Cessna 310 pilot disorientation Night ILS Alice Springs
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From: Australia
Cessna 310 pilot disorientation Night ILS Alice Springs
Flight below minimum sector altitude involving Cessna 310R, VH-ZMB, 14 km west-north-west of Alice Springs Airport, Northern Territory, on 1 July 2024 AO-2024-039 01/07/2024 Final 20/03/2025. The Final Report just published
For some unknown reason I was unable to download the Final Report despite earlier having no trouble dowloading it successfully. Could be finger trouble on my part.
Basically it seems the pilot got badly disoriented while manoevering to get on to the ILS on a black night approach into Alice Springs. He had angles of bank varying from 60 degrees to 45 degrees while on the LLZ which he thought was failure of the captains AH and gyro compass. He was within 800 ft of high terrain at one stage. Eventually he landed safely.
The ATSB investigation revealed the AH did have slight errors beyond normal tolerances but was considered by ATSB as not affecting safety of flight and that it was pilot disorientation in IMC that was the primary cause of the incident. Certainly a frightening experience for the pilot. Then you have to ask how bad was the maintenance to allow an out of tolerance AH which no doubt would not have been written up in the maintenance by other pilots who flew that particular Cessna 310
The report showed a photo of this Cessna 310 flight instrument panel. The first thing that interested me was the position of the second AH which was on the co-pilot's side if one was carried. It was situated low down and to the far right and completely out of view from the left seat pilot unless he leaned right over to his right and looking down which would have really disoriented the most competent of pilots. I understand that two AH's are required to be installed for IFR twins. In this case the pilot of this aircraft having a suspicion that his AH is defective could have checked the second AH as a comparison. But it was practically impossible for him to do this because that second AH was well out of his scan
I have seen this type of installation of second AH's on numerous GA types making the aircraft hard to fly in IMC since that AH is often placed in an awkward spot on the instrument panel that makes it difficult to scan easily. Yet it apparently meets the IFR requirements. This situation was like that 30 years ago. If a second AH is the legal requirement then put it directly in front of the right seat pilot not impossibly tucked in the bottom corner of the instrument panel. CASA flight safety people - where are you when you are needed most?. I would have thought ATSB could have mentioned the impossibility of the pilot being able to use the second AH in its present position on the instrument panel and make appropriate flight safety recommendations.
It could be argued the pilot already had an electrically powered Turn Coordinator as a cross reference to his AH. But what an utterly useless flight instrument that is when the chips are down on a black IMC night unless you are current and highly proficient on limited panel flying - a very rare attribute nowadays.
In response to the CASA input to this incident, the company recommended its pilots use the autopilot in IMC to reduce pilot workload. While they are fine words, autopilot proficency is far removed from manual instrument flying proficiency. Ask any airline pilot if is he happy to fly a raw data ILS in IMC. No way!.
For some unknown reason I was unable to download the Final Report despite earlier having no trouble dowloading it successfully. Could be finger trouble on my part.
Basically it seems the pilot got badly disoriented while manoevering to get on to the ILS on a black night approach into Alice Springs. He had angles of bank varying from 60 degrees to 45 degrees while on the LLZ which he thought was failure of the captains AH and gyro compass. He was within 800 ft of high terrain at one stage. Eventually he landed safely.
The ATSB investigation revealed the AH did have slight errors beyond normal tolerances but was considered by ATSB as not affecting safety of flight and that it was pilot disorientation in IMC that was the primary cause of the incident. Certainly a frightening experience for the pilot. Then you have to ask how bad was the maintenance to allow an out of tolerance AH which no doubt would not have been written up in the maintenance by other pilots who flew that particular Cessna 310
The report showed a photo of this Cessna 310 flight instrument panel. The first thing that interested me was the position of the second AH which was on the co-pilot's side if one was carried. It was situated low down and to the far right and completely out of view from the left seat pilot unless he leaned right over to his right and looking down which would have really disoriented the most competent of pilots. I understand that two AH's are required to be installed for IFR twins. In this case the pilot of this aircraft having a suspicion that his AH is defective could have checked the second AH as a comparison. But it was practically impossible for him to do this because that second AH was well out of his scan
I have seen this type of installation of second AH's on numerous GA types making the aircraft hard to fly in IMC since that AH is often placed in an awkward spot on the instrument panel that makes it difficult to scan easily. Yet it apparently meets the IFR requirements. This situation was like that 30 years ago. If a second AH is the legal requirement then put it directly in front of the right seat pilot not impossibly tucked in the bottom corner of the instrument panel. CASA flight safety people - where are you when you are needed most?. I would have thought ATSB could have mentioned the impossibility of the pilot being able to use the second AH in its present position on the instrument panel and make appropriate flight safety recommendations.
It could be argued the pilot already had an electrically powered Turn Coordinator as a cross reference to his AH. But what an utterly useless flight instrument that is when the chips are down on a black IMC night unless you are current and highly proficient on limited panel flying - a very rare attribute nowadays.
In response to the CASA input to this incident, the company recommended its pilots use the autopilot in IMC to reduce pilot workload. While they are fine words, autopilot proficency is far removed from manual instrument flying proficiency. Ask any airline pilot if is he happy to fly a raw data ILS in IMC. No way!.
Last edited by Centaurus; 21st March 2025 at 12:15.
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From: Oz
Can they also post the experience of the ATC on these reports? And how many jobs at the time they had been doing? And why they didn’t advise a safety alert? They reported the PIC sounded stressed, then mentions 800ft above terrain. Safety Alert please! This isn’t the first time the ATSB has called out this area in recent times.
I get the pile on for PICs in any incident, and in this case, I get that it was probably the PICs first month or so checked to line in the first job, but I still think closer analysis on what is going on inside ASA at the moment is also required.
I get the pile on for PICs in any incident, and in this case, I get that it was probably the PICs first month or so checked to line in the first job, but I still think closer analysis on what is going on inside ASA at the moment is also required.
Joined: Oct 2023
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From: Townsville
That kid is lucky to be alive! The lack of safety actions from the operator is concerning….
I’d suggest that the root cause of this near CFIT occurrence would be due to lack of training and subsequent inability of the pilot to adequately fly an IAP in actual IMC conditions…. Yes using a basic autopilot may help, but I’d suggest that’s that doesn’t really fix the underlying issue.
I’d suggest that the root cause of this near CFIT occurrence would be due to lack of training and subsequent inability of the pilot to adequately fly an IAP in actual IMC conditions…. Yes using a basic autopilot may help, but I’d suggest that’s that doesn’t really fix the underlying issue.
Joined: Jul 2008
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From: Australia
Basically it seems the pilot got badly disoriented while manoevering to get on to the ILS on a black night approach into Alice Springs.
The pilot got himself all out of shape and was lucky to get away with it. Low TT and low IF experience is a risky combination in single pilot piston engine ops. With all the posts about trying to get work in the top end it seems unusual that someone was given a job flying 310s with 320 hours and a brand new CPL MECIR. My recommendation to any low time IFR pilot in that part of the world is to hand fly and practise instrument approaches "eyes down" as often as possible. The operator's solution is to mandate the use of the autopilot. My question would be how well is the auto pilot maintained if the AH wasn't up to specs?
The pilot is lucky he didn't join the Westwind, hopefully he has learnt a valuable lesson.
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From: Oz
With all the posts about trying to get work in the top end it seems unusual that someone was given a job flying 310s with 320 hours and a brand new CPL MECIR.
Perhaps the PIC is a family member or well known to the owner/operator, or could be the owner. I knew a guy a long while back who purchased an outfit, then gave himself a job on the twin off the bat.
Fleet Manager
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From: various places .....
The first thing that interested me was the position of the second AH which was on the co-pilot's side
Centaurus, like me, has a concern with stupid instrument panel layouts. While not arguing against the contention that inexperience and lack of training don't fit well with increasing aircraft sophistication and speed, the inside additional difficulties due to panel layout is a very real problem.
Historically, there have been more than a few fatalities where inappropriate pilot controls/switching has been implicated in the causation.
From a design point of view, the underlying requirement is that panel stuff is supposed to be assessed for acceptability by appropriate FT folk. For whatever reason, in Australia, that has never been a driving consideration in the airworthiness field.
As an aside, I well remember (from very long ago) an endorsement on a single seater done in a hurry on the Friday so I could do the glider towing on the weeked to help out the gliding club. The endorsement was done in weather which might not have been considered ideal ... but that's another story. The point of this yarn is that the ASI was stuck up on the top of the instrument coaming (go figure ?) and, due to the low weight and relatively big motor, on the first takeoff the bird went like SOAS and I found myself about three circuits behind the aircraft. By the time it was well off the ground, I eventually found the ASI, which helped out just a little bit. By the time I had ripped around a (fairly) low circuit, all was well and a little bit more saw me happy with the aircraft. I can't recall whether, subsequently, I ever got around to having a look at the bird's stall characteristics but, that again, is another story for another day.
There be dragons out there for the unwary. I thought an observation the other day from a colleague, in regard to some of our newchum theory students was very pertinent -"Wisdom and hindsight are two sides of the same coin, they (as in the students) have yet to discover their piggy bank is empty".
Centaurus, like me, has a concern with stupid instrument panel layouts. While not arguing against the contention that inexperience and lack of training don't fit well with increasing aircraft sophistication and speed, the inside additional difficulties due to panel layout is a very real problem.
Historically, there have been more than a few fatalities where inappropriate pilot controls/switching has been implicated in the causation.
From a design point of view, the underlying requirement is that panel stuff is supposed to be assessed for acceptability by appropriate FT folk. For whatever reason, in Australia, that has never been a driving consideration in the airworthiness field.
As an aside, I well remember (from very long ago) an endorsement on a single seater done in a hurry on the Friday so I could do the glider towing on the weeked to help out the gliding club. The endorsement was done in weather which might not have been considered ideal ... but that's another story. The point of this yarn is that the ASI was stuck up on the top of the instrument coaming (go figure ?) and, due to the low weight and relatively big motor, on the first takeoff the bird went like SOAS and I found myself about three circuits behind the aircraft. By the time it was well off the ground, I eventually found the ASI, which helped out just a little bit. By the time I had ripped around a (fairly) low circuit, all was well and a little bit more saw me happy with the aircraft. I can't recall whether, subsequently, I ever got around to having a look at the bird's stall characteristics but, that again, is another story for another day.
There be dragons out there for the unwary. I thought an observation the other day from a colleague, in regard to some of our newchum theory students was very pertinent -"Wisdom and hindsight are two sides of the same coin, they (as in the students) have yet to discover their piggy bank is empty".
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From: The Coal Face
Someone obviously forgot to spell check the document prior to publish
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
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.
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
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?
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:
Come again?
Fly the aircraft first. Now we're reporting risk increases?
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.
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
ATC subsequetly cleared the pilot to climb to 5,500 ft
Tracking greater the 90° off LOC
and tracking at a perpindicular direction
In their state of distress, the pilot did not broadcast a PAN 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.
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.
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.
And then there's this:
to achieve an altitude that would remove the aircraft’s exposure to the risks of collision with terrain.
Pilots should not hesitate to report an urgent condition when encountering situations that may not be immediately perilous but significantly increase risk.
Instrument flight can be considered one of the more challenging operational environments to which a pilot can be exposed.
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.
Post occurrence fault-finding of the artificial horizon, identified gradual and inconsistent deviations outside the manufacturer’s required tolerances?
Last edited by Chronic Snoozer; 22nd March 2025 at 13:20.
Joined: Jul 1999
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From: Australia
Out of interest are we talking a raw data ILS or using a flight director ?
Not sure I have quite the confidence as one of the posters above who claims instrument flight to be bread and butter stuff for anyone with an instrument rating. I have flown IMC for the last 25 years and I always move up a gear of concentration and alertness when entering cloud or decreased visibility environments.
I wish the pilot well and hope he receives some extra training to regain confidence in the black arts.
Not sure I have quite the confidence as one of the posters above who claims instrument flight to be bread and butter stuff for anyone with an instrument rating. I have flown IMC for the last 25 years and I always move up a gear of concentration and alertness when entering cloud or decreased visibility environments.
I wish the pilot well and hope he receives some extra training to regain confidence in the black arts.
Joined: Jan 2008
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From: All at sea
Out of interest are we talking a raw data ILS or using a flight director ?
Not sure I have quite the confidence as one of the posters above who claims instrument flight to be bread and butter stuff for anyone with an instrument rating. I have flown IMC for the last 25 years and I always move up a gear of concentration and alertness when entering cloud or decreased visibility environments.
I wish the pilot well and hope he receives some extra training to regain confidence in the black arts.
Not sure I have quite the confidence as one of the posters above who claims instrument flight to be bread and butter stuff for anyone with an instrument rating. I have flown IMC for the last 25 years and I always move up a gear of concentration and alertness when entering cloud or decreased visibility environments.
I wish the pilot well and hope he receives some extra training to regain confidence in the black arts.
Instrument flight becomes hard either through lack of practice in real IMC (as opposed to ‘pretending’ in bright daylight under the hood), or after being spoiled by over reliance on flight directors and automation.
Joined: Jul 2007
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From: Australia
Something that always intrigues me, this C310 has been on the register in Australia since 1978, but in 2025 we still have the standby AH down on RHS side of the panel.
Back in the day DCA would have been involved in getting it on the register, how many pilots would flown the thing, numerous IFR renewals would have been conducted in it, surely somebody would have said this standby AH is in the wrong position, or RHS side of the panel needs to be tidied up?
An AH failure on night rotation at Alice Springs, that standby AH is not really going to be in your scan is it? Not to mention the high quality instrument light in a nearly fifty year old twin!
Back in the day DCA would have been involved in getting it on the register, how many pilots would flown the thing, numerous IFR renewals would have been conducted in it, surely somebody would have said this standby AH is in the wrong position, or RHS side of the panel needs to be tidied up?
An AH failure on night rotation at Alice Springs, that standby AH is not really going to be in your scan is it? Not to mention the high quality instrument light in a nearly fifty year old twin!
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From: Aust
Man Bilong Balus long PNG
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From: Back home again after another fantastic time in Japan; once again back to the 'real world' and continuing the seemingly never ending search for a bad bottle of Red.
I often wonder how the much missed Mac Job would view the current situation......
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From: cowtown
Scan Scan Scan
For pilots that do not hand fly a lot of approaches I heartily recommend playing video games . Playing video games maintains eye hand coordination and improves the Scan . Far better than the old playboy- penthouse eye hand coordination training . Not really sure if that helped anyone improve their scan .
Scan Scan Scan
Flying single pilot at night with old steam driven dials in poor lighting with random non standard configurations of the instrument panel has been replaced with far safer more productive instrumentation . Reducing workload and allowing the GA aircraft to be operated far more productively. Highly recommend upgrading to lighter instrument panels and getting rid of heavy old equipment. We gained 150 lbs removing old radios with recent upgrading in one Aircraft .
Scan Scan Scan
The best trick for IFR flying is to Scan by moving your eyes first before moving your head . The technique reduces head movement minimizing opportunities for disorientation. Makes a huge difference in turbulence . Allows the eyes to override what your vestibular ears are telling your brain .
Blue Skies .
For pilots that do not hand fly a lot of approaches I heartily recommend playing video games . Playing video games maintains eye hand coordination and improves the Scan . Far better than the old playboy- penthouse eye hand coordination training . Not really sure if that helped anyone improve their scan .
Scan Scan Scan
Flying single pilot at night with old steam driven dials in poor lighting with random non standard configurations of the instrument panel has been replaced with far safer more productive instrumentation . Reducing workload and allowing the GA aircraft to be operated far more productively. Highly recommend upgrading to lighter instrument panels and getting rid of heavy old equipment. We gained 150 lbs removing old radios with recent upgrading in one Aircraft .
Scan Scan Scan
The best trick for IFR flying is to Scan by moving your eyes first before moving your head . The technique reduces head movement minimizing opportunities for disorientation. Makes a huge difference in turbulence . Allows the eyes to override what your vestibular ears are telling your brain .
Blue Skies .
