Pilot LOST CONTROL & Crashes due to spatial disorientation in IMC
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- เผยแพร่เมื่อ 21 ก.ย. 2024
- The airline transport pilot and passenger departed on a cross-country flight in instrument meteorological conditions in the light business jet. About 1 minute after departure, air traffic control instructed the pilot to climb and maintain an altitude of 14,000 ft mean sea level (msl). About 3 minutes later, the pilot stated that the airplane's flight management system (FMS) had failed. Shortly thereafter, he requested a climb and stated that he was "trying to get to clear skies." Over the next several minutes, the controller provided the pilot with headings and altitudes to vector the airplane into visual meteorological conditions. During this time, and over the course of several transmissions, the pilot stated that he was "losing instruments," was hand-flying the airplane (likely indicating the autopilot was inoperative), and that he wanted to "get clear of the weather."
Radar data indicated that, during the 10-minute flight, the airplane conducted a series of climbs and descents with large variations in airspeed. About 2 minutes before the loss of radar contact, the airplane entered a climbing right turn, reaching its highest altitude of about 21,000 ft, before it began a rapidly descending and tightening turn. Performance data revealed that, during this turn, the airplane entered a partially-inverted attitude, exceeded its design maneuvering speed, and reached a peak descent rate of about 36,000 ft per minute. Radar contact was lost at an altitude of about 16,000 ft msl, and the airplane subsequently experienced an inflight breakup. The wreckage was distributed over a debris path that measured about 3/4-mile long and about 1/3-mile wide.
Postaccident examination and testing of various flight instruments did not indicate what may have precipitated the inflight anomalies that the pilot reported prior to the loss of control. Additionally, all airframe structural fractures were consistent with ductile overload, and no evidence of any preexisting condition was noted with the airframe or either engine.
The airplane was equipped with three different sources of attitude information, all three of which were powered by separate sources. It is unlikely that all three sources would fail simultaneously. In the event the pilot experienced a dual failure of attitude instrumentation on both the pilot and copilot sides, airplane control could have been maintained by reference to the standby attitude indicator. Further, the pilot would have been afforded heading information from the airplane's standby compass.
Although the pilot did not specifically state to the controller the nature of the difficulties he was experiencing nor, could the investigation identify what, if any, anomalies the pilot may have observed of the airplane's flight instruments, the pilot clearly perceived the situation as one requiring an urgent ascent to visual conditions. As a single pilot operating without the assistance of an additional crewmember in a high-workload, high-stress environment, the pilot would have been particularly susceptible to distraction and, ultimately, a loss of airplane control due to spatial disorientation.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of control due to spatial disorientation while operating in instrument meteorological conditions, which resulted in an exceedance of the airplane's design stress limitations, and a subsequent in-flight breakup. Contributing to the accident was the pilot's reported inflight instrumentation anomaly, the origin of which could not be determined during the investigation.
Jan 18, 2016 at 1000 LT
Audio source Liveatc.net
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My first jet, the autopilot rarely worked. I don't understand how someone can be qualified to fly a jet and not hand fly it better than the stupid autopilot. Insane.
he lost some intstruments
@@C.D.-tz6sk We know this for sure? Which instruments?
@@nuclearrabbit1 No we don't, he said he was dealing with instrument failures... so don't cast stones.
@@C.D.-tz6sk Fair enough. We'll let the NTSB cast the stones.
@@nuclearrabbit1 We may never know all the failures they had instrument wise. RIP
'I'm hand flying'... if you hear that from a pilot you just know that the guy is out of his depth.
I’ve worked at an airport for nearly 30 years and I’m an instrument rated private pilot. The best (and worst) things to happen to pilots is the advent of all the modern electronics in the cockpit, iPads included. I see so many pilots who rely on the iPad so much that if it fails, they couldn’t navigate to the bathroom if they had to. I’m all for anything that helps us fly safer and more informed but there is also a cost to be paid for all that information. Pilots are getting “rusty” because of over reliance on automation. I flew with a guy who literally engaged the autopilot as soon as the gear was up and used almost until landing. Once the check ride or sim session is over these guys do little stick and rudder flying. It’s autopilot “on” and “direct to” on the gps. We’re killing ourselves because complacency has taken the place of being current. The most important rating a pilot will ever get is the instrument rating. It literally is life or death.
I’m not sure I agree with all that. Autopilot doesn’t make a sloppy pilot. Some sloppy pilots overuse autopilot and don’t try to stay current on all skills. Can’t blame the tech.
@@RetreadPhoto Agreed. As a former 121 check airman I saw that too often. The weak pilots definitely used it as a crutch. The good ones knew when to turn it off. Just going by how flustered he sounded, he definitely was the former, a more proficient guy would've not panicked so much.
Agreed, as a long term pilot, I believe stick and rudder skills will never be out of date, but electronics are always subject to failure.
The only problem is stick and rudder won’t help if you are in IMC and have no instruments. If he had a wet compass and at least airspeed, he should be able to maintain control. He didn’t say which instruments were failing. He should have had the secondary attitude indicator but if it was a catastrophic electrical/pitot system problem, that could cause panic.
Best aircraft I ever flew was the Irish Concord, the venerable Shorts SD330 as it had no autopilot.
All flying was hands on and with a high instrument panel making it hard to see the horizon ,all flying was on the AH.
Hard work but really sharpened up your flying.
I keep saying it but I wish the training centers would tighten up on upholding the passing standards.
Many years ago, experiencing spatial disorientation during a right turn after takeoff at low altitude really shook me up. Clinging to my instruments became an instinct. It's such a lethal situation that any pilot, regardless of experience, could face serious trouble if they don't rely solely on their instruments
his instruments were failing, most likely also his AHRS and his attitude indicator.
I know what you mean, I experienced this at night turning crosswind into a black hole area, the attitude indicator saved my sorry ass. Lesson learned and lived to fly another day.
@@robertg5393 I think his instruments APPEARED to be failing because they weren't agreeing with his perception as he was spatially disorientated
Twice I experienced this phenomenon after I was instrument rated…got to focus on keeping wings level
I think the only thing failing other than possibly his autopilot was his IMC proficiency
Aviate, navigate, communicate. Gotta keep air under the wings.
How the hell did he get rated in a Citation if he cant hand fly it ??
Happens more than we may know. 😩
When aviators became automation conductors. And it all started to go to poop. The Bonanza (V-35) was in our past called "the doctor killer" With the modern birds level of performance and complexity, we see the same syndrome of bird capabilities exceeding pilot capacity/experience. **"Son, your ego is writing checks your body can't cash".**
Tragic...!!
But why do IR rated pilots lose it when the autopilot/ instruments fails... That's what we trained for and stayed current in IFR for... This is simply lack of current practice...
Only Airline crews get the regular practice, day in day out, sim. and check rides, there's no hiding if you're rusty...... This is avoidable.
Shit happens man. Who knows what was going on in his life. Panic can cause all kinds of bad decisions to happen. Maybe he didn't get much sleep. Who knows what his instruments were doing. When I was a Blackhawk crew chief had a pilot who was going through stuff basically freeze up.
I think it’s unfair to draw conclusions. We have no idea what "I’m losing different instruments" means.
"I've lost the autopilot. Uh-oh, I'm losing more instruments! Mayday!!"
"Would you like to continue to Tucson?"
"Affirmative"
I had to listen to that part again. Found it very confusing.
The issue lies in the lack of manual flying practice. Airline pilots spend scant minutes hand-flying per leg, even less so with automated landings. Placing a pilot accustomed to solely autopilot-guided instrument approaches into a Cessna 172 would highlight the challenge of manual flight, particularly executing instrument approaches without automation
This is completely false. At Spirit we generally hand fly below 10k on take off. We usually hand fly after local capture. I haven't used autopilot to land in 3 years. And I own a Aerocommander Lark that doesn't have an autopilot.
I’ve never had an autopilot not fail
Pilot made it sound like he was losing instruments. Partial panel in IMC is a MAYDAY.
Accidents like this what manufacturers and airlines will use to push for even more automation into single pilot or remote pilots
This shouldn't happen. ATP, type rated, annual sim training probably demanded by insurance company or equivalent.
You can count on that. Annual training required by insurance company.
I do 2 hours of sim in a G1000 motion sim twice a year with the most challenging settings for wind, visibility and turbulence. Need to be ready. In real life I try hard to stay light IFR daylight only. I do the sim under night settings to increase the difficulty even more. All of that is hand flied. Trying very hard to stay alive in the dangerous pastime. There is a reason airplanes are so expensive. we lose more every week than they build!
When the going gets tough throttle back.
He lost his autopilot…. Maybe he lost it because of another instrument malfunctions…. You guys don’t need to cast stones….
Forgot to switch ice protection on?
A combination of other problems may have totally messed him up we don’t know what information he was getting or not getting. Everybody is an expert till it happens to you. I agree we should all be capable of flying with a broken autopilot but what we don’t know is what else was piled on. At some point everyone breaks or we would not loose so many of our fellow pilots. I know from personal experience how fortunate it is when you just have one emergency and not multiple.
Can't fly without autopilot? Why do I need a pilot at all then?
We may have to put a new restriction on licenses like the must wear corrective lens. New restriction, can only fly with functioning autopilot.
Haha, sad huh.
I wonder if any of his instruments failed, or he just stopped believing what they showed?
If the autopilot fails, you would have to bail out under that rule.
Probably was working when he started. Didn’t see Murphy sneaking up the air stairs and hiding under a seat…😢
New restriction.... Can only perform flight duties when shown to have basic skills and knowledge, without technology to save their ass.
We just need more buttons to push… and more aural warnings… and more red lights… yeah, and maybe Elons FSD too…
But definitely not more time and focus on basic instrument skills… nah, thats just for rookies…
As everyone’s insurance rates go to the moon…. Absurd….
Need AQP for GA...where is the FAA..TRAGIC!!!!!!!!!!!
They're too busy busting Trent in his KitFox.
Loss of PILOT SKILLS …..PILOTS DONT FLY ANYMORE THEY PUSH BUTTONS …..NO SKILLS NO Technique no nothing! You can’t fly when the autopilot quits ???
NEED AQP for GA !!!!!!!!!!!!!!!! Where is the FAA?!?!?!?
Im pretty certain any pilot in a regular airline can easily hand fly in this situation.
There are training standards that needs to be met😊
In the GA secment you can however sometimes find some not so great pilots at times.
@@torben6137I’ve flown with captains who would be absolutely screwed if we dumped the AP/AT/FD and/or the FMS. It’s embarrassing, and you have no idea how many airline pilots couldn’t navigate without the magenta line. It’s horrifying.
I flew my instrument check ride in actual instrument conditions- I didn’t have an autopilot. Didn’t need one…
@michaelgarrow3239 what a Chad
push button IFR pilots?
Why the re-upload?
Did some mistake in the last portion of the video! So corrected
@@Flight_Follower Gotcha. Good job correcting and uploading so quickly 👍🏼😎
Appreciated🙏