NTSB Factual Report

HISTORY OF FLIGHT

On October 10, 2013, about 1209 eastern daylight time, a Cessna 340A, N4TK, collided with the ground while maneuvering in the vicinity of Hampton Roads Executive Airport (PVG), Norfolk, Virginia. The commercial pilot and three passengers were fatally injured. The airplane was located in a marsh area and was destroyed by impact forces. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions (IMC) prevailed and an instrument flight rules (IFR) flight plan was filed. The flight originated from Fort Lauderdale Executive (FXE), Fort Lauderdale, Florida, about 0743. This accident occurred during a government shutdown, and the National Transportation Safety Board and Federal Aviation Administration (FAA) did not travel to examine the wreckage at the accident scene.

According air traffic control (ATC) radio communication information and radar data provided by the Federal Aviation Administration, about 1144 the flight was cleared for the GPS RWY 10 instrument approach at PVG. During the arrival segment of the approach the flight tracked off course by 6 nm, paralleling the direction of the final approach course, before correcting and proceeding toward the initial approach fix.

The airplane crossed PEFOC, the final approach fix, at 1,200 feet msl. The published minimum altitude for crossing PEFOC was 1,600 feet msl. The published minimum descent altitude (MDA) for the approach when utilizing only lateral GPS guidance was 420 feet msl. The pilot flew the approach and descended the airplane to the approximate MDA according to radar data.

The flight reached the missed approach point and, based on weather radar data, began the missed approach and flew southeast, into an area showing no precipitation. The published missed approach procedure was a climbing right turn to 2,500 feet while navigating direct to PSALM, which was located generally southwest of the airport. Radar data showed the flight's altitude varied drastically during the initial part of the missed approach.

At 12:04:59, the flight began a descent from 1,100 feet to 700 feet msl; then made an abrupt right turn and began to climb. At 12:05:31, the flight started a decent from 1,600 feet to 1,000 feet and turned about 45 degrees back to the left, away from the correct direction. During this time, ATC attempted to contact the pilot four times, and received no response. The flight continued on an approximate 155-degree magnetic track, and gradually climbed to 2,700 feet msl. At 12:07:13 the flight began to turn to the right and began descending, and descended from 2,700 feet to 1,600 feet msl. During the descent, the flight's ground speed increased from 151 to 214 knots. The flight then abruptly climbed, and the ground speed decreased from 214 knots to 140 knots, before leveling at 2,800 feet msl. The ground speed continued decreasing to 107 knots, and about that time the pilot radioed ATC and requested an airport with greater than "500 feet visibility."

The controller provided weather information for the Norfolk International Airport (ORF), Norfolk, Virginia, which was 12 nm northeast of the pilot's position. During this transmission, the airplane's rate of decent, ground speed, and rate of turn all increased. When ATC personnel queried the pilot about whether to go to ORF, the pilot responded, "Standby, we're fighting some bad weather, and it's causing us to lose altitude tremendously."

At 12:09:08, the flight maintained a constant rate of turn, from about a track of about 030 to 231 degrees. Between 12:08:26 and 12:09:08, the airplane's ground speed increased from 107 knots to 225 knots. Radar data showed the final descent from 2,800 feet to 1,200 feet msl, which was the last radar return from the flight.

PERSONNEL INFORMATION

The pilot, age 61, held a commercial pilot certificate, and according to his most recent application for an FAA medical certificate, dated June 3, 2013, he reported a total of 4,256 flight hours. The pilot was issued a second-class medical certificate with limitations requiring the use of corrective lenses. A review of partial copies of the pilot's logbook revealed that he had accumulated a total of 6.4 flight hours as of September 21, 2013. No flight hour totals from previous logbooks were carried forward into the logbook examined, and none of the pilot's previous logbooks were recovered.

According to the logbook, on September 13, 2013, the pilot received a "sign off" from a certificated flight instructor in the accident airplane. During a telephone interview, the flight instructor stated that the pilot handled the airplane "well," and that pilot had previous flight experience the accident airplane make and model. The flight instructor finally noted that their flight did not include instrument procedures and that the pilot did not have previous experience operating the airplane's Garmin GTN-750 GPS.

The pilot's instrument currency could not be established due to the limited amount of information contained within the recovered logbook. In a telephone conversation with a representative of the pilot's insurance carrier, the representative noted that the pilot had provided some information about his flight experience in an insurance policy application dated September 11, 2013. On that application the pilot reported a total time of 5,541 hours, 3,076 hours multi-engine, 600 hours in the accident airplane make and model, and 40 hours in the last 90 days.

AIRCRAFT INFORMATION

The twin-engine airplane was manufactured in 1979, and was powered by two Continental model TSIO-520 series engines equipped with Hartzell PHC-C3YF-2UF propellers. Review maintenance records showed an annual inspection was completed on April 30, 2013, at a recorded airframe total time of 4,045.20 hours. The altimeters, automatic pressure altitude reporting equipment, ATC transponder and static pressure system were all tested on May 17, 2012, and were found compliant with regulations that governed the units. The airplane was equipped with a Garmin GTN-750 navigation system that was also installed at the time of the inspection.

METEOROLOGICAL INFORMATION

The recorded weather at the Chesapeake Regional Airport (CPK), Norfolk, Virginia, located 4.21 miles from the accident site at an elevation of 19 feet, at 1155, included calm wind, 7 statute miles visibility, light rain, a broken ceiling at 600 feet above ground level (agl), overcast skies at 1,100 feet agl, temperature of 21 degrees Celsius (C), dew point temperature of 20 degrees C, and an altimeter setting of 29.88 inches of mercury.

The conditions at 1235 included calm wind, 5 statute miles visibility, light rain, an overcast ceiling at 600 feet agl, temperature of 21degrees C, dew point temperature of 21 degrees C, and an altimeter setting of 29.87 inches of mercury.

The PVG reported weather conditions at 1135 located 6.58 miles from the accident site at an elevation of 28 feet, included wind from 360 degrees at 8 knots, varying in direction between 320 and 020 degrees, 3 statute miles visibility, an overcast ceiling at 400 feet agl, temperature of 19 degrees C, dew point temperature of 18 degrees C, and an altimeter setting of 29.92 inches of mercury.

The PVG reported weather conditions at 1235 were winds from 360 degrees at 7 knots with gusts to 17 knots, wind variable between 330 and 030 degrees, 9 miles visibility, an overcast ceiling at 500 feet agl, temperature of 18 degrees C, dew point temperature of 17 degrees C, and an altimeter setting of 29.91 inches of mercury.

A Meteorological Impact Statement (MIS) was issued at 0932 and was valid for the accident site at the accident time. The MIS warned of IFR ceilings, visibilities between 1 and 5 miles, rain, and mist for Virginia. It also warned of light to moderate turbulence below FL420 with thunderstorms along the Virginia and North Carolina coast

Airmen's Meteorological Information Tango and Sierra issued at 1045, and valid at the accident time, forecasted IMC for the accident site with ceilings below 1,000 feet, visibilities below 3 statute miles in precipitation and mist, and moderate turbulence below 8,000 feet.

ORF, located 14 miles northeast of the accident site, was the closest location with a terminal area forecast (TAF). The TAF issued at 0735 forecast for the time period from 1100, winds 040 degrees at 18 knots with gust 26 knots, 5 miles visibility, light rain and fog, overcast 600 feet agl; from 1400, wind from 060 at 14 knots with 21 knot gust, 5 miles visibility, drizzle and fog, overcast 900 feet agl; and from 1700, wind from 020 at 10 knots with 18 knots gust, 5 miles visibility, drizzle and fog, broken at 900 feet agl and overcast at 1,500 feet agl.

There was no record of the pilot having received a preflight weather briefing from a Lockheed Martin Flight Service facility, nor was there a record of the pilot having received a briefing through the Direct User Access Terminal Service.

WRECKAGE AND IMPACT INFORMATION

According to first responders, the airplane came to rest on a northeast heading. The wreckage debris field was about 150 feet long. At the end of the debris field, there was an impact crater 8 feet wide, 30 feet long, and about 4 feet deep. All flight control surfaces, controls, and cable hardware were observed at the wreckage site and were impact-damaged.

An examination of the airframe revealed that all of the trim settings were unreliable due to impact damage. The rudder remained attached to the vertical stabilizer and the rudder trim tab remained attached to the rudder. The left elevator was separated from the horizontal stabilizer. The right elevator remained attached to the horizontal stabilizer and the elevator trim tab remained attached to the elevator. The left aileron was separated into two sections, with the trim tab attached. The right aileron was separated into three sections.

Examination of the fuel system revealed that only one fuel selector valve was found loose in the wreckage and it was in the "OFF" position and the strainer screen was free of debris. The fuel caps for both wing tip tanks and both aux fuel tanks were observed in place and latched. The aircraft was equipped with a left and right wing locker fuel tanks, and the wing locker tank fuel caps were not recovered.

Examination of the left engine revealed that all of the cylinders were impact-damaged. The engine crankshaft was rotated by hand, and all cylinders displayed thumb compression. All cylinders were examined using a borescope and displayed varying amounts of mud impaction and normal operating signatures. The three blade, variable pitch propeller remained attached to the propeller flange; however, the propeller flange had sheered from the crankshaft. The spinner remained attached to the propeller and displayed signatures of impact damage. All three of the blades remained within the propeller hub and were locked in place. Two of the three blades displayed varying amounts of tip curling; the third blade displayed minor bending of the tip. All three of the propeller blades had minor bending deformation.

Examination of the right engine revealed all cylinders were impact-damaged. All cylinders were examined using a borescope, and the cylinders displayed normal operating signatures. The crankcase displayed impact damage concentrated to the bottom portion of the crankcase. The crankshaft was unable to be rotated by hand, and it was noted that the crankshaft had shifted towards the rear of the case. There were no anomalies noted with the crankcase. The three blade, variable pitch propeller remained attached to the propeller flange; however, the propeller flange had broken free from the crankshaft. The propeller displayed damage consistent with impact damage and the spring and spring housing had separated from the propeller hub. All three blades remained within the propeller hub; however, all three blades were loose in the hub. One blade's tip had broken free from the rest of the blade; the blade also displayed twisting deformation. One blade was bent approximately 90-degrees and displayed tip curling. The third blade displayed minor bending and tip curling deformation.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on December 15, 2013, by the Commonwealth of Virginia, Office of the Chief Medical Examiner, Norfolk, Virginia.

Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no drugs were detected in the muscle. Ethanol in concentrations of 73 (mg/dL, mg/hg), N-Butanol and N-Propanol were detected in the muscle.

ADDITIONAL INFORMATION

Spatial Disorientation

The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility conditions. Somatogyral illusions, those involving the semicircular canals of the vestibular system, were generally placed into one of four categories, one of which was the "graveyard spiral." According to the text, the graveyard spiral, "…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues 20 seconds or more, the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing latitude.

" Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground."

NTSB Probable Cause

The pilot’s failure to maintain airplane control due to spatial disorientation in low-visibility conditions while maneuvering during a missed approach. Contributing to the accident was the pilot’s ineffective use of the onboard GPS equipment.