What happened
On the night of October 13, 2006, a Piper PA28-140 crashed into a field near Dolsenhain, Germany, while attempting to land at Altenburg-Nobitz airport. The flight, conducted under Visual Flight Rules (VFR), was traveling from Paderborn-Lippstadt to Altenburg for a social event. Earlier that day, the pilot had contacted the Altenburg tower to inquire about the weather and was advised by the flight manager to avoid flying due to low cloud ceilings and poor visibility. Despite this advice and warnings from others at the departure airport, the pilot proceeded with the flight.
As the aircraft approached Altenburg, the pilot requested to switch to the local frequency. Upon contacting Altenburg Info, the pilot was informed of the current weather, which included visibility of 2,000 meters and cloud ceilings at approximately 400 feet. The pilot then requested permission to perform a "simulated ILS approach" for runway 22, a request the flight manager granted. During the approach, the pilot attempted to intercept the localizer at a 90-degree angle approximately 5 NM from the runway. In the process of attempting to correct the flight path, the aircraft's speed increased, and it descended below the glide path. The aircraft struck a field with the right wingtip, causing the aircraft to break up and catch fire. Both occupants were killed.
The investigation
The BFU investigation examined radar and GPS records, radio communications, and meteorological data. The investigation confirmed that the ILS equipment at Altenburg-Nobitz was fully functional. Investigators also reviewed the pilot's experience and the communication between the air traffic controller and the flight manager. The investigation found that the pilot's attempt to fly an instrument-based approach under VFR conditions led to spatial disorientation. Furthermore, the investigation noted that the communication between the controller and the flight manager regarding the weather update was not sufficiently professional, as the controller did not clearly confirm whether the weather information should be passed to the pilot.
Findings
- The primary cause of the accident was a collision with terrain resulting from poor decision-making and an unsuccessful flight tactic involving an instrument approach under VFR conditions.
- The pilot experienced spatial disorientation because the approach lacked the external visual references required for VFR flight.
- The pilot's decision-making was influenced by "homitis," a state where a pilot focuses solely on reaching a destination, potentially neglecting risk assessments.
- The pilot's maneuver to intercept the localizer at a 90-degree angle was ineffective for stabilizing the approach.
- The flight manager's response to the pilot's request for a simulated ILS approach was ambiguous and did not prevent the hazardous maneuver.
Safety action
- Safety Recommendation 11/2009: The Federal Ministry of Transport, Building and Urban Development should ensure that the "VFR Practice Approach," which is not regulated by ICAO, is not utilized during Instrument Meteorological Conditions (IMC).