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Pilot loses situational awareness, life

By NTSB · November 5, 2009 ·

This November 2007 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

Aircraft: Cirrus SR20. Location: New Windsor, N.Y. Injuries: 1 Fatal, 2 Serious. Aircraft damage: Destroyed.

What reportedly happened: The pilot was attempting his second ILS approach in night instrument meteorological conditions. The weather was below the published approach weather minimums when the accident happened. The first approach resulted in a missed approach. The pilot executed a missed approach and was given clearance to land again. The pilot acknowledged the clearance. There were no further transmissions. The wreckage was found in trees about two miles from the approach end of the runway. The pilot did not survive, but both passengers did. The passengers stated that the airplane was flying in foggy conditions and seemed normal until the airplane hit trees.

Examination of the airplane did not reveal any pre-impact malfunctions. The post-crash investigation determined that the pilot woke up about 19 hours prior to the accident and did not sleep prior to the flight. During the approach the aircraft descended below the glide slope but the pilot was not issued a minimum safe altitude warning (MSAW) by air traffic control because the radar sensor being used to track the airplane did not provide sufficient coverage to trigger an MSAW alarm. A different system was available to the controller that, had it been selected, would have sounded a low altitude alarm.

Probable cause: The pilot’s failure to maintain the proper glide path during an instrument-landing-system approach in fog. The pilot’s fatigue and air traffic control’s failure to issue a minimum safe altitude warning were factors.

For more information: NTSB.gov

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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