ANC08FA133

The pilot's decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. Contributing to the accident was the pilot's self-induced pressure to complete the flight.

The instrument-rated private pilot departed from a remote lake with a pilot-rated passenger (his older son) and camping gear on board. The pilot had previously conducted a round-trip flight from the lake to the destination airport, dropping off his younger son and returning to the lake to retrieve the camping gear. The airplane's flight path for the second trip from the lake to the destination airport would have been on a north-northwest heading over mountainous terrain. The area frequently has low ceilings and reduced visibility due to rain, fog, and mist. According to the younger son, when they left the lake on the earlier flight, the weather was "open" on the north end of the lake but was "closed" on the south end of the lake. When the airplane did not arrive at the destination airport as expected, the younger son thought that the airplane might have been delayed due to the poor weather conditions in the area. A search was initiated that continued for about 10 days before it was suspended. No radar data were available for the flight, and no emergency transmitter locator (ELT) signal was received from the airplane.About 9 years after the accident, the airplane wreckage was located by a hunter in densely-forested steep terrain about 1.25 miles northwest of the north end of the lake. The location of the wreckage suggested that the airplane impacted the terrain about 5 minutes after departure from the lake. Examination of the engine and airframe at the accident site revealed no evidence of mechanical anomaly or failure that would have precluded normal operation. Due to extensive airframe fragmentation and thermal damage, flight control continuity could not be verified. An examination of the airplane's maintenance records revealed no evidence of uncorrected mechanical discrepancies. Due to the remote location, the wreckage was not recovered. The younger son's statement and reported weather data indicated that the pilot likely encountered low visibility conditions after departure. Given the deteriorating weather conditions when the pilot departed, it is likely that the pilot continued visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. The younger son reported that when search personnel checked the cabin at the lake that they had used, it was absent of camping gear and only trash remained. The son further reported that this probably meant that his father and brother felt they only had a small weather window and quickly departed. A rapid departure in deteriorating weather conditions is consistent with the pilot experiencing self-induced pressure to complete the flight. The autopsy of the pilot and passenger were limited due to only skeletonized remains being recovered. No toxicological tests were carried out. As a result, whether a medical condition or substance use contributed to the accident could not be determined. The airplane's ELT was not identified in the wreckage, and it could not be determined why search and rescue personnel did not receive an ELT signal from the airplane. The lack of radar data available for the flight was likely due to the remoteness and rugged topography of the area where the accident occurred.

Aviation Safety in Alaska The NTSB's safety study, Aviation Safety in Alaska SS-95/03, discusses aviation safety issues with weather and risk taking in Alaska and states, in part: Flying weather in Alaska can be quite variable depending on the climate zone and time of year. Although all parts of Alaska experience periods of instrument meteorological conditions, such conditions are frequent in the Aleutian Islands, Alaska Peninsula, southeast Alaska, and the Arctic Coast during the summer and early fall. Weather conditions can change rapidly in Alaska, and the vast distances between some reporting points will often conceal significant local variations in the weather. VFR flight into IMC usually involves poor pilot decision making, whether in initiating the flight or continuing it into adverse weather. VFR into IMC Accidents The FAA's report, A Human Factors Analysis of Fatal and Serious Injury Accidents in Alaska 2004-2009, discusses five factors associated with poor pilot decision-making in VFR into IMC accidents and states, in part: Weigmann and Goh (2000) list four factors associated with poor pilot decision-making in VFR into IMC accidents. The first factor is poor situation assessment. The pilot lacks experience in interpreting changing weather conditions, especially slowly changing weather. Tiredness, fatigue, and increased workload, or some combination of these, can also increase the likelihood of an inaccurate assessment of the weather. The second factor associated with poor pilot decision-making is faulty risk perception of the dangers involved in flying in marginal weather conditions. Recent research by Shappell et al. (2010) supports the notion that many pilots have a poor understanding and appreciation of the hazards associated with adverse weather conditions. Contributing to this perception, many pilots might have successfully navigated during marginal conditions in the past and so have gained confidence in their ability to succeed again in similar circumstances. The third factor associated with poor pilot decision-making is inappropriate motivations that bias the decision-making process. The term "get-home-itis" refers to the motivation of the pilot to complete the journey. The fourth factor associated with poor pilot decision-making is called "decision framing." Decision framing refers to the idea that a person's choice between a risky or safe course of action depends on whether the choice is framed in terms of a gain or a loss. When the safer course of action is framed in terms of a loss, the decision tends to be risk-seeking. When framed in terms of a gain, the decision tends to be risk-averse. In the case of VFR flight into IMC, research has shown that framing the decision to not fly into marginal weather conditions as a loss (i.e., wasted time, money, and effort) leads to a greater likelihood of continuing the flight, but framing the decision to not fly as a gain (i.e., it is safer) leads to a greater likelihood of diverting the flight (O'Hare & Smitheram, 1995). A fifth factor, one that is not discussed by Weigmann and Goh, is what is referred to as problem- solving set (Gick & Holyoak, 1979), which is the tendency to repeat a solution process that has been previously successful. In addition to altering one's perception of risk, successfully conducting a flight in marginal conditions by using a specific strategy (e.g., following a river while flying underneath the clouds) will increase the likelihood that the strategy will be used again under similar circumstances. Memory plays a crucial role in problem-solving, and repetition plays a crucial role in memory. So when faced with a problem (how do I make it through this weather?), humans tend to adopt a strategy that has been used successfully in the past, even if the current situation does not quite match previous events. Previous NTSB Case Number The previous NTSB case number associated with this accident when the airplane was missing was ANC08FAMS01. An examination of the airplane's maintenance records revealed no evidence of uncorrected mechanical discrepancies with the airframe, engine, and propeller. According to the maintenance records, an Aero Electronics Development Company, Inc., Pointer II ELT was installed in the airplane. On May 21, 2007, an annual inspection was conducted on the airframe, and the logbook entry stated, "inspected and tested ELT, replaced ELT battery, new due date is October 2008." On June 26, 2008, an annual inspection was conducted on the airframe, and the logbook entry stated, "inspected and tested ELT." On August 9, 2008, about 1605 Alaska daylight time, a float-equipped Cessna 182E airplane, N9350X, impacted steep mountainous terrain after departure from Young Lake on Admiralty Island about 15 miles south of Juneau, Alaska. The private pilot and the pilot-rated passenger sustained fatal injuries. The airplane was destroyed. The airplane was registered to and operated by the pilot as a visual flight rules (VFR) personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) were reported along the airplane's anticipated flight path, and no flight plan was filed. The airplane departed from the remote lake about 1600, and the intended destination was the Juneau International Airport Seaplane Base (PAJN) in Juneau. The pilot's youngest son reported that he, his older brother, and his father had been on a family camping trip at Young Lake, and, on the day of the accident, the group was returning to Juneau and determined that it would take two trips to transport all their camping gear. The pilot's son said that after discussing various options, they decided that all three would fly back to Juneau, one of them would stay behind in Juneau, and the other two would return to pick up the remaining camping gear. The son reported that they departed from Young Lake about 1515 and arrived in Juneau about 1540. He reported that when they left Young Lake, the weather was "open" on the north end of the lake but was "closed" on the south end of the lake. The youngest son remained in Juneau, and he reported that the airplane with his father and older brother on board departed from Juneau about 1540 with an anticipated return time of about 1630. The son reported that his father and brother were both experienced pilots and that his father was seated in the left seat when the airplane departed Juneau. He said that he was confident that his father was flying the airplane on the accident flight. After the airplane's 1540 departure from Juneau, there were no reports of communications with the airplane. No radar data were available for the flight. No emergency transmitter locator (ELT) signal was received from the airplane. An Alaska State Trooper reported that about 1915, the pilot's youngest son walked into the Federal Aviation Administration (FAA) Juneau Flight Service Station, to report that the airplane had not returned to Juneau and to inquire about any radio contact with the airplane. The airplane was officially declared overdue at 1932. The son said that he thought that the flight might have been delayed due to poor weather conditions around the Juneau area. Another Alaska State Trooper who participated in the search reported that a witness recalled seeing the airplane depart from Young Lake about 1600. The airplane's anticipated flight path from Young Lake in the Tongass National Forest to Juneau would have been on a north-northwest heading over about 16 miles of tree-covered steep mountainous island terrain, numerous ocean channels, and an extensive shoreline, containing small coves and bays. The area frequently has low ceilings and reduced visibility due to rain, fog, and mist. The U.S. Coast Guard, the U.S. Army Alaska National Guard, the Civil Air Patrol, the Alaska State Troopers, Juneau Mountain Rescue (JMR), and additional search voluntee