NTSB Factual Report

HISTORY OF FLIGHT

On March 4, 2015, about 0413 eastern standard time, a Mooney M20F, N66BB, was substantially damaged when it impacted trees and terrain while conducting an instrument approach to Norfolk International Airport (ORF), Norfolk, Virginia. The private pilot and two passengers were fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Dark night instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed and active for the flight, which originated from Palatka Municipal Airport (28J), Palatka, Florida, about 2353 on the preceding day.

According to the owner of the airplane, the pilot and two friends had borrowed the airplane and departed from its home base of Suffolk Executive Airport (SFQ), Suffolk, Virginia on February 25. The group flew to Key West International Airport (EYW), Key West, Florida.

At 1916 on the evening of March 3, the pilot contacted Flight Service to file two IFR flight plans for the return trip to SFQ. The first flight plan requested GPS-direct routing from EYW to 28J, and the second requested GPS-direct routing from 28J to the Brunswick, Georgia (SSI) VOR and then direct to SFQ. For the flight to SFQ, the pilot declared a planned departure time of 2300, an estimated time en route of 3 hours 30 minutes, and an estimated 5 hours of fuel onboard. He did not specify an alternate destination airport. When asked if he would like a standard weather briefing, the pilot declined, stating that he would like the NOTAMS at 28J and SFQ.

After filing the flight plan for the SFQ flight leg, the briefer provided the pilot with a partial weather briefing for that leg. The pilot was advised of AIRMETs forecasting instrument meteorological conditions and mountain obscuration, moderate turbulence, and possible low-level windshear beginning in the Carolinas and extending to the planned destination. After being provided with these advisories, the pilot stated, "I'm familiar with that, I've looked it over," and "I got weather earlier." There was no record of the pilot obtaining a complete weather briefing from an official, access-controlled source.

The flight subsequently departed EYW about 2030 and arrived at 28J about 2240. According to self-service fueling records, while at 28J, the pilot purchased 31 gallons of 100LL aviation fuel at 2244. The flight departed 28J for SFQ at 2353.

According to air traffic control (ATC) voice communication and radar data provided by the Federal Aviation Administration (FAA), along with data recovered from a handheld GPS receiver, the pilot contacted the approach control facility at ORF at 0253, while en route to SFQ. The controller asked the pilot to advise when he had obtained the weather conditions at SFQ. The pilot subsequently asked the controller for permission to change frequencies so that he could obtain the weather information and said, "I can't get it on my phone." About 3 minutes later, the pilot requested the RNAV GPS RWY 22 instrument approach to SFQ. (See figure 1 for the instrument approach procedure.)

Figure 1 - SFQ RNAV RWY 22 instrument approach procedure (excerpt).

At 0307, the pilot was given a radar vector and cleared to execute the instrument approach (see figure 2 for the GPS-derived ground track plotted on the instrument approach procedure). About 1 minute later, the controller noted that the flight had not intercepted the proper final approach course and queried the pilot. The pilot responded, "we're having a problem with our GPS plates." The controller provided the pilot with another radar vector to intercept the course and re-issued the approach clearance. At 0312, the controller again advised the pilot that the flight was not tracking along the correct final approach course, and the pilot responded, "we're trying to get our wind correction angle dialed in here." The controller subsequently provided the pilot with another radar vector to intercept the final approach course and advised him to climb to 2,300 ft.

At 0313, the controller asked the pilot if he was established on the final approach course, and the pilot replied, "we're having to put in a heck of a wind correction angle, it's really howling up here, we got it now." The controller then terminated radar services and asked the pilot to cancel his instrument clearance when he was able.

According to GPS track log data, the airplane passed abeam WOLIB, the final approach fix for the approach, at 0319:43. The airplane's GPS-derived altitude was 1,571 ft, and its groundspeed was 50 knots. The airplane continued toward JOVAM and passed abeam JOVAM at 0322:41, at a GPS altitude of 600 ft and a groundspeed between 75 and 85 knots.

Figure 2 - The airplane's GPS-derived ground track overlaid onto the SFQ RNAV GPS 22 instrument approach procedure plan view.

The airplane continued toward the runway 22 threshold, passing abeam it at 0323:54 and turning to the east. At this time, track log data showed that the airplane had a groundspeed of about 80 knots and a GPS altitude of 331 ft. The airplane continued descending to a lowest-recorded GPS altitude of 167 ft (about 100 ft above ground level [agl]) at 0324:16, at which time the ground speed was 109 knots. The airplane was about 3/4 nautical miles east of the runway 22 threshold and tracking to the east away from the runway threshold (see figure 3).

Figure 3 - Orthographic projection of the airplane's final approach to SFQ, descent to 167 feet GPS altitude, and flight away from the airport.

The airplane subsequently began climbing, and at 0324, the pilot contacted ATC and advised that he was executing a missed approach and would like to divert to ORF. The controller advised the pilot to fly the published missed approach procedure (a straight ahead climb to 2,100 ft, then to the OLUCE fix) and to climb to 3,000 ft. The pilot responded by asking for a radar vector and stating, "we're really bouncing around." The controller responded that he needed the pilot to climb to at least 1,600 ft before he could provide a vector. The pilot responded that he was currently flying at 900 ft and again asked for a radar vector. The controller again responded that the pilot should continue to fly the published missed approach procedure and climb to 3,000 ft. The pilot then responded, "I can't, I'm off course." The controller then provided the pilot with a radar vector of 090°.

At 0326, the controller provided the pilot with the current weather conditions at ORF, which included wind from 220° at 15 knots, gusting to 23 knots, visibility 6 statute miles in mist, and an overcast ceiling at 400 ft. Shortly thereafter, the pilot asked the controller for the weather conditions in Newport News, Virginia, to which the controller responded that the wind was 230° at 14 knots, 7 statute miles visibility, with an overcast ceiling at 400 ft. The pilot then responded that he would like to continue to ORF. The controller advised the pilot to expect the ILS RWY 23 instrument approach there and provided radar vectors toward the downwind portion of the approach.

At 0328, the controller solicited a pilot report from another airplane arriving at ORF via the ILS RWY 23 instrument approach. The pilot of the arriving airplane responded that the localizer was "varying around." The controller advised that pilot that he had not received any other reports from other arriving aircraft in the previous 2 hours. The pilot of the arriving airplane then advised the controller that the final approach was "bumpy" with "moderate chop." Additionally, upon landing, the arriving pilot advised the controller that he was able to see the airport's approach lights when he had descended to an indicated altitude of 350 ft. The controller then passed along the arriving pilot's report of the ceilings and turbulence to the accident pilot, who responded, "we got hammered on the way down into Suffolk."

At 0332, the controller offered the pilot a report of the weather conditions at two other airports in the area and stated that, across the area, the ceilings were generally at 400 ft. Over the next 2 minutes, the controller provided descent instructions to the pilot and advised him of the reported fluctuation of the localizer, adding that it was the first such report he had received from the three arriving aircraft during the previous hours. The pilot acknowledged the information and stated, "the air is mixing down in the bottom layers, I imagine the needles are bouncing around."

The controller continued to provide the pilot with radar vectors toward the final approach course. At 0340, the pilot asked the controller for a report of the winds at ORF, and the controller responded 230° at 14 knots, gusting to 18 knots, and that the airplane had a groundspeed of 30 knots. The pilot confirmed that he observed a similar groundspeed indication. Shortly thereafter, the controller advised the pilot to change radio frequencies, and, after the pilot reported that he was on the frequency, the controller asked the pilot to verify the airplane's altitude, told him to maintain 1,600 ft, and stated that the airplane was south of the final approach course. He then provided the pilot with a radar vector back toward the final approach course.

At 0342, the controller confirmed that the pilot had established the airplane on the localizer course. The pilot responded, "we are on the localizer at 1,300 ft, glideslope is coming down to us." The controller reiterated that the pilot should maintain 1,600 ft until reaching LUFSY (see figure 4) and stated, "once you get to LUFSY, you can follow the glideslope down, but the proper height now is 1,600." The controller then advised the pilot that he had adjusted the runway lights to their maximum intensity.

Figure 4 - ORF ILS RWY 23 instrument approach procedure (excerpt).

The controller contacted another air traffic controller at Norfolk Naval Station (NGU), Norfolk, Virginia, at 0345, and inquired whether that facility had the capability to provide a precision approach radar (PAR) instrument approach. He added that it may be necessary for the accident pilot to make an emergency approach there based on the difficulty he had experienced during the previous approach to SFQ and was experiencing during the current approach to ORF. The NGU controller acknowledged the situation and the contact terminated shortly thereafter. Between 0348:22 and 0348:51, the controller provided the pilot with two lateral position warnings and suggested corrections back toward the localizer course. At 0349, the controller canceled the approach clearance and instructed the pilot to climb to 2,000 ft.

When asked his intentions, the pilot advised the controller that he would like to attempt the approach a second time, stating, "we'll take another swing at it." The controller then provided radar vectors and altitude instructions. About this time, personnel at NGU contacted the approach controller inquiring about the airplane's situation. The controller advised that the pilot was having difficulty maintaining courses and altitudes and stated that, "we could have an emergency situation." At 0351, the controller asked the pilot to advise of the airplane's fuel state, and the pilot replied that about 1 hour 15 minutes of fuel remained. When asked by the controller if he was experiencing any equipment problems, the pilot stated, "It's literally a washing machine as soon as we go through the cloud deck, the cloud deck's at 1,200 ft, before that everything's very easy, but once we get to 1,200 ft it's a washing machine." The controller then asked the pilot if it would be easier to attempt the RNAV approach, to which the pilot replied, "no localizer's way better."

At 0354, the controller instructed the pilot to descend to 1,600 ft. About that time, the pilot stated that he had encountered, "…moderate turbulence, there was things floating around in the cabin on these approaches." After radar vectoring the airplane to a point about 3 miles from the final approach fix, the controller issued the pilot another clearance for the ILS RWY 23 instrument approach. The pilot acknowledged the clearance and stated, "…we're having a lot of precession with our gyro, don't know if the turbulence disrupted it, if at all possible radar vectors would be appreciated on the glide slope, I mean it's a very very wild ride." The controller asked the pilot if he was requesting no-gyro radar vectors for the approach or just radar vector corrections on the ILS approach. The pilot responded, "We have some gyro, it appears we have to reset the gyro periodically in a descent, but yeah if you could give us some vector feedback that would be wonderful." The controller acknowledged the request.

At 0357, the pilot advised the controller that the airplane's airspeed was 105 knots, while its groundspeed was 32 knots. The controller then relayed that, due to the airplane's low groundspeed, he was having difficulty interpreting its track across the ground, and asked the pilot if he had intercepted the localizer course. The pilot confirmed that he was joining the localizer course. At 0359, the controller provided the pilot with an update on the weather conditions at ORF, stating that the wind was from 220° at 19 knots, gusting to 23 knots, the visibility was 2 1/2 miles in mist, the ceiling was overcast at 300 ft, and the altimeter setting was 29.92 inches of mercury. The pilot responded, "roger two niner niner two, we had it set higher."

At 0403, the controller advised the pilot that the airplane was left of the localizer course, and asked if he wanted "standard rate no gyro vectors." The pilot answered in the affirmative, stating, "we're having a real problem with precession." At 0405, the pilot clarified the airplane's fuel state to the controller stating, "…got about half hour, not an hour and a half as I advised you earlier." The controller continued to provide the pilot with radar vectors, and, at 0407, the pilot advised the controller that he had intercepted the glideslope for the approach. The controller advised the pilot to descend via the glideslope for the approach, and, at 0411, the controller stated that the airplane was about 2 miles from the approach end of the runway. At 0411, the controller reminded the pilot of the ceiling height reported by the pilot who had previously landed at the airport and stated that he had turned the airport lighting to its maximum intensity. After the controller provided the pilot with several additional radar vectors, at 0413:07, the pilot stated, "have the field mooney six six bravo bravo." At 0413:07, the airplane was about 0.7 nautical mile north of the runway 23 threshold, at a GPS altitude of 265 ft, and on a ground track oriented roughly toward the runway threshold. No further radio transmissions were received from the pilot.

At 0413:20, the airplane began tracking westward and away from the runway, while its GPS altitude varied between 180 and 280 ft. At 0413:34, the airplane began tracking back toward the runway and entered a descent. During the final 9 seconds of recorded GPS data, the airplane descended from a GPS altitude of 269 ft to 134 ft, and the calculated average descent rate during this period was 900 ft per minute. The final recorded point was nearly coincident with the as-found position of the airplane at the accident site, and the final GPS-depicted location was also consistent with the debris path observed there.

PERSONNEL INFORMATION

The pilot, age 61, held a private pilot certificate with ratings for airplane single and multi-engine land, as well as instrument airplane. He held an FAA third-class medical certificate, which was issued in March 2013 with the limitation "must wear corrective lenses for near and distant vision." On that date, the pilot reported that he had accumulated 1,160 total hours of flight experience, 18 hours of which were accumulated in the 6 months prior. The pilot's personal flight logs could not be located, and his currency and recency of flight experience could not be verified.

According to the owner of the accident airplane, shortly before the accident pilot initially departed from Virginia on the trip to Florida

NTSB Probable Cause

The pilot's failure to properly execute the instrument approach procedure. Contributing to the accident were the pilot's improper preflight planning and his decision to conduct the flight in instrument meteorological conditions at night into forecast moderate turbulence and with inadequate avionics equipment for the planned flight.