CEN15FA092

The noninstrument-rated pilot’s continued flight into night instrument meteorological conditions, which resulted in his failure to maintain clearance from terrain.

The operator reported that the noninstrument-rated pilot departed on a cross-country flight in the airplane after topping off the fuel tanks. Radar data and fuel records revealed that, about 3 hours later, the airplane stopped at an airport and was fueled. The airplane subsequently departed and flew toward the pilot's destination airport for about 30 miles, but it then returned to the same airport to be fueled again. The airplane subsequently departed again and flew toward the destination airport. Radar data showed that the airplane then climbed to 10,500 ft mean sea level but that it subsequently began to descend; the last radar return showed the airplane at 7,100 ft msl. The airplane was reported missing when it did not arrive at the destination. A subsequent search was conducted, and the airplane's emergency locator transmitter signal was used to find the wreckage. The airplane had impacted rising terrain in a level flight attitude. An examination of the wreckage did not reveal any preimpact anomalies that would have precluded normal operation. Witness marks and bending found on the propeller were consistent with the engine producing power at the time of impact. Multiple weather sources showed that instrument meteorological conditions existed along the route of flight and that these were reported before the accident airplane departed. Additionally, the freezing level was at the surface, and moderate turbulence was expected from the surface through 24,000 ft. Pilots flying in the area around the time of the accident confirmed the presence of turbulence and/or mountain-wave conditions, and they indicated the presence of icing in the clouds with cloud tops near 9,000 ft. Further, no moonlight was present during the flight. No record was found indicating that the pilot received a formal preflight weather briefing; if the pilot had received a formal weather briefing, he would have been made aware of the weather conditions along the route of flight. Although the investigation could not determine what weather information the pilot might have reviewed before departure, his decision to conduct the flight in poor weather conditions was indicative of poor decision-making. The evidence is consistent with the noninstrument-rated pilot flying at night in instrument conditions while likely attempting to fly under the clouds when the airplane hit rising terrain. Toxicological testing of the pilot detected tetrahydrocannabinol (THC). However, the investigation could not determine if the pilot was impaired from the THC before or during the accident flight.

An NTSB air traffic control specialist acquired radar data from the FAA. The data was examined and the flight's data was extracted and placed in a file for use by the senior meteorologist. The radar data is appended in the meteorologist's report associated with this investigation. The Vaughn Municipal Airport, near Vaughn, New Mexico, was about 9.75 miles and 34 degrees from the accident site. The airport's elevation was 5,928 feet msl. The safety recommendation section in the operator's accident report, in part, stated: As [the operator], I will treat the owners of the leaseback airplanes the same as the renters, and they will sign [the] Renter's Agreement. [The] Renter's Policy does NOT allow night Cross-Country unless you are Instrument Rated or with a Flight Instructor. The Renter's Policy also states that any flight more than 50 NM, the renter will file a VFR or IFR Flight Plan. The owner, just like the rental customers will fill out [a] Flight Load Manifest. This includes actual weather for the departure and weather forecast for the destination. Current Weight & Balance for the Flight, a list of the passengers on board and their emergency contacts, the route of flight and emergency contact as well as contact number at destination. From now on for any renter wanting to fly after hours, the renters will fax or email their Flight Load Manifest before the aircraft will be dispatched for that flight. I will also notify the Flight Service Station immediately before we start our own search. I will also spend more time with an owner that we did not train to see where their knowledge level and attitude are. Make sure that the copies of the pilot certificate in eludes the front and the back of the certificates Instill in my instructors to make sure unusual altitudes and basic altitude instrument flying are part of the Flight Reviews. Stress the importance to the VFR pilot of not getting into IFR. Rather be on the ground wishing you were in the air, than in the air wishing you were on the ground. As well as spend more time emphasizing Aeronautical Decision Making and Risk Management. Spending time to make sure the pilot understands the importance of seeing the problem and making correct decisions for safe outcomes and not letting the external pressures push the pilot beyond their limitations. An autopsy was performed on the pilot by the Torrance County Office of the Medical Investigator. The report indicated that the pilot's cause of death was blunt trauma sustained during the accident. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report from samples taken during the pilot's autopsy and from an unidentified tablet found on the pilot. The report, in part, indicated: Amphetamine detected in Tablet(s) - Scored: No | Color: Pink | Shape: Round | Imprint: COR 0.0762 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver 0.0755 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung 0.033 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Muscle 0.239 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver 0.0261 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung 0.011 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Muscle The airplane came to rest about 7.5 miles and 198 degrees from the western cloverleaf intersection of US Highway 285 and US Route 54. Examination of the accident site revealed that the airplane impacted rising terrain in a level flight attitude. A ground scar was observed with a heading of about 186 degrees magnetic. Seat rails were observed, embedded in the ground scar, in the direction of the scar. The right wing separated from the fuselage and was found at the end of the ground scar. The fuselage remained attached to the empennage and they came to rest upright on an easterly heading about 280 feet from the start of the ground scar. The rudder and vertical stabilizer remained attached to the empennage. The horizontal stabilizer separated from the empennage. The left wing came to rest inverted east of the fuselage. Flight control cables were traced and all breaks in the cables were consistent with overload. No preimpact flight control continuity anomalies were detected. The engine throttle and mixture levers were in their forward positions and separated from their control cables. The engine control cables moved when their opposite ends were pulled with pliers. No preimpact engine control continuity anomalies were detected. The fuel selector was found selecting the left tank. The tachometer indicated 2,600 rpm and its hour meter indicated 5,930.95 hours. The primer was in and locked. The ignition switch was in the both position. The engine separated from the airframe and the propeller separated from the engine. Both were found east of the fuselage. The propeller blades exhibited leading edge abrasion, torsional twisting, chordwise striations across their cambered propeller backs, and "S" shaped bending. The carburetor was separated from the engine and was found under the forward fuselage. Disassembly of the carburetor did not reveal any anomalies. The engine driven fuel pump was attached to the engine and disassembly did not reveal any anomalies. A liquid consistent with the color and smell of avgas was found within the fuel pump. The engines bottom sparkplugs were removed and they displayed a normal wear appearance according to the Champion Spark Plugs Check-A-Plug chart AV-27 along with a color consistent with normal operation. The vacuum pump drive was sheared. Disassembly revealed the rotor assembly was fractured and its vanes were in-place. Both magnetos produced spark. The no. one and three cylinder pushrods sustained impact damage. All four cylinders produced a thumb compression when the crankshaft was rotated by rotation of a rear accessory drive pad. The exhaust heat muff was deformed and it did not exhibit any discoloration consistent with sooting. A National Transportation Safety Board (NTSB) senior meteorologist collected and reviewed weather documents and produced a factual report. The meteorologist's report is appended to the docket associated with this investigation. The report, in part, showed that a dissipating cold front along the route of flight and in the vicinity of the planned destination airport was depicted on a National Weather Service (NWS) Surface Analysis Chart. Forecast IFR conditions, over the route of the route of flight to immediately east of the destination, was shown on a NWS Weather Depiction Chart. A forecast of a stationary front over western New Mexico, a strong pressure gradient over the area, and scattered snow showers over the region were depicted on a NWS 12-hour Low-Level Significant Weather Prognostic Chart. The chart also depicted an extensive area of IFR conditions from Texas, into eastern New Mexico northward into Colorado. The freezing level was depicted on the prognostic chart at the surface and it also showed that moderate turbulence was expected from the surface through 24,000 feet. At 0335, the recorded weather about 110 miles and 90 degrees from the accident site at the Clovis Municipal Airport, near Clovis, New Mexico, was: Wind 020 degrees at 22 knots gusting to 27 knots; visibility 7 statute miles; sky condition overcast clouds at 800 feet; temperature -6 degrees C; dew point -8 degrees C; altimeter; 30.34 inches of mercury. At 0335, the recorded weather about 47 miles and 312 degrees from the accident site at the Moriarty Airport, near Moriarty, New Mexico, was: Wind 110 degrees at 14 knots gusting to 17 knots; visibility 5 statute miles; present weather light snow; sky condition overcast clouds at 500 feet; temperature -7 degrees C; dew point -8 degrees C; altimeter; 30.21 inches of mercury. At 0321, the recorded weather about 37 miles and 330 degrees from the accident site at the weat