Deadly Disorientation: Leaving an Approach Between Cloud Layers

An instrument approach is a protected path to the ground. Leave it early, below the clouds but not clear of them, and you give up that protection while still needing the instruments to stay upright.

The AOPA Air Safety Institute (ASI) re-creates this flight in its video "Accident Case Study: Deadly Disorientation," which you can watch below. The summary that follows is ours and is based on the NTSB final report (WPR22FA004), which also gives the official probable cause. Watch the full case study for ASI's own analysis.

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The flight, in short

On October 11, 2021, a 64-year-old commercial pilot with an instrument rating and about 1,566 hours was flying a Cessna 340A into Montgomery-Gibbs Executive Airport (MYF) in San Diego. The controller's weather update gave 10 miles visibility, a broken layer at 1,700 feet and an overcast at 2,800 feet. He was cleared for the ILS to runway 28R, circling to land on runway 23. His logbook showed a recent instrument proficiency check but no circle to land in the period it covered. The airplane's avionics had been replaced about 11 months earlier, and the NTSB found no record of training on that equipment.

About to join the localizer, the airplane drifted right of course. Asked if he was correcting, the pilot said yes, then about 9 seconds later reported “VFR runway 23.” The controller said he wasn't tracking the localizer, canceled the approach clearance and told him to climb to 3,000 feet, then issued a low altitude alert. Over the next 2 minutes the controller told him several times to climb to 4,000 feet. The pilot acknowledged, but the airplane stayed between 2,500 and 3,500 feet, between the two cloud layers and in and out of the clouds. After another low altitude alert and an instruction to expedite a climb to 5,000 feet, the pilot stopped responding.

The airplane climbed to 3,500 feet, then entered a descending right turn at about 5,000 feet per minute and struck the ground in a Santee neighborhood. The pilot and one person on the ground were killed, and two others on the ground were seriously injured. The NTSB found no problem with the airframe or engines.

The NTSB determined the probable cause to be: “Loss of control due to spatial disorientation.”

Why staying on the approach matters

The NTSB noted that continuing the ILS would have let the pilot fly a stabilized approach in protected airspace and get below the clouds before circling. Leaving it put him maneuvering in instrument conditions, which is where spatial disorientation takes hold. The NTSB could not determine whether the avionics were set up wrong for the approach.

• Fly the whole approach. A glimpse of the runway through a broken layer is not the same as being clear of the clouds.
• Know the new avionics cold before you fly them in instrument conditions. Get training on the exact equipment in your airplane.
• Practice circling approaches. They're low, slow and close to the ground, and they rarely show up in routine training.
• When a controller says climb, climb now, on instruments, and fly the attitude indicator.