1 fatality

2019-12-09: Cessna 208B Grand Caravan (N4602B) — Martinaire — Victoria, United States of America

Victoria, United States of AmericaFlight

On December 9, 2019, a Cessna 208B Grand Caravan (registration N4602B) operated by Martinaire was involved in an aviation accident near Victoria, United States of America in flight. One person was killed. Investigators recorded the probable cause as: The pilot’s loss of control due to spatial disorientation. Contributing to the accident were the inoperative attitude indicator and horizontal situation indicator on the pilot’s side of the cockpit, and the pilot’s failure to reference the flight instruments… This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 7 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781190656Data APIEditorial standards

A cargo pilot reported instrument problems before losing control after takeoff. Investigators found the pilot's attitude indicator and HSI were inoperative due to an unpowered inverter system, while the copilot's vacuum instruments remained functional.

Flight Details

A cargo flight departed at night under an overcast cloud ceiling with hazy visibility, as reported by another pilot. Approximately one minute after takeoff, the pilot executed a series of course changes and large deviations in altitude and airspeed. The air traffic controller queried the pilot multiple times about the erratic flight path, and the pilot responded that he had "some instrument problems." The pilot attempted to return to the departure airport, but the airplane entered a near-vertical dive and impacted terrain.

Instrument System

The accident airplane was one of two in the operator's fleet equipped with an inverter system that electrically powered the pilot's left-side flight instruments. Examination of the annunciator panel lighting filaments revealed that the inverter system was not powered at the time of impact. Without electrical power from an inverter, the pilot's attitude indicator and horizontal situation indicator (HSI) would have been inoperative, and warning flags would have been displayed over these instruments. However, the vacuum-powered flight instruments on the copilot's right side were operational, and the pilot could have referenced these instruments to maintain orientation. Due to impact damage, the operational status of the two inverters installed in the airplane could not be confirmed.

Pilot Background

The pilot had a history of poor procedural knowledge and weak flying skills. Investigators noted that it was possible he either failed to turn on an inverter during ground operations and did not respond to the accompanying warning flags, or he did not switch to the other inverter in the event that an inverter failed in flight.

Investigation Findings

Based on the available information, the pilot likely lost control of the airplane after experiencing spatial disorientation. The night marginal visual flight rules conditions and instrumentation problems would have been conducive to the development of spatial disorientation, and the airplane's extensive fragmentation indicative of a high-energy impact was consistent with the known effects of spatial disorientation. Ethanol identified during toxicology testing may have come from postmortem production and, based on the low levels recorded, was unlikely to have contributed to the accident. Morphine identified in the pilot's liver could not be used to extrapolate to antemortem blood levels; therefore, whether or to what extent the pilot's use of morphine contributed to the accident could not be determined.

Probable cause

The pilot’s loss of control due to spatial disorientation. Contributing to the accident were the inoperative attitude indicator and horizontal situation indicator on the pilot’s side of the cockpit, and the pilot’s failure to reference the flight instruments that were operative.