What happened
On December 8, 2015, a Cessna 340A was conducting a private instrument flight (IFR) from Mönchengladbach to Augsburg. During the approach to runway 25, the aircraft encountered significantly degraded weather conditions. Although the pilot was informed by air traffic controllers that visibility and runway visual range (RVR) were well below the required minimums for a Category I approach, the pilot elected to proceed with the landing attempt.
As the aircraft progressed along the ILS approach, the pilot manually controlled the aircraft, at one point descending below the prescribed intermediate altitude. During the final stages of the approach, the aircraft entered a thick layer of fog. The pilot reported reducing power to idle to touchdown, but the aircraft entered an uncontrolled state. A passenger's video recording captured a continuous stall warning for seven seconds immediately preceding the impact. The aircraft struck the runway 423 meters past the threshold, slid for 104 meters, and caught fire due to leaking fuel ignited by sparks. All 5 persons on board sustained injuries, with 4 persons seriously injured and 1 person lightly injured.
The investigation
The BFU examined the aircraft's flight path, radar data, and cockpit communications. Investigators reviewed the maintenance history of the Cessna 340A, finding the aircraft to be airworthy and the electronic equipment, including the autopilot, to be fully functional. The investigation also analyzed the meteorological reports from the time of the accident, noting that while fog was forecast, the actual visibility at Augsburg was much lower than the pilot had anticipated. The BFU also reviewed the pilot's credentials, noting his extensive experience as a commercial pilot and flight examiner.
Findings
- The primary cause of the accident was the pilot's failure to initiate a missed approach despite being in a state of disorientation due to the fog.
- The pilot's decision-making was flawed; he ignored both the warnings from air traffic controllers regarding sub-minimum visibility and the suggestions from the co-occupant to divert to Oberpfaffenhorgen, where weather conditions were much better.
- The pilot exhibited tunnel vision and a lack of situational awareness, focusing heavily on the landing attempt while disregarding available alternatives.
- The aircraft entered an aerodynamic stall at a low altitude, leading to the impact on the runway.
- The pilot's high level of experience may have contributed to a sense of overconfidence, leading him to underestimate the risks of the approach.