CEN17FA354

The non-instrument-rated pilot's inadequate preflight weather planning, his decision to depart into forecast instrument meteorological conditions along the route of flight, and his continued visual flight into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control.

The non-instrument-rated private pilot and three passengers departed on a night cross-county flight over mountainous terrain. Radar track data showed that the airplane traveled mainly on a southwesterly heading directly towards its destination with a series of altitude changes. About 5 minutes before the accident, the airplane turned to the northwest, a deviation off the destination course, and continued northwest for about 12 miles. After the turn, a passenger sent a text message to a family member stating that they were "taking the long way around, lots of weather, keep you posted." Shortly thereafter, the airplane entered a gradual left turn to the southwest, descending from 11,500 ft to 11,300 ft, then climbing back to 11,400 ft. The last recorded radar return was about 1/4 mile south of the accident site, which was located at an elevation of 10,800 ft. Postaccident examination of the airframe and engine showed severe fragmentation of the airplane consistent with a high-energy impact and did not reveal any preimpact anomalies that would have precluded normal operation. The flight was likely operating in instrument meteorological conditions (IMC) at the time of the accident, including light to moderate icing conditions. The airplane likely encountered intermittent IMC beginning about 30 minutes after takeoff, and continued into an area of solid IMC about 3 minutes before the accident occurred. There was no record of the pilot retrieving preflight weather information from an official, access-controlled source, and what weather information, if any, he obtained before or during the flight could not be determined. Based on the weather forecasts and information valid before the airplane departed and while en route, and the equipment available onboard the airplane, there was sufficient weather information available to the pilot before and during the flight to make informed decisions regarding the weather he would likely encounter. The night instrument conditions present at the time of the accident were conducive to the development of spatial disorientation and the circumstances of the accident. The non-instrument-rated pilot's continued flight into IMC, the airplane's descending turn depicted on radar, and the fragmentation of the wreckage due to high-energy impact are all consistent with the known effects of a loss of control due to spatial disorientation. It is likely that, while maneuvering, the pilot experienced spatial disorientation, which resulted in a loss of control and subsequent descent into terrain.

The Garfield County Coroner's Office, Grand Junction, Colorado, performed autopsies on the pilot and passengers. The cause of death listed for each occupant was multiple blunt force injuries. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Testing was not performed for carbon monoxide and cyanide, and testing was negative for ethanol and drugs. According to Leidos Flight Service and Direct User Access Terminal Service (DUATS), the accident pilot did not contact Leidos or DUATS for preflight weather information. A search of archived ForeFlight data revealed no record of the accident pilot accessing weather information; however, with no internet access while in flight, ForeFlight is able to access weather information directly from the FAA, leaving no remote record of such access. Therefore, it is possible that the accident pilot was receiving weather updates during the flight. There was no record of the accident pilot receiving or retrieving any other weather information before the accident flight. The National Weather Service (NWS) Storm Prediction Center (SPC) Day One convective outlook was issued at 1400 and valid through 0600 the following day. The accident site was included in a "TSTM" area, defined as an area where a 10% or higher probability of thunderstorms is forecast during the valid period. Rifle Garfield County Airport (RIL), Rifle, Colorado, located 20 miles southwest of the accident site, was the closest official weather station to the accident site. It was at an elevation of 5,537 ft and was equipped with an Automated Surface Observing System (ASOS). At 1953, the RIL ASOS reported wind from 300° at 5 knots, 10 miles visibility or greater, broken ceiling at 7,500 ft agl, overcast skies at 9,500 ft agl, temperature 12° C, dew point temperature 8° C, and an altimeter setting of 30.04 inches of mercury. Remarks, station with a precipitation discriminator, lightning distant south, rain ended at 1948. At 2053, the RIL ASOS reported variable wind direction at 3 knots, 10 miles visibility or greater, broken ceiling at 6,000 ft agl, overcast skies at 8,000 ft agl, temperature 12° C, dew point temperature 8° C, and an altimeter setting of 30.07 inches of mercury. Sunlight Peak (5SM), located 16 miles south of the accident site at an elevation of 10,604 ft, was equipped with an Automated Weather Observing System (AWOS). At 1950, the 5SM AWOS reported wind from 240° at 11 knots with gusts to 23 knots, wind direction variable from 210° to 280°, 1/4 mile visibility, thunderstorm with light rain in the vicinity, overcast ceiling at 200 ft agl, temperature 1° C, dew point temperature 1° C, and an altimeter setting of 30.23 inches of mercury. At 2008, the 5SM AWOS reported wind from 240° at 11 knots with gusts to 23 knots, wind direction variable from 210° to 280°, 1/2 mile visibility, fog, overcast ceiling at 200 ft agl, temperature 2° C, dew point temperature 1° C, and an altimeter setting of 30.24 inches of mercury. At 2031, the 5SM AWOS reported wind from 240° at 12 knots with gusts to 24 knots, wind direction variable from 180° to 300°, 1 1/4 miles visibility, light rain, overcast ceiling at 200 ft agl, temperature 2° C, dew point temperature 1° C, and an altimeter setting of 30.24 inches of mercury. The observations from 5SM indicated low instrument flight rules conditions with gusty winds, light rain, distant lightning, and thunderstorms in the vicinity. RIL reported VFR conditions with rain and distant lightning. Upper air data near the accident site at 2000 indicated a mostly conditionally unstable layer between the surface (10,548 ft) and 18,000 ft. Rawinsonde Observation program indicated that clouds were likely near the surface through 12,000 ft. A small layer of rime icing conditions was indicated about 12,500 ft. Infrared data from the Geostationary Operational Environmental Satellite number 16 (GOES-16) was obtained. Satellite imagery surrounding the time of the accident was reviewed and indicated cloud cover over the accident site with the cloud cover moving from southwest to northeast. At 2015, the approximate cloud-top heights were 22,000 ft over the accident site (See Figure 3). Figure 3 GOES-16 Infrared Image at 2015 MDT The closest NWS Weather Surveillance Radar-1988, Doppler (WSR-88D), was the Grand Junction, Colorado, radar, located 55 miles southwest of the accident site at an elevation of 9,992 ft. Base reflectivity values between 2007 and 2012 above the accident site corresponded to light precipitation (See Figure 4). No lightning strikes were noted near the accident site at the accident time. Figure 4 WSR-88D Reflectivity Scan at 2012 MDT Convective SIGMET advisory 1W was valid for the accident site from 1855 to 2055 and warned of an area of thunderstorms with tops to flight level (FL) 350 with the SIGMET area moving from 250° at 25 kts. Convective SIGMET 10C was valid for the accident site from 1955 to 2155 and warned of an area of thunderstorms with tops to FL370 with the SIGMET area moving from 230° at 20 kts. AIRMET advisory Tango was issued at 1445 and valid for the accident site at the accident time. The AIRMET forecasted moderate turbulence below 18,000 ft. The Area Forecast issued at 1345 and valid at the accident time forecast a broken ceiling at 9,000 ft with tops at FL230, isolated thunderstorms with light rain, and thunderstorm tops at FL360. Between 1800 and 2100, conditions were forecast to include a broken cloud ceiling at 8,000 ft with tops at FL270 and isolated thunderstorms with light rain. The Forecast Icing Potential (FIP) indicated that icing near the accident site would likely be trace to moderate levels at 2000. The FIP did not indicate any Supercooled Large Droplet potential over the accident area at the accident time. According to the U.S. Naval Observatory, the sunset near the accident site at 1917, and the end of civil twilight was at 1944. The moon was not visible around the accident site at the accident time. A review of FAA records revealed that the pilot obtained his private pilot certificate on March 1, 2017. The pilot did not hold an instrument rating; his logbook revealed that he had accumulated 2.4 hours in simulated instrument conditions. The pilot's logbook contained an entry for a flight on May 2, 2017, that contained the pilot's remarks, "First flight over clouds where I could not see the ground (CO Springs)." According to the pilot's flight instructor, the pilot had recently completed a mountain flying and high altitude operations course sponsored by the Colorado Pilot's Association. A few days before the accident, the flight instructor spoke to the pilot about the planned flight to CNY. The pilot stated that he did not want to leave later than 1800 and that he would use ForeFlight to obtain weather and flight plan information. According to family members, the pilot's initial plan was to depart for CNY about 1530; however, a business issue resulted in a delayed departure. The accident site was located on rocky, tree-covered mountainous terrain about 10,800 ft msl (See Figure 5). The airplane impacted trees and terrain on a measured magnetic heading about 075°. A postimpact fire consumed a portion of the airplane. The initial impact point contained a portion of a propeller blade, fragments of the engine and engine mount, and forward fuselage structure. Several trees were severed at different heights before the initial impact with terrain. Based on the tree impacts, the calculated bank angle at the initial impact was about 34° right wing low. Figure 5 Accident Site The airframe and engine were fragmented and distributed in the debris field. The CAPS components were separated from the airframe and distributed in the debris field. The parachute was fully extended in a folded sta