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NTSB investigation record

CEN12FA080

Completed

Diamond aircraft ind inc Da20-c1· N203MK

Date
November 24, 2011
Location
Bern, WI
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The non-instrument-rated pilot's continued visual flight into instrument meteorological conditions, which resulted in a loss of control and subsequent impact with the terrain.

Investigator assessment

Analysis narrative

The non-instrument-rated pilot checked the weather prior to the night cross-country flight. Two other pilots, who individually discussed the weather conditions with the pilot, reported that the weather appeared to be deteriorating for his intended route of flight. The accident pilot stated to the other pilots that he would "scud run," or fly below the weather, if he had to. Weather conditions at the departure airport were clear, but deteriorated to instrument meteorological conditions along the route of flight. Based on the weather information, the pilot likely flew into an area of instrument meteorological conditions and lost control. The airplane impacted trees and terrain about 22 miles from the destination airport. Conditions at the destination airport, which was the nearest weather observation station, around the time of the accident included 3-mile visibility with mist and an overcast ceiling at 500 feet. No mechanical failures or malfunctions were identified that would have precluded normal operation of the airplane.

Source record

Factual narrative

An autopsy was performed on the pilot at the University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin, on November 25, 2011. The death of the pilot was attributed to injuries sustained in the accident. Toxicology testing for the pilot was performed by the Federal Aviation Administration Civil Aerospace Medical Institute. The test results were negative for all substances tested. According to a witness the pilot used the computer at North Star Aviation to check the weather conditions earlier in the evening on the day of the flight. North Star Aviation uses the MX Vision Aviation Sentry system for obtaining weather data. Discussion with personnel from MX Aviation Sentry revealed that they cannot retrieve data that was requested for a weather briefing. Therefore, it could not be determined exactly what weather data the pilot retrieved for the flight. Several recorded surface weather observations were reviewed. Those observations were as follows: RLL, 22 miles east-northeast of the accident site, reported the conditions at 2255 were wind from 240 degrees at 8 knots; visibility 3 miles with mist; ceiling 500 overcast; temperature 2 degrees Celsius; dew point 2 degree Celsius, and altimeter 30.07 inches of mercury. Wausau Downtown Airport (AUW), Wausau, Wisconsin, 27 miles southeast of the accident site, reported the conditions at 2254 were wind from 230 degrees at 6 knots; visibility 5 miles with mist; ceiling 700 overcast; temperature 3 degrees Celsius; dew point 1 degree Celsius, and altimeter 30.07 inches of mercury. Wausau- Central Wisconsin Airport (CWA), Wausau, Wisconsin, 31 miles southeast of the accident site, reported the conditions at 2255 were wind from 230 degrees at 7 knots; visibility 5 miles with mist; ceiling 600 overcast; temperature 2 degrees Celsius; dew point 2 degree Celsius, and altimeter 30.09 inches of mercury. Chippewa Valley Regional Airport (EAU), Eau Claire, Wisconsin, 68 miles west-southwest of the accident site reported the conditions at 2156 were wind from 180 degrees at 5 knots; visibility 5 miles with mist; clear skies; temperature 2 degrees Celsius; dew point 1 degree Celsius, and altimeter 30.06 inches of mercury. The departure airport, MKT, reported the conditions at 2135 were wind from 190 degrees at 8 knots; visibility 5 miles; clear skies; temperature 3 degrees Celsius; dew point 1 degree Celsius, and altimeter 30.05 inches of mercury. Airmen's Meteorological Information (AIRMET) Sierra, issued at 1836, was in effect at the time of the accident. The AIRMET called for instrument meteorological conditions with ceilings below 1,000 feet and visibilities below 3 miles with mist and fog. The AIRMET encompassed the location of the accident. Radiosonde data from the Austin Straubel International Airport (GRB), Green Bay, Wisconsin, at 1800 indicated the cloud tops were around 2,300 feet. The airplane impacted the terrain in a heavily wooded area which contained trees in excess of 60 feet tall. The airplane traveled about 350 feet through the trees on a magnetic heading of 84 degrees prior to coming to rest. Trees along the wreckage path were broken along a descent angle of about 30 degrees. The first impact mark was with a tree at a height of 40 feet above the ground. A section of the right wing flap and pieces of the canopy were located near the initial tree strike. A piece of one wooden propeller blade was located about 50 feet from the initial tree strike. Sections of the elevator were located about 75 feet from the initial tree strike. The majority of the right wing and a section of the rudder were located within the first 150 feet of the wreckage path. The first identifiable ground scar was about 175 feet from the initial tree impact. Sections of the fuselage, cockpit, engine cowl, and propeller were located near the initial ground scar. The engine was separated from the fuselage and it was located about 50 feet from the main wreckage. The propeller spinner and nose gear were located near the engine. Airframe The main portion of the fuselage was located on its right side with the left wing lying nearby. Both main landing gears remained attached to the fuselage. The canopy was completely separated from the fuselage. The fuselage area was separated just aft of the wing attach point. The empennage was separated 3 feet forward of the vertical stabilizer. The fuel tank was compromised and empty of fuel. The emergency locator transmitter was separated from the wreckage. The propeller hub was separate from the engine at the crankshaft with pieces of the wooden propeller blades attached in the hub. The majority of both propeller blades were separated and found along the wreckage path. The tips of both blades were not located. The empennage was separated into numerous pieces. The rudder was partially separated from the vertical stabilizer. The right horizontal stabilizer was separated from the empennage. The outboard 2/3 of the elevator remained attached to the horizontal stabilizer. The left horizontal stabilizer was fractured and separated from the empennage. The elevator remained intact except for the inboard section. Continuity was established between the cockpit control stick and the elevator push/pull tube in the aft fuselage at which point the tubes were broken and separated. The rudder cables were attached to the rudder pedals in the fuselage. Continuity was established aft to where the cables were separated from the rudder surface. Both rudder cables exhibited broomstraw separations. The left wing was located near the nose of the airplane. The flap was separated into three pieces and the aileron was separated into two pieces. The leading edge outboard section of the wing was ripped and shredded aft to the main spar. The right wing was separated into four sections which were located along the wreckage path. The aileron was separated into three pieces; a one-foot-long outboard section was not located. The flap was separated from the wing in two pieces. Aileron continuity was established from the control stick to aft of the cockpit bulkhead. One push-pull control tube for the right aileron was separated and missing, and the other was separated near the wing root. Both tubes for the left aileron were present. One was separated at the mixing unit in the fuselage and the other remained attached at the mixing unit. Sections of push/pull tubes were located amongst the wreckage. It was not identified which control surfaces the tubes were for. The power lever was in the idle position, the mixture control was full rich, and the alternate air lever was in the closed position. Engine The crankshaft propeller flange was fractured and remained attached to the separated propeller. All of the cylinders remained attached to the crankcase. The rocker arms and rocker arm covers for the intake valve on the number 2 and number 3 cylinders were missing. Both magnetos and the vacuum pump were separated from the engine. The right magneto sustained impact damage. The magneto was disassembled and no anomalies were noted. The left magneto was fractured into several pieces. All of the spark plugs exhibited normal operating signatures. A portion of the mixture control cable remained attached to the mixture control lever; the mixture control lever was observed near the lean position and it moved freely. The fuel pump drive coupling was intact and the fuel pump drive moved freely by hand. The fuel pump was disassembled and no anomalies were noted. The fuel manifold valve was disassembled and the fuel screen was clean. The diaphragm was intact and the diaphragm retaining nut was secure. No scoring was observed on the fuel valve assembly. The fuel injector lines remained attached to their respective f

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