Weather (Other) · NTSB ERA15FA325

CESSNA 310R — Titusville, FL

1 fatal High-time pilotIMC
DateAugust 26, 2015
LocationTitusville, FL
AircraftCESSNA 310R
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceApproach-IFR missed approach Windshear or thunderstorm
Pilot age59
Pilot total time1,000 hrs · Experienced
Time in type300 hrs
Fatalities1

Probable cause

The pilot's continued flight into known convective weather conditions, which resulted in the airplane's encounter with thunderstorms and the pilot's subsequent loss of airplane control during a missed approach. Contributing to the accident was the failure of the approach controllers and the tower controllers to provide timely and accurate weather information to the pilot.

NTSB findings

  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
  • Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - C
  • Personnel issues-Action/decision-Action-Lack of action-ATC personnel - F
  • Environmental issues-Conditions/weather/phenomena-Convective weather-Thunderstorm-Effect on operation - C

What happened

About 11 minutes before departing on the personal, cross-country flight between two airports that were about 28 nautical miles (nm) apart, the commercial pilot filed an instrument flight rules flight plan and received a weather briefing. The briefer informed the pilot that the planned route was clear but that thunderstorms were in the areas to the north and to the south of the destination airport. The briefer recommended that the pilot call back before takeoff for an update; however, the pilot did not do so.

When the airplane was about halfway to the destination airport, a terminal radar approach controller informed the pilot that the instrument landing system (ILS) for runway 36 was in use and that the airport was reporting thunderstorms and rain in the vicinity, a visibility of 3 miles, and a broken ceiling at 1,000 ft. The controller also informed the pilot that moderate precipitation extended from the destination airport to 2 nm south of the airport, light precipitation to 8 nm, and heavy to extreme precipitation beyond that; the controller said that he planned to vector the airplane to intercept the ILS 36 approach course about 6 to 7 nm south of the airport in order to keep it clear of the heavy precipitation. However, weather radar information shown on the controller's display indicated that the precipitation directly over the destination airport at that time was of extreme intensity, and it should have been described as such by the controller in accordance with published Federal Aviation Administration (FAA) guidance.

A relief approach controller subsequently provided the pilot with instructions to intercept the ILS 36 approach course. The controller did not provide, nor did the pilot request, any updated weather information. Radar data indicated that the airplane intercepted the approach course about 4.4 nm south of the airport, which was about 1.6 nm inside the final approach fix, and descended along the glideslope. The controller's vectoring of the airplane to intercept the final approach course inside the final approach fix was not in compliance with FAA procedures; however, there is no evidence indicating that the pilot experienced additional difficulty as a result of the abnormal intercept. The pilot subsequently contacted the control tower at the airport and was cleared to land. About 2 minutes later, the pilot advised the tower controller that he did not have the airport in sight and was executing a missed approach.

The tower controller then transferred communications back to the approach controller. Radar data indicated that, while the approach controller was asking the pilot if he wanted to turn to the south to avoid weather north of the airport, the airplane was flying over the airport, and the pilot had begun a right turn. The pilot reported that the airplane was in heavy precipitation, the controller then instructed the pilot to turn right to 210 degrees, and the pilot acknowledged the instruction. No further communication was received from the pilot.

Radar data indicated that, while operating in precipitation of extreme intensity, the airplane completed a 180-degree climbing right turn and then entered a rapid descent. The airplane subsequently impacted a river, and only about half of the airframe was recovered. Examination of the recovered components revealed no evidence of any preimpact mechanical malfunctions that would have precluded normal operation of the airplane. The level of fragmentation of the recovered components indicated that the airplane impacted the water with significant energy; however, it could not be determined whether any components separated from the airplane in flight.

During interviews, both approach controllers reported that they were aware of the precipitation depicted on the radar over the destination airport. Although the radar-depicted weather differed from the reported visual flight rules (VFR) conditions at the airport, they did not discuss the weather conditions with the tower controllers. Further, during interviews, the tower controllers reported that they were aware that the airport visibility had decreased below VFR minima, that a thunderstorm was over the airport, and that the control tower had been struck by lightning. Special weather observations should have been issued when the thunderstorm began about 35 minutes before the accident and when the visibility decreased below VFR minima about 23 minutes before the accident. However, the tower controllers did not issue any special weather observations or provide information about the worsening weather conditions to the approach controllers as required by published FAA guidance.

Although the airplane was equipped with devices, including onboard weather radar, capable of providing in-cockpit weather data to assist the pilot's decision-making, it could not be determined what devices, if any, the pilot was using during the flight. It is likely that, given the adverse weather conditions in the area, the airplane encountered turbulence or windshear associated with thunderstorms, which resulted in the pilot's loss of airplane control. Although the pilot was aware of convective activity in the vicinity of the destination airport, the air traffic controllers' did not provide him with timely and accurate weather information for the airport, such as the increased severity of the storm, lightning activity, and the reduced visibility, as required by FAA directives.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

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