Lessons Not Learned

The accident occurred nine years almost to the day after an 18,600-hour airline transport pilot flew a Beech Baron into the lake just after departing from the same airport on a nighttime positioning flight. In the case of the Citation, the Board surmised that due to the pilots recent transition from a Citation Mustang with a different panel layout, he might have been unaware that hed never engaged the autopilot as hed presumably intended. On the night of the Baron accident, ceilings were 25,000 feet and visibility unrestricted, but the moon and city lights were behind the pilot once he turned north over the lake.

David Jack Kenny

Friday, April 26, 2019 at 12:00 AM ET

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Key Takeaways:

Spatial disorientation (SD) remains a persistent and deadly problem in aviation, causing fatal accidents despite over a century of technological advancements in instrumentation and aircraft automation.
Even with sophisticated equipment like glass cockpits and autopilots, pilots often succumb to SD due to human physiological limitations, misuse or non-engagement of automation, and a tendency to expand operational envelopes rather than simply reduce existing risks.
Effective mitigation against SD relies heavily on rigorous pilot training, consistent proficiency maintenance, trusting instruments over unreliable sensory perceptions, and employing smooth control inputs, as technology alone has not eliminated the risk.

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On December 29, 2016, a Cessna 525C Citation CJ4 crashed into Lake Erie less than a minute and a half after taking off from Cleveland’s Burke Lakefront Airport, killing all six on board. The NTSB eventually concluded that the pilot became disoriented climbing into low clouds over the lake on a dark night.

The accident occurred nine years almost to the day after an 18,600-hour airline transport pilot flew a Beech Baron into the lake just after departing from the same airport on a nighttime positioning flight. In the case of the Citation, the Board surmised that due to the pilot’s recent transition from a Citation Mustang with a different panel layout, he might have been unaware that he’d never engaged the autopilot as he’d presumably intended. On the night of the Baron accident, ceilings were 25,000 feet and visibility unrestricted, but the moon and city lights were behind the pilot once he turned north over the lake.