Someone obviously forgot to spell check the document prior to publish
ATC subsequetly cleared the pilot to climb to 5,500 ft
Tracking greater the 90° off LOC
and tracking at a perpindicular direction
I've read better reports. It focuses on a PAN call (13 mentions) and mentions terrain clearance of 810 feet no fewer than 5 times which is a touch sensationalist, as is
In their state of distress, the pilot did not broadcast a PAN PAN call
I'd say this pilot learnt a very salient lesson but I doubt that he is thinking "I should have made a PAN call".
No doubt, IMC below MSA is a horrible situation to be in but
why did it happen? As Centaurus touched on, the ridiculous placement of the second AH is arguably the one of the main factors yet sails by the investigators' gaze.
The pilot reported that the autopilot could not be engaged post the occurrence, when positioning for the second approach.
In spite of this, the report continues to lecture us about what an autopilot does and why it's a good thing. There is no substitute for being able to hand fly in IMC to the minima and conduct a safe landing. This report recommends using the autopilot more. What a retrograde step, let's ignore fundamental flying skills and use more automation in a 50 year old aircraft. Perplexing.
Listed under Contributing Factors
The pilot did not maintain track or glidepath and deviated from instrument landing system below the minimum sector altitude. Once outside of the required tolerances, the pilot did not conduct a missed approach, which increased the risk of collision with terrain.
That is not a factor, that is a symptom of spatial disorientation. It's pretty difficult in midst of that, to recognise it and initiate a missed approach.
Why did it happen?
The pilot did not broadcast a PAN PAN call notifying air traffic control and other traffic of their situation, leading to the pilot remaining below minimum sector altitude for an extended period without air traffic control instruction to climb.
Making a PAN call under such circumstances would do little more than use up what mental capacity is left. Aviate then Navigate. Communicate when it's appropriate. Once you know which way is up, advise ATC and ask them to monitor your next approach which this pilot appears to have done.
And then there's this:
to achieve an altitude that would remove the aircraft’s exposure to the risks of collision with terrain.
Come again?
Pilots should not hesitate to report an urgent condition when encountering situations that may not be immediately perilous but significantly increase risk.
Fly the aircraft first. Now we're reporting risk increases?
Instrument flight can be considered one of the more challenging operational environments to which a pilot can be exposed.
No, it's bread and butter stuff for anyone with an instrument rating. That's what all the training is for.
Speaking of training, where's the section in the report which explores the pilot's training? What we get is swathes of text quoting chapter and verse from the regulations without any meaningful analysis of why and how this occurred to a Part 135 operator. No confirmation that fatigue or medical issues were checked.
What has been done as a result The operator has since introduced an automation policy for the use of autopilot in instrument meteorological conditions and in high workload single-pilot operations.
But what has been done to ensure that anyone who flies that aircraft and cannot engage the autopilot, doesn't suffer from spatial disorientation given that
Post occurrence fault-finding of the artificial horizon, identified gradual and inconsistent deviations outside the manufacturer’s required tolerances?