2 fatalities

2015-11-09: Cessna 441 Conquest (N164GP) — Legal Airways — Climax, United States of America

Climax, United States of AmericaFlight

On November 9, 2015, a Cessna 441 Conquest (registration N164GP) operated by Legal Airways was involved in an aviation accident near Climax, United States of America in flight. 2 people were killed. Investigators recorded the probable cause as: The pilot's loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot's impairment by the combined effects of multiple medications and drugs. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781192680Data APIEditorial standards

A commercial pilot lost control during an instrument approach after canceling IFR clearance above clouds. Erratic flight, expired GPS databases, overdue inspections, and impairing medications contributed to spatial disorientation and loss of control.

Flight and Weather Conditions

The flight was intended to pick up passengers at a destination airport and return. While in cruise at 3,300 feet mean sea level (msl) above a solid cloud layer, 33 miles from the destination, the pilot declared the airport "in sight" to air traffic control (ATC) and canceled his instrument flight rules (IFR) clearance. Over the next 13 minutes, radar tracking showed erratic left, right, and 360-degree turns, moving the airplane away from the destination westward, with altitudes varying between 4,000 and 900 feet msl.

Loss of Visual Contact and ATC Interaction

The pilot later reestablished communication, reported losing visual contact with the airport, and requested an instrument approach. ATC provided heading and altitude assignments to vector the airplane, but the pilot did not maintain them, prompting several corrections. The pilot expressed difficulty identifying the initial approach fix (IAF) and asked for the correct spelling. The radar target then climbed and entered a descending right turn at 2,500 feet msl and 180 knots ground speed near the IAF, after which radar contact was lost.

Aircraft and Pilot Factors

Examination of the wreckage showed both engines at high power at impact, with no preimpact mechanical anomalies. Maintenance records indicated the airplane was overdue for several inspections. The panel-mounted GPS used for navigation had expired navigation and obstruction databases. During a preflight weather briefing, the pilot was warned of low ceilings and visibility, and conditions near the destination at the time included low ceilings and visibilities.

Spatial Disorientation and Impairment

The restricted visibility and likelihood of inadvertent entry into instrument meteorological conditions were conducive to spatial disorientation. The erratic flight track, with altitude and directional changes inconsistent with progress toward the airport, likely resulted from spatial disorientation. After reestablishing contact with ATC, the pilot was not adequately prepared to execute instructions. The loss of control likely stemmed from spatial disorientation due to increased workload and distractions from configuring navigation radios or charts.

Toxicology Results

Postaccident toxicological testing detected ethanol (with undetermined origin), amphetamine, an opioid painkiller, two sedating antihistamines, and marijuana. While blood levels could not be quantified, the combined effects would have directly impacted the pilot's decision-making and flying ability.

Pilot Decision-Making

The pilot likely could not see the airport when canceling IFR clearance, as weather conditions did not permit. Canceling IFR so far from the destination increased exposure to low ceilings and reduced visibility. Additional lapses included failing to file an alternate airport despite warranted conditions, operating the aircraft beyond inspection intervals, and flying while impaired by a combination of medications and drugs.

Probable cause

The pilot's loss of airplane control due to spatial disorientation. Also causal to the accident was the pilot's impairment by the combined effects of multiple medications and drugs.