AOPA Pilot Magazine - June 2013 - 63

The assigned missed approach was to fly runway heading, and climb to 4,000 feet, which the pilot
acknowledged. There were no further transmissions
and after reaching only 1,600 feet at 5:45:52, the aircraft
descended. The Baron crashed two miles from the runway and about 800 feet left of the localizer. There were
no survivors.

is rapidly applied. An airplane
will naturally pitch up with
power application, which adds
to the illusion. A pilot may overreact by lowering the nose too
far and flying into the ground.
ANALYSIS. Perhaps there’s

THE PILOT. The 49-year-old pilot held an airline transport pilot certificate issued in 2008. Her private pilot
certificate was issued in 1984. She added an instrument rating in 2000 with a commercial pilot certificate
in 2001. Second-in-command (SIC) type ratings were
issued for the Lear 45 and Beechjet 400 in 2007. The
pilot was qualified to act as PIC in the Baron exactly one
year prior to the accident, on March 30, 2010.
At the time of the accident the pilot had 2,884 hours
of flight experience, 856 hours of which were acting as
PIC. She had logged 117 hours in the Baron, with 95
hours as PIC. Since her last instrument proficiency
check in October 2010 four instrument approaches
and five hours of instrument flight experience were
recorded.
The autopsy revealed that the pilot had taken a number of prescription medications for migraine headaches.
They may, as noted by an NTSB medical officer, “cause
sedation and may impair mental and/or physical ability
required for the performance of potentially hazardous
tasks.” The report further noted, “No blood sample
was available for toxicology testing, therefore the precise blood levels, accurate predictions about a potential
level of impairment, or knowledge about timing of medication ingestion could not be determined.”
THE AIRCRAFT. The 1975 Baron 58 was equipped with
a Garmin GNS 530W (GPS receiver) and complied
with all maintenance requirements at the time of the
accident. An autopilot was installed, as required for
single-pilot operations under Part 135. An unapproved
terrain avoidance warning system also was installed but
it is unknown whether it was in use. No aircraft discrepancies were identified.
NTSB FINDINGS. The probable cause(s) of this accident
was determined as: “The pilot’s spatial disorientation due to a somatogravic illusion while conducting
a missed approach in instrument meteorological conditions, which resulted in the airplane’s descent into
objects and terrain.”
Somatogravic illusion is the sensation that the pitch
attitude is much steeper than it actually is. It can occur
when—during a missed approach, for example—power

SUMMARY
> A Beech Baron 58 is scheduled to fly a roundtrip charter flight from Winston-Salem to
Wilmington, North Carolina.
> Returning to Winston-Salem, weather is below
minimums for an approach and the flight holds
briefly before diverting to Greensboro.
> On a missed approach the pilot experiences
somatogravic illusion. The aircraft crashes two
miles from the runway. There are no survivors.

more to this than just somatogravic illusion. The medications,
speculatively, may have been a
factor despite the pilot having
made two ILSs earlier in the
day. Fatigue and stress should
also be considered. The pilot had been up since 4:30 a.m.
and while she may have been able to nap at Wilmington,
the quality of FBO rest is always in question. She also
was consciously thinking about the weather and wanted
to get her charter customer back to his destination. The
charter business depends on providing excellent service to the customer and pilots try very hard to please.
An experienced professional pilot usually will not
miss a localizer intercept and almost certainly will not
descend below the glideslope inside the final approach
fix. Clearly, she recognized that something was wrong
and started corrective action by initiating the miss.
Unexpected wake turbulence from the preceding
Embraer 145 could have complicated a go-around but
that is also conjecture, and there were no indications
that the flight experienced any sort of upset.
Based on the transcript, the pilot seemed uncertain
about the Greensboro weather and when the controller
noted that nobody else was missing approaches, it was
a natural—if somewhat impulsive—decision to give it a
go. In the 20 minutes preceding the accident, six other
aircraft successfully completed the approach, so that’s
a good indication that it was flyable. Mix fatigue, stress,
possibly some impairment from medication, and really
low weather, and the accident chain is nearly in place.
All that’s needed is perhaps a moment’s inattention
and some vertigo. It can take half a minute or more to
recover once becoming disoriented—more time than
usually is available.
Obvious guidance is to pay extremely close attention during approach. The eyes must be locked on the
primary flight instruments with the appropriate segment altitudes clearly in mind. Write them down on a
Post-it note if needed. On the miss, nothing else is as
important as establishing a positive climb and getting
away from the ground. But more strategically, was her
“inner voice” talking to her, suggesting that this may
not have been the place to be?
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AOPA Pilot Magazine - June 2013

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