There were two basic rules I learned early on in my aviation career. One of them was to avoid instrument conditions because I didnt have the training, even if the airplane was adequately equipped. The other was to never fly an airplane with known deficiencies that could affect the flights outcome. This included balky airspeed indicators, as one example, or inoperative radios as another. There have been many rules learned-and sometimes bent-since then, but these stand out. Ive tried mightily to comply with them. Call it self-preservation. Unfortunately, the reason I learned those rules involved the lessons learned by the many who had come-and gone-before me and that had been handed down. Ive always tried to learn and benefit from the mistakes of others. After all, even if they didnt learn something from the experience, why shouldnt I? All of which makes my job as one of your editors very frustrating when, each month, we read and report on a new slew of accidents, each and every one of which is almost a carbon-copy of events that have happened before. Sure, every now and then, someone invents a new way to bend or break an airplane. But, as a rule, there is rarely anything new or different-often just the date and time, the aircraft type and the Zip Code-about each fresh batch of accident reports. We all can and must do better. Perhaps most frustrating is reading about someone doing something for which he or she clearly isnt trained or equipped. After the fact, we try to put ourselves in that cockpit, imagine the information being processed and decisions being made-or not made-and wonder how and why the pilot didnt recognize the warning signs. Yes, its easy to armchair-quarterback some of this, but much of it is repetitive. But I already said that. A pilot lacking an Instrument rating who intentionally flies into instrument conditions an airplane exhibiting a known problem with its attitude indicator (AI) pretty much exemplifies the problem. After the wreckage is sifted and the investigation complete, were still left with the big question: Why? History On June 1, 2005, at 2306 Pacific time, a Mooney M20C collided with terrain while executing the ILS Runway 16 localizer approach to the Van Nuys (Calif.) Airport. The non-Instrument rated Private pilot and sole occupant, who had slightly more than 200 hours total time, was fatally injured; the airplane was destroyed. Instrument conditions prevailed. The flight originated at the Orange County (Calif.) Airport and was en route to the Whiteman Airport in Los Angeles. Because the flight was conducted wholly within airspace managed by the SoCal Tracon, detailed radar and ATC communications records were available. They depict a flight meandering in altitude and heading over much of the area in an attempt to find its destination visually. At 2256:19, the pilot contacted SoCal at 5000 feet over Santa Clarita and requested an ILS approach to Van Nuys, which is about four miles southwest of Whiteman, the destination airport. After being vectored to intercept the localizer, the pilot was cleared for the approach. At 2300:23, ATC advised the pilot he was left (east) of centerline; the pilot responded that he was correcting. At 2304:42, the pilot told ATC he had some problems and was climbing out. The controller issued missed-approach instructions, to which the pilot only responded that he was climbing to 5000 feet. That was the last communication with the pilot. The pilot never specified what the problem was. The aircraft owner later reported the pilot had the AI overhauled but remarked it was not performing correctly. Numerous digital images of the instrument panel recovered from the pilots camera and dated within several days of the accident show the airplane in level flight with the AI indicating a 10-degree left bank. Investigation Radar data associated with the accident aircraft shows it crossed the final approach course from the west between the initial approach fix and the outer marker. The airplanes track overshoots the final approach course to the east and then corrects back so that it is on course at the outer marker. The track then deviates to the east again and corrects back to the final approach course, which is then followed by a 90-degree turn away from the final approach course to the west. The track proceeds westerly for 27 seconds climbing from 2100 to 2500 feet and then down to 2400 feet. The track turns south for 32 seconds climbing from 2400 feet to 3000 feet. The last leg of the track proceeds northwesterly for the final 12 seconds and the altitude descends from 3000 feet to 2600 feet, to 2400 feet, to the accident elevation at 1253 feet. All major components of the airplane were present at the accident site. The airplanes engine analyzer was recovered and its stored data examined. In the minutes prior to the accident, engine rpm was steady at around 2680 rpm prior to 2256:42, at which point the rpm dropped to 1794 at 2257:54, consistent with executing the ILS approach. The engine rpm then increased to about 2700 rpm by 2259:06, and stayed at that level until the end of the data. Probable Cause The NTSB determined the probable causes of this accident to be: “The pilots decision to attempt flight into instrument meteorological conditions, which resulted in the pilots loss of aircraft control due to spatial disorientation. Factors in the accident were haze and low ceilings, the night lighting condition, an undetermined attitude gyro problem and the pilots lack of qualification/experience for flight in instrument conditions.” The NTSB excerpted material from the FAAs
So, once again, a non-rated pilot decides to defy both all that is known about instrument operations and his training. With an attitude instrument known to be defective, he attempts a nighttime ILS approach, apparently loses control in the clouds and tries to climb back up to visual conditions. Instead, he again loses control and crashes, killing himself and destroying the airplane.
Maybe we can finally learn the frustrating lessons from this accident and all the others like it.
