Accident Details
Probable Cause and Findings
The failure of the instrument-rated pilot to maintain control of the airplane while in instrument meteorological conditions after reporting a gyro malfunction. Contributing to the accident was the loss of primary gyro flight instruments due to the failure of the vacuum pump, the inadequate assistance provided by FAA ATC personnel, and the inadequate recurrent training of FAA ATC personnel in recognizing and responding to in-flight emergency situations.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On December 16, 2012, about 1532 eastern standard time, a Piper PA-28-160, N5714W, registered to and operated by a private individual, crashed in a wooded area near Parkton, North Carolina. Instrument meteorological conditions prevailed at the time and an instrument flight rules (IFR) plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Summerville Airport (DYB), Summerville, South Carolina, to Fayetteville Regional Airport/Grannis Field (FAY), Fayetteville, North Carolina. The airplane sustained substantial damage and the private pilot, the sole occupant, was fatally injured. The flight originated from DYB about 1400.
The pilot departed VFR and at 1412, he established contact with Charleston air traffic control tower (ATCT) and was issued a discrete IFR transponder code. About 1 minute later the airplane was radar identified, the pilot was issued IFR clearance, and instructed to climb and maintain 5,000 feet which he acknowledged. While proceeding towards the destination airport, air traffic control (ATC) communications were transferred to Shaw Air Force Base Approach, followed by Fayetteville Approach Control.
According to a transcription of communications with Fayetteville Air Traffic Control Tower, at 1451:41, the pilot established contact with the radar controller of the East Radar position of Fayetteville ATCT, and advised the controller that the flight was at 5,000 feet mean sea level (msl). The radar controller instructed the pilot to advise when he had automated terminal information service (ATIS) Alpha, and to expect instrument landing system (ILS) runway 4 approach, to which he immediately acknowledged having obtained ATIS information Alpha and to expect ILS runway 4 approach. The controller then provided the altimeter setting to the pilot and he read-back correctly the last 2 digits.
At 14:57:20, the radar controller asked the pilot if he could accept direct ZODGI, which is the initial approach fix (IAF) for the ILS to runway 4. While the transcription of communication indicates the pilot's response was unintelligible, NTSB review of the certified voice tape revealed his comment was in the affirmative. The controller issued the pilot a 055 degree heading to join the localizer, and instructed him to report established on the final approach course. The pilot did not respond, so the radar controller repeated the transmission. The pilot apologized and acknowledged the instructions.
At 14:59:41, the radar controller issued the pilot a weather advisory for a small area of moderate precipitation at the pilot's one o'clock position and 3 miles, which he acknowledged. At 1504:38, the radar controller instructed the pilot to descend and maintain 2,300 feet and, "…verify established" on the localizer. The pilot acknowledged the altitude assignment, and stated, "…couldn't (unintelligible) isn't quite established yet sir." At 1504:51, the pilot asked if a heading of 055 was good to intercept, and the radar controller replied affirmative.
At 1506:07, the controller advised the pilot that the flight was 10 miles from the final approach fix, fly the present heading and to maintain at or above 2,300 feet until established on the localizer, cleared for ILS straight in runway 4 approach. The pilot acknowledged the instructions and advised the controller, "…I think we're established now thanks." Radar data indicates that before reaching ZODGI, the pilot flew slightly east of the final approach course, followed by a left turn flying west of the final approach course. Air traffic control communications were transferred to local control of the FAY ATCT, and at 1507:10, while west of the final approach course but before ZODGI, the pilot established contact with local control and was cleared to land. The local controller also provided the wind direction and velocity information to the pilot but he did not reply. The radar data indicated that as the flight continued towards FAY near ZODGI, the airplane flew in an easterly direction flying east of the final approach course. The airplane was observed on radar turning to the northwest and intercepting the final approach course, then turned again and flew east of the final approach course.
At 1509:43, the radar controller contacted the local controller and advised that the airplane appeared to be right of course; at that time the airplane was east of the final approach course. The radar data indicates that the pilot performed S type turns while remaining right of course and at 1510:34, the local controller questioned the pilot if he was receiving the localizer to which he replied, "having a little bit of trouble right now I seem to have lost some gyros but I think we're getting there." The local controller advised the pilot to maintain 2,000 and suggested a heading of 020 to join the localizer, which he acknowledged. At that time, coordination between the local and radar east positions occurred. At 1511:24, the local controller advised the pilot to maintain 1,900 feet until receiving the glideslope, which he acknowledged. Radar data indicates that the flight proceeded towards FAY, and at 1512:15, the pilot was advised that the flight was crossing CINLO, which is the final approach fix. At 1513:30, when the flight was at 1,700 feet msl, about 211 degrees and 2.8 nautical miles from the approach end of runway 4, the local controller asked the pilot if he was receiving the glide slope. The pilot responded, "I'm sorry sir yes sir ah, I would have [unintelligible words] I realize we're coming now."
At 1513:37, the local controller asked the pilot if he wanted, "…to come back out for another approach" to which the pilot stated that, "…I think we're doing OK if it looks OK to you." The local controller informed the pilot that he could not tell with the rate of descent and cleared the pilot for a localizer approach to runway 4. The local controller later stated during an interview that he wanted to give the pilot every opportunity to complete the approach and wanted him to worry less about the glideslope so that is the reason that he cleared him for a localizer approach. The pilot acknowledged the clearance with part of his call sign and approximately 37 seconds later, or at 1514:29, the controller cancelled the approach clearance and advised the pilot to climb and maintain 2,000 feet and fly runway heading, which he acknowledged. Radar data indicates that about that time, the airplane was at 1,300 feet and 1.0 nautical mile from the approach end of runway 4.
At 1514:40, the local controller informed the pilot that overcast clouds existed at 500 feet, the flight was at 1,200 feet about ½ mile away from the runway, and asked the pilot if he wanted to perform another approach. The pilot responded, "that'll be fine thanks one four whiskey." Coordination between the local and east radar positions occurred. Radar data indicates that beginning about 1514:29, to about 1515:03, the pilot turned right to a nearly due east heading despite the instruction from the controller to maintain runway heading. At 1515:05, the local controller advised the pilot to fly heading 090 degrees climb and maintain 2,000 feet which he correctly read back. The controller then asked the pilot what heading he was flying he reported 081 degrees. The local controller again instructed the pilot to fly heading 090 degrees, climb and maintain 2,000 feet, and to contact Fayetteville Departure Control on frequency 133.0 MHz. Coordination between the local controller and radar east radar controller occurred during which time the local controller stated, "he's having a lot of problems holding a steady heading he's trying a ninety heading right now at two thousand." The transcription does not indicate that the local controller advised the radar controller that the pilot had stated that he lost some of his gyros.
The pilot established contact with Fayetteville Approach Control at 1515:44, and he advised the Radar East controller that he was heading 095 degrees going to 090 degrees. The flight was radar identified and the controller then advised the pilot to climb and maintain 2,300 feet which the pilot acknowledged. At 1516:09, a position relief briefing of the radar east radar control position occurred. During the briefing the weather conditions at FAY was discussed and the comment was that the airport was IFR due to the ceilings. The radar east control position was manned by an OJTI (instructor) and developmental (controller in training). At 1516:42, the radar east OJTI and/or the developmental controller instructed the pilot to turn right to heading 140 degrees, which he acknowledged. At 1517:18, the radar controller advised the pilot to turn right to heading 220 degrees, though the pilot did not respond. The controller repeated the heading which the pilot read back. Radar data indicates that the pilot flew past the instructed heading and at 1517:49, the radar controller asked the pilot what heading he was on and the immediate reply was, "…three one zero" The radar controller again advised the pilot that he was to fly heading 220 degrees, to which the pilot correctly read back the heading. At 1518:01, the controller then stated, "…are you having problems with your airplane you can't um fly an appropriate heading", to which the pilot replied at 1518:05, "ok I'm currently no gyro I think the best thing for me to climb a little bit and go to my alternate of ah Columbus or some point south."
The radar controller questioned the pilot about his ability to navigate to his alternate airport without gyros and he replied he could. The controller then asked the pilot what airport he wanted to go to and at 1518:26, he replied, "…columbus would be fine sir." The radar controller cleared the flight to Columbus County Airport (CPC), and to climb and maintain 3,000 feet, which the pilot did not acknowledge. The controller repeated the clearance and the pilot did not reply. Tw...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA13FA088