Back in August 2015, a 55 year old lawyer from Pennsylvania purchased a 1981 A36 Bonanza. The lawyer was instrument rated and had nearly 800 hours of flying time. According to his friend, he had considerable IFR experience, but in fixed-pitch, fixed gear Piper-Cherokee.
The Bonanza that he purchased was, however, equipped with a Garmin 530 EFIS navigator and a flight director. All this was something more of an aircraft than the lawyer had flown before.
An hour and a half of ground instruction and six hours in flight comprised the quick checkout he obtained. The instructor illustrated how to set IFR approaches in the Garmin. All the approaches that he flew were without a hood and in VMC.
The pilot was cautioned by the instructor not to fly in actual IMC conditions till the time he is well aware about the new equipment and the Bonanza aircraft.
After few days, the pilot along with his father, wife and a friend flew to Florida to meet his daughter. The friend decided to stay back in Florida while all others plan to fly back north on September 7.
An IFR flight plan was filed by the pilot just before the leg from Sarasota to Greensboro, North Carolina. For someone who is used to flying a PA-28, it must have been quite satisfying flying at 190 knots at 8,000 feet.
The pilot telephoned for a weather briefing, but it was cut short as he saw an approaching thunderstorms and prepare to fly away from it. This less than four hours flight from Sarasota to Greensboro in VMC was quite lively. The pilot soon learned that the weather at Piedmont Triad (KGSO), the destination airport, was 1,100 foot overcast with cloud layer as deep as 1,500 feet.
The pilot contacted the approach control to ask if he will get visual approach. The controller replied that he will expect the ILS to Runway 5R and there was no objection from the pilot.
The next few minutes of the pilot must be consumed in setting up the Garmin for the approach. For a novice, like this lawyer pilot, the 530 can be quite intimidating. Apart from nearly endless number of options in menu, there are 20 knobs and buttons to navigate around.
It was clearly evident that the pilot was completely distracted as he was told 3 times that his runway was not 5L, but 5R. To intercept the localizer, the pilot was assigned the heading of 020 by the approach controller.
The Bonanza was nearly 9 miles away from PAGAN intersection, the initial approach fix.
Around 2 minutes later, the pilot contacted the controller with a strange question, “How do you like this route of flight?”
This was an unconventional question for the controller and he replied that the aircraft looks a little bit right from the course. He gave the instruction for a heading of 360 degree, an adjustment of 20 degree.
Soon, the second a bigger surprising question came, “turn left or right for 360?” It was an illogical question and something that clearly indicates that the pilot may be in trouble.
After some time, the controller called, “are you established on the localizer?”
The pilot replied, “I believe I am”. However, the Bonanza had already flown past the localizer.
The pilot than made the request for “vectors to final”, to which he expected something like the virtually obsolete GCA (ground controlled approach). In this the aircraft is guided all the way to the runway by the controller.
The controller, however, canceled the ILS clearance and directed the Bonanza to set up for another try. After few minutes, the Bonanza pilot made another call to the controller asking for vectors. The controller noticed that the pilot’s voice was shaking and that he was flying at 2,500 feet although he was assigned 3,000.
At last, the pilot accepted and said, “we need a descent and we are almost disoriented.”
It was now clear to the controller that the pilot was facing trouble flying. He tried to make things easy for the pilot by providing him no-gyro turns in place of vectors.
The radar screen of the controller was set on large scale and he did not realized that the pilot was flying in circles actually, first in right turns then in left. Plus, the aircraft was loosing altitude continuously.
Finally, the pilot was asked by the controller to climb and maintain 4,000 feet. He was of the view that out in the sunshine and above the overcast will help pilot to recollect and reorient himself.
However, the Bonanza aircraft never climbed, but continued with its downward path, whether inadvertently or deliberately.
The aircraft passed through the cloud in one piece, fortunately, the terrain below was relatively flat. But, the story did not end here.
The pilot never managed to gain control of the aircraft, even though the conditions below the overcast were good VFR. Possibly, vertigo or panic might have engulfed the pilot beyond the point of recovery.
The Bonanza A36 finally stalled and crashed nearly 7 miles away from KGSO, with no one surviving.
Investigation from the National Transportation Safety Board put forward the difficulty faced by the board in finding the “cause”. According to NTSB the main cause was spatial disorientation.
The in-flight decision-making of the pilot is worth nothing here, which is not mentioned by NTSB here.
Keeping aside the advice from his instructor, the pilot put himself in a position where he had to make an ILS approach using the still-unfamiliar equipment.
The pilot was ultimately disoriented, but it was his unfamiliarity with the new equipment that lead to disorientation.
The FAA is criticized by the NTSB as the controllers are not trained properly to recognize and respond effectively to disorientation scenarios. It was pointed out by the NTSB that no-gyros turns in any directions may have deteriorated the pilot’s situation. It also pointed out that most controllers at the facility were not familiar with standard-rate turn concept.
The rate at which a pilot executes a turn at the time of a no-gyro approach is of minimal importance to controllers.
This accident points to the ability of the pilot to come out of such situations. Disorientation may lead pilot into a situation from where they are not able to execute even normal maneuvers such as climbing out of clouds.
Pilots, particularly those having low-flying hours, should realize that the stress to try solve a problem may erode their power to solve it. Problems faced in aircraft are different from those faced otherwise in life, and can soon turn life-threatening.
A lesson from this accident is that pilots should not go in clouds with their new EFIS till the time they know to operate it effectively and efficiently.