5L as the runway visual range (RVR) on runway 5R was lower. He further stated that the most recent cloud base report was from an airplane that had departed about 30 minutes prior, and had reported that the clouds were at 50 feet. Additionally, two other aircraft had arrived at the airport and, "nobody's going around yet." The outgoing controller then also provided a briefing on each of the flights in the area, and stated that the accident airplane was holding at INGON with the pilot waiting for the ceilings at INT to improve, and that he expected the INT tower controller to advise when that happened.
At 1734, the pilot contacted the GSO approach controller and stated that after discussing the issue with her passenger, proceeding to GSO would be an acceptable alternative if the weather conditions were "good." The controller immediately cleared the pilot to GSO via radar vectors. At 1735, the controller advised the pilot that the ceiling at GSO was overcast at 100 feet, to which the pilot responded, "That's not going to help much..." Two minutes later, at 1737, the controller asked the pilot her intentions. The pilot responded that if no other aircraft were arriving at GSO, she would return to the previous holding pattern. The controller responded, "Everybody's getting into Greensboro, nobody's gone around yet," to which the pilot replied, "Alright, let's do it." The controller then began vectoring the pilot for the ILS approach to runway 5L at GSO [see the AIRPORT INFORMATION section of this report for a detailed description of the ILS RWY 5L instrument approach procedure].
At 1740, the pilot was cleared to descend to 3,000 feet and was given a radar vector to intercept the localizer for runway 5L. After passing through the localizer course from the northwest about 1 minute later, the pilot turned the airplane and re-intercepted the localizer course from the southeast. The controller contacted the pilot to advise and provide assistance if necessary, and the pilot declined.
After establishing the airplane on the localizer and being cleared for the approach, the pilot descended the airplane to the published minimum altitude of 2,500 feet for the intermediate segment of the approach. The controller advised the pilot to contact the GSO tower controller, at 1743. Upon contacting the tower controller, the pilot was advised that the RVR for runway 5L was 4,000 feet and that she was number two to land behind an Embraer 145 that was 1 mile from the runway threshold.
At 1744:33, about 0.5 nautical miles from the final approach fix, the airplane began descending from 2,500 feet, and crossed the fix about 200 feet below the published intercept altitude. Over the next 2 nautical miles, and over the course of about 2 minutes, the airplane descended to 1,300 feet, and remained below the calculated glideslope for the final 8 nautical miles of the approach. Upon reaching 1,300 feet msl, the airplane was about 400 feet above ground level and about 3 nautical miles from the runway 5L threshold. The airplane then began climbing at 1745:42, and about that time, the GSO tower controller issued a low altitude alert to the pilot. The pilot responded, "we're goin' around." The controller subsequently advised the pilot to fly the runway heading, and to climb to 4,000 feet, and the pilot acknowledged the instructions. No further transmissions were received from the pilot. After reaching 1,600 feet at 1745:52, the airplane descended to 1,500 feet at 1745:56, about the time the pilot concluded her final radio transmission. No further radar targets were observed.
PERSONNEL INFORMATION
The pilot held an airline transport pilot certificate with a rating for multi-engine land, and a private pilot certificate with a rating for airplane single engine land. According to the pilot's FAA Airman File, she obtained her private pilot certificate in 1984, her instrument rating in 2000, and her commercial pilot certificate in 2001. The pilot was issued second-in-command (SIC) type ratings in the LR-45 and BE-400 in 2007, and a pilot-in-command (PIC) type rating in the BE-400/MU-300 when she was issued her airline transport pilot certificate in 2008. The pilot was issued a LR-JET SIC type rating in October 2010.
Review of company records revealed that the pilot was hired by the operator in March 2010, and at that time had reported 2,590 total hours of flight experience, 770 hours of which were acting as PIC. The operator provided training to the pilot in the accident airplane, and she was found proficient to act as PIC on March 30, 2010.
The operator provided the pilot with 6 hours of flight training in preparation for her LR-JET SIC type rating. During three simulator sessions while acting as second-in-command, the pilot satisfactorily completed precision, non-precision, circling, and missed approach procedures. During this training session, the operator also certified that the pilot completed the required 6-month instrument proficiency check in accordance with CFR 135.297, on October 26, 2010.
According to company records, as of the date of the accident flight the pilot had accumulated 2,884 total hours of flight experience, 856 hours of which were acting as a PIC. The pilot also logged 117 total hours of flight experience in the accident airplane make and model, 95 hours of which were acting as a PIC. Between the time of the pilot's most recent instrument proficiency check in October and th...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA11FA219