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 has remained a persistent and deadly problem in aviation for over a century, affecting even qualified pilots flying technologically advanced aircraft.
Despite significant advancements in aircraft instrumentation and automation, pilots often fail to properly utilize available tools, maintain proficiency, or override their unreliable senses with instruments, contributing to continued accidents.
The introduction of new technologies, from gyroscopic instruments to glass cockpits and autopilots, has not eradicated spatial disorientation accidents, sometimes introducing new challenges like automation misuse or encouraging pilots to push flight envelopes.

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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.