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Old July 13th 03, 07:38 PM
James Robinson
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Dan Luke wrote:

It is too simple to chalk up all these accidents simply to lack of
proficiency.


I was just reading the NTSB report of the King Air that crashed in
Colorado, attributed to spatial disorientation after a partial panel
failure. It seems representative of the problem. The facts are
chilling:

- IMC, alt. 23,200 ft.
- Two person cockpit.
- Experienced pilot - 5117 hours total, 2520 in type.
- Partial panel loss due to AC power failure.
- Failure immediately indicated by flags on affected instruments.
- Remaining instruments, powered by vacuum:
Left - airspeed, turn/slip,
Right - airspeed, turn/slip, altimeter, attitude.
- Aircraft began gently increasing turn within one minute of failure.
- Time between instrument loss and impact - one minute, 33 seconds
- Flight path consistent with graveyard spiral

http://www.ntsb.gov/publictn/2003/AAR0301.pdf

There is something else going on - some human factors issue that
has not been properly identified. I suspect it may be related to
task saturation. If so, instrument panel clutter could be a
contributing factor.


One comment in the report was that the pilot might have had a tendency
to focus on a single problem, and mot paid attention to other things.
He could have been trying to troubleshoot the electrical problem, and
not handed control over to the copilot, who would have had a better view
of the remaining functional instruments.

In any event, it is amazing how quickly the pilot lost control of the
aircraft, considering how this should have been fairly routine: If an AC
inverter had failed, then the changeover to the remaining inverter is
accomplished with a simple flip of a switch, and should have been almost
a reflexive action. The failure would have been immediately obvious, so
it wasn't one of those insidious failures that people don't notice at
first. An experienced IFR pilot should have been aware of the need to
maintain attitude and yet lost control almost immediately. In reading
the report, it seems like such an avoidable accident, yet...