CEN17FA361

The noninstrument-rated pilot's decision to depart into instrument meteorological conditions, and his subsequent loss of control due to spatial disorientation.

The noninstrument-rated private pilot and 2 passengers departed in instrument meteorological conditions (IMC) with an overcast cloud layer at 400 ft above ground level (agl). Data obtained from an onboard GPS unit showed the airplane depart toward the destination airport and climb and descend several times. About 2 minutes after takeoff, the airplane descended to 250 ft above ground level (agl), then turned and quickly climbed to 1,400 ft agl. The final GPS points showed the airplane in a descending right turn. A witness reported hearing the airplane overhead and stated that the engine was "screaming" before impact. The airplane impacted a field about 4 minutes after takeoff resulting in a debris path about 230 yards long, consistent with a relatively high forward airspeed at the time of impact. A postaccident examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operation. The primary vacuum pump was not found in the wreckage; however, an examination of the standby vacuum pump revealed that the rotor was fractured by impact, but the vanes were intact. The heading indicator and turn coordinator gyros exhibited rotational scoring consistent with rotation at the time of impact. The damage to the propeller blades was consistent with the engine producing power at impact. The autopsy report revealed no significant coronary artery disease; however, microscopic examination revealed focal areas of fine fibrosis suggestive of prior ischemic episodes. This finding was not significant enough to suggest an incapacitating event. No other significant natural disease was present that could pose a hazard to flight safety. Review of the pilot's logbook and his statements to individuals who spoke with him before the accident suggested that he had a history of flying in and around IMC. Given the weather conditions at the time of departure and observations of the pilot checking the weather conditions before the flight, the pilot was aware that he would be required to fly in or under IMC during the flight and chose to do so despite not holding an instrument rating. Based on the reported weather conditions and GPS data, it is likely that, while maneuvering on course after takeoff, the pilot entered IMC; he likely subsequently experienced spatial disorientation, which resulted in a loss of control and descent into terrain.

University of North Dakota School of Medicine and Health Sciences, Forensic and Autopsy Service, Grand Forks, North Dakota, completed an autopsy on the pilot. The autopsy report concluded that the cause of death was blunt force trauma. The autopsy revealed no significant coronary artery disease; however, microscopically, there were focal areas of fine fibrosis suggestive of prior ischemic episodes. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Toxicology results were positive for salicylates (aspirin) in the urine and negative for any other substances. The investigation did not find any evidence that the pilot obtained an official preflight weather briefing. The only evidence of the pilot checking the weather conditions was the statement from the hotel employee. At 0701, the automated weather observation system (AWOS) at TVF recorded wind from 340° at 6 knots, 10 statute miles visibility, overcast clouds at 400 ft agl, temperature 50°F, dew point 48°F, and an altimeter setting of 29.95 inches of mercury; remarks – pressure rising rapidly. At 0801, the TVF AWOS recorded wind from 310° at 7 knots, 10 statute miles visibility, overcast clouds at 400 ft agl, temperature 50°F, dew point 48°F, and an altimeter setting of 29.98 inches of mercury. Around the time of the pilot's flight into TVF the previous evening, at 1701, the TVF AWOS recorded wind from 040° at 10 knots, 10 statute miles visibility, overcast clouds at 2,200 ft agl, temperature 75°F, dew point 67°F, and an altimeter setting of 29.69 inches of mercury. At 1801, the AWOS recorded wind from 070° at 8 knots, 10 statute miles visibility, overcast clouds at 2,000 ft agl, temperature 74°F, dew point 68°F, and an altimeter setting of 29.68 inches of mercury. Review of FAA records revealed that the pilot did not hold an instrument rating; his logbook revealed that he had accumulated 6.4 hours in simulated instrument conditions. The pilot's logbook contained entries for the flights to and from TVF. The entry for the flight on September 17 from RWL to TVF contained the pilot's remarks, "[passengers flown to TVF for] training at Arctic Cat. Very smooth and cold. Had to fly around and under clouds most of the way." The logbook entry for the return flight on September 17, from TVF to RWL, contained the pilot's remarks, "Flew above and between clouds most of the way back. Very windy and bumpy and thick clouds. Went up to 16,500 ft." The accident site was located in a harvested wheat field next to a gravel road. The wreckage debris path began with a ground impact mark, which contained broken green glass from the right wing navigation light, and continued on a heading of 060° for about 230 yards. The airplane was highly fragmented, but all major components were found at the accident site (figure 2). Figure 2 – Debris Path and Main Wreckage Isolated postimpact fire damage was observed on the left wing, parts of the seats, and some of the baggage. Vegetation throughout the accident site exhibited fuel blighting. The fuel lines were fragmented and found along the wreckage path. The fuel selector handle was separated from the airplane and found positioned to BOTH; the fuel selector valve was also positioned to BOTH. The instrument panel was impact damaged and several instruments were found along the wreckage path. The panel was bent downward above the landing gear selector handle; the handle was in the gear-extended position. The right main landing gear was found separated from the airplane. The nose gear remained attached at its mounting point and was entangled in the wreckage. The left main landing gear actuator and landing gear were retracted. The seats were found separated from the seat rails. The front left seat remained attached to the fuselage floor via the secondary seat stop locking reel strap. Complete flight control cable continuity was not established due to fragmentation and overall condition of the wreckage. The elevator, elevator trim, and rudder cables remained attached to their respective positions in the aft tail cone. Fragments of the aileron cables remained attached to the forward pulleys. The elevator cables remained attached to the forward bellcranks. The rudder cables remained attached to the torque tubes. The flap actuator was separated from the right wing and found in the retracted position. The engine came to rest upright 10 ft beyond the fuselage and remained loosely attached by the stretched propeller governor control cable. The engine sustained significant impact damage and several engine accessories were found separated at the accident site; the alternator and primary vacuum pump were not found. The three-bladed propeller was impact separated at the crankshaft flange. Propeller blades 1 and 3 remained attached to the hub; blade 2 was separated and found about 20 ft beyond the hub. Propeller blade 1 was bent aft, twisted, and exhibited diagonal scoring on the cambered side of the blade. There was also impact damage to the trailing edge of blade 1 near the tip. Propeller blade 2 was twisted and exhibited lengthwise scoring on the back of the blade near the shank. Propeller blade 3 exhibited S-bending, twisting, and paint burnishing on the cambered side of the blade. The trailing edge of blade 3 exhibited an impact mark about 9 inches from the tip. During a postaccident examination, the engine was rotated by hand using a turning tool from the vacuum pump pad. Thumb suction and compression was obtained on cylinder Nos. 2, 4, 5, and 6. The push rods for cylinder Nos. 1 and 3 were impact damaged. Valve train continuity was verified. All cylinders were examined using a lighted borescope with no anomalies noted. The turbocharger was rotated by hand and the turbine wheel moved with no restrictions noted. The fuel pump remained secure on its mount and was removed and actuated by hand; thumb suction and compression were obtained. Residual fuel was observed in the pump. The single-drive dual-magneto was manually actuated and produced a spark at each terminal. The starter housing exhibited rotational scoring and impact damage from the adjacent starter ring gear support. Disassembly of the standby vacuum pump revealed that the rotor was fractured, but the vanes were intact. There were no preimpact anomalies observed during the examination that would have precluded normal engine operation. A postaccident examination and disassembly of the heading indicator and turn coordinator revealed rotational scoring on each internal gyro and gyro casing consistent with rotation at the time of impact. Fueling records from RWL showed that the pilot serviced the airplane with 81.1 gallons of 100LL fuel on September 20, 2017. The manager of the fixed-base operator at TVF stated that the pilot purchased about 55 gallons of 100LL on September 22. On September 23, 2017, about 0742 central daylight time, a Cessna TR182 airplane, N4777T, impacted terrain about 3 miles west of Thief River Falls Regional Airport (TVF), Thief River Falls, Minnesota. The private pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time of the accident and no flight plan was filed for the personal flight, which departed from TVF at 0738 and was en route to Rawlins Municipal Airport (RWL), Rawlins, Wyoming. Several individuals who spoke to the pilot in the days preceding the accident stated that he had flown the same passengers from RWL to TVF on September 17, 2017. The pilot stated to one individual that he descended through the clouds on approach to TVF that day. The pilot returned to RWL, then flew back to TVF the day before the accident to re