Fatal Crash Following Multiple Diversions and Go-Arounds Despite ATC Assistance Efforts

At about 4:13 a.m. on March 4, 2015, a Mooney M20F was approaching Norfolk International Airport, Virginia, after a long overnight flight from southern Florida. Three people were aboard. The weather was poor, the airplane was being flown in darkness and instrument meteorological conditions, and the pilot was struggling to keep the aircraft where it needed to be.

Within minutes, the Mooney would disappear from radar and collide with trees and terrain.

The accident was not caused by a sudden mechanical failure. Instead, the investigation reconstructed a chain of increasingly difficult decisions: a demanding night flight, forecast turbulence, inadequate navigation equipment, difficulty maintaining the instrument approach, an unsuccessful missed approach, a diversion, and finally a visual transition in an environment where there were very few outside visual references. The NTSB ultimately classified the accident as controlled flight into terrain.

The flight into deteriorating conditions

The pilot had planned a night cross-country flight from southern Florida to Virginia. Before departure, he contacted flight service and filed IFR flight plans for the two legs.

The briefing included an important warning. The second leg was expected to encounter instrument meteorological conditions, moderate turbulence and possible low-level wind shear. The pilot acknowledged the information, but investigators could not establish how thoroughly he had reviewed the forecast because there was no record of a complete briefing from an official access-controlled source.

The first leg was uneventful. After departing around 8:30 p.m., the Mooney landed around 10:40 p.m., refueled and departed again at approximately 11:53 p.m.

By about 3:00 a.m., the airplane had reached the Norfolk area.

The destination was under low IFR conditions.

That was when the problems began to accumulate.

The airplane was equipped with only a handheld GPS receiver, yet the pilot requested an RNAV GPS approach. The controller soon noticed that the aircraft was having difficulty maintaining the final approach course. When questioned, the pilot attributed the problem first to difficulties displaying the approach chart on the GPS and later to the wind correction required to maintain the course.

This distinction mattered.

An approach in instrument conditions is not simply a matter of pointing the airplane toward the runway. The pilot must continuously maintain the published lateral and vertical path while monitoring altitude, heading, navigation information and aircraft performance. In severe weather, workload can rise rapidly.

Here, the pilot was already struggling.

The first approach

The pilot attempted to correct, but the approach eventually became unstable enough that he could not complete it normally. Instead of immediately following the published missed-approach procedure, the airplane descended to an estimated 100 feet above ground level before climbing again.

The controller then instructed the pilot to fly the published missed approach.

The aircraft had now reached a critical point.

The original approach had failed. The weather remained poor. The pilot was having difficulty with the navigation equipment. And the airplane had descended far below the altitude associated with the missed approach before beginning the climb.

Controllers assisted the pilot in diverting to another airport where an ILS approach was available.

In practice, the same problems followed the airplane.

A second airport, the same struggle

The diversion airport offered an ILS, potentially giving the pilot a more robust approach aid than the handheld GPS.

Controllers provided radar vectors.

But the pilot continued to have difficulty maintaining assigned headings and altitudes. He repeatedly described the turbulence and high winds as severe.

At one point, he reported difficulty with his heading indicator, describing apparent precession.

Investigators later examined the gyroscopic heading indicator and found no mechanical anomaly. A functional test showed no abnormal precession. The NTSB concluded that the apparent precession was most likely related to the turbulence itself.

This is an important part of the accident because it demonstrates how an airplane can remain mechanically serviceable while the pilot's workload becomes overwhelming.

The instruments were functioning.

The ILS was functioning.

The controller eventually cancelled one approach after the airplane again failed to remain where it was supposed to be.

A second attempt followed.

The final approach

Around 4:00 a.m., the Mooney was once again attempting an approach.

This time, the aircraft descended to within roughly a mile of the runway and about 200 feet above ground.

The pilot reported that he had the airport in sight.

That statement changed the nature of the situation.

After emerging from the clouds, the pilot was no longer relying exclusively on instruments. He was attempting to complete the final portion of the flight visually.

But the environment below was extremely dark.

The NTSB reconstructed the aircraft's GPS-derived ground track alongside the ATC recordings. At approximately the point where the pilot reported seeing the airport, the airplane was about one-quarter mile offset from the localizer but tracking toward the runway.

Then the airplane abruptly turned.

It made an approximately 90-degree right turn, followed seconds later by a turn back toward the runway.

During the final nine seconds of the flight, investigators calculated a descent rate of approximately 900 feet per minute.

The terrain beneath the airplane was largely unlit water and forest.

The pilot had very little external visual information with which to judge his height or flight path.

The airplane struck the terrain.

All three occupants were killed.

What the wreckage revealed

Investigators found no evidence of a pre-impact mechanical malfunction or failure that would have prevented normal operation.

The diversion airport's ILS equipment was also examined, and no discrepancies were identified with the system used during the attempted approach.

That eliminated one of the most obvious explanations.

The airplane had not simply become uncontrollable because a critical system failed.

Instead, the investigation pointed toward pilot performance, planning and operating conditions.

The pilot's personal flight logs were not recovered, so investigators could not establish his recent instrument experience or currency directly. But his performance during the flight provided significant evidence. He repeatedly struggled to maintain assigned headings, altitudes and navigation courses.

The NTSB concluded that his proficiency in instrument flight was inadequate for the demanding conditions encountered that night.

The handheld GPS was another significant factor. It was not suitable for IFR navigation and instrument approaches.

The accident therefore developed through a combination of small disadvantages rather than one dramatic failure.

The NTSB's conclusion

The NTSB's probable-cause statement was:

“The pilot's failure to properly execute the instrument approach procedure.”

The Board identified contributing factors as the pilot's improper preflight planning and his decision to conduct the flight in IMC at night, into forecast moderate turbulence, while using inadequate avionics for the planned flight.

The wording is significant.

The NTSB did not identify the weather alone as the cause.

It did not identify an equipment failure.

It did not identify ATC as the primary cause.

The weather, equipment limitations and pilot decisions interacted to create an increasingly difficult situation.

Accident Facts

The NTSB investigation docket contains ATC radio communication transcripts and the actual ATC audio, making this accident particularly useful for reconstruction.

The safety lesson

This accident illustrates one of the most difficult realities of instrument flying: a flight can remain technically possible long after it has ceased to be operationally sensible.

The pilot continued trying to complete the flight despite mounting evidence that the combination of weather, equipment and workload was beyond what he could comfortably manage. Each individual problem was survivable. Together, they produced a situation from which there was no longer much margin.

For pilots, the lesson is not simply “don't fly in bad weather.” It is to recognize when a flight is becoming progressively less manageable and to make the conservative decision before workload becomes incapacitating.

The Mooney did not suddenly fall out of the sky.

By the time the final descent began, there was very little margin left.

Sources

• Original ATC recording