CEN24FA024

The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions and failure to maintain clearance from trees and terrain during an unapproved instrument approach. Contributing to the accident was the pilot’s inadequate preflight weather planning.

The airplane was operated on a personal cross-country flight. Recorded data indicated that the airplane made an approach to an airport but did not land and the airplane apparently diverted due to the instrument meteorological weather conditions (IMC) present at that airport. The airplane then flew toward another airport about 60 nautical miles away. The airplane was aligned with the extended runway centerline but impacted trees and terrain about 2.5 miles from the diversion airport. The weather conditions at the diversion airport were night IMC with a 400-ft ceiling. Data indicated that the originally intended destination was IMC at the time of the airplane’s departure. The pilot did not request weather information from known sources, and it is unknown what weather information, if any, the pilot checked or received before or during the flight. During the flight, the airplane’s transponder beacon code was set to 1200, indicating that the airplane was operating as a visual flight rules flight, and the investigation did not find record of communication with any air traffic control facility. Based on the flight track data it appeared that the pilot was attempting an approach to the diversion airport when the accident happened. The airplane was configured with one navigation radio that was approved for instrument flight navigation. It also was equipped with a handheld GPS receiver that was capable of monitoring approaches but was not approved for instrument flight navigation. Investigators could not determine which system the pilot was using to navigate. Examination of the airplane and engine did not reveal any pre-accident mechanical failures or malfunctions that would have precluded normal operation. Exhaust gas temperature recordings from the airplane’s engine monitoring system indicated that the engine was operating at the time of the accident. Additionally, the engine monitor recorded fuel pressure until the end of the recorded data, indicating that the airplane’s engine was still receiving fuel. ADS-B data showed that the airplane was descending at 900 ft/min during the final portion of the flight. Based on the available information, the experienced pilot chose to operate in instrument meteorological conditions without an instrument flight rules clearance and without communicating with any air traffic control facility. He then executed an unapproved instrument approach. During the approach the airplane descended into trees and terrain. There was no indication of any failure or malfunction of the airplane that contributed to the accident.

The pilot held an airline transport pilot certificate for multi-engine land airplanes with commercial privileges for single engine land airplanes. He held type ratings for B-737, DC-9, CV-640, and CV-600 airplanes. The pilot’s flight logbook was not available for review; however, he reported having 26,400 hours of flight experience, including 300 hours in the 6 months preceding his most recent aviation medical examination. His most recent aviation medical examination was conducted on August 26, 2023, at which time he was issued a first-class medical certificate. According to FAA registration information the pilot purchased the airplane on March 16, 2021. Maintenance records were not available for review by the investigation. Postaccident examination revealed that the airplane was equipped with a Dynon EFIS-D10A primary flight display (PFD), a Dynon EMS D210 engine monitor, a Garmin GPSMAP 496 handheld GPS receiver, and a Narco NCS 812 combination navigation/communication receiver with very high frequency omnirange (VOR), localizer (LOC), glideslope (GS), and distance measuring equipment (DME) capability. The Narco NCS 812 was the only installed equipment approved for instrument flight rules (IFR) navigation. An autopsy of the pilot was conducted by the Manitowoc County Coroner. According to the autopsy report, the cause of death was multiple injuries. The FAA Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot, which was negative for all compounds in the screening profile. On October 25, 2023, at 1829 central daylight time, a Lancair 320 airplane, N320P, was substantially damaged when it was involved in an accident near Manitowoc, Wisconsin. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. ADS-B data indicated that the accident flight originated from the Jesse Viertel Memorial Airport (VER), near Boonville, Missouri, about 1545. The airplane flew northeast in a straight line toward the Wisconsin Door County peninsula. The airplane then descended and turned toward the Ephraim/Gibraltar Airport (3D2), near Ephraim, Wisconsin. The airplane did not land at 3D2 and proceeded toward the south-southwest. According to the airport manager at the Manitowoc County Airport (MTW), near Manitowoc, Wisconsin, the airport’s pilot-controlled lighting system activated at 1825. ADS-B data indicated the airplane was about 15 miles north of MTW at this time. When the airplane was about 12 miles north of MTW, it turned to the south and aligned with runway 17 at MTW. The accident site was located about 2.5 miles north of the approach end of runway 17 at MTW. The final ADS-B target was recorded at 1829:29. ADS-B data recorded the airplane’s transponder code as 1200 for the entire flight, indicating that it was operating as a visual flight rules flight. During the final 1 minute and 30 seconds of the flight the airplane was descending at a rate of 900 ft/min. Shortly thereafter, the airplane impacted trees and came to rest submerged in a small lake, which resulted in substantial damage to both wings, fuselage, and empennage. Figure 1. Plotted image of the accident flight. Figure 2. Plotted image of the final portion of the accident flight. The accident site consisted of trees and a small lake. Evidence is consistent with the airplane initially impacting trees, with most of the wreckage coming to rest in the lake. Various airframe pieces were found around the perimeter of the lake. The Manitowoc County Sheriff’s Office dive team assisted in removing the wreckage from the lake. The fuselage and engine were recovered from the lake to the lake shore. The fuselage was broken into 2 pieces just forward of the empennage. The landing gear was found in the retracted position. The vertical tail and rudder were intact and remained attached to the aft fuselage. All rudder hinges were intact. The right horizontal tail and elevator were intact, and all hinges were intact. The left horizontal stabilizer and elevator were separated at a point just outboard of the fuselage. Portions of the separated horizontal stabilizer and elevator, including the stabilizer and elevator tips, were found along the lake shore. The hinges were intact. The left and right outboard wing panels were fragmented but portions of each main spar remained attached to the inboard wing section. Portions of both fragmented wings were found among the wreckage debris. The outboard 2 ft of the left wing and the right-wing navigation light were located in the debris field. The airplane’s flight control system was examined and all identified breaks were consistent with overload failure. Postaccident examination of the engine revealed that it was free to rotate. Suction and compression were verified on all cylinders. Rotation of the engine after removal of the No. 1 rocker cover revealed valve movement, which indicated continuity of the engine valvetrain. Both magnetos were removed from the engine. The left magneto was equipped with an impulse coupling and rotation by hand confirmed spark on all leads. The right magneto was not equipped with an impulse coupling and hand rotation did not produce spark. Rotation using an electric drill confirmed spark on all leads. Engine control continuity was verified. The cover of the fuel distribution manifold on the top of the engine was removed and no anomalies were noted. The distribution manifold contained fuel. The 2-blade constant speed propeller had chordwise scratching on the forward face of both blades. One blade exhibited rearward bending with a slight s-bend and the other blade exhibited rearward bending. Both blades exhibited slight twisting toward low pitch. Several tree branches were found that had slicing and paint transfer consistent with propeller impact. The fuel system of the airplane consisted of 16-gallon fuel tanks in each wing, with a total fuel capacity of 32 gallons. The amount of unusable fuel was not known. A mechanical fuel selector was installed in the cockpit for selecting either the right-wing fuel tank, off, or the left-wing fuel tank. The selector handle was found positioned past the detent for the right-wing fuel tank. The airplane was equipped with Dynon EFIS-D10A PFD, a Dynon EMS D210 engine monitor, and a Garmin GPSMAP 496 handheld GPS receiver, all capable of recording data. The PFD and GPS receiver were downloaded but did not contain any data pertinent to the accident flight. According to the owner’s manual for the Garmin GPSMAP 496, its database included instrument approach procedures that could be used for monitoring an instrument approach. The manual cautioned that the GPSMAP 496 was not approved as a primary navigation source in instrument conditions. The investigation could not determine what navigation source the pilot may have been using during the accident flight. The Dynon EMS D210 engine monitor data was recorded at 10-second intervals and showed that the accident flight lasted about 2 hours and 45 minutes. The EMS recorded a reduction of engine power to 20” of manifold pressure (MAP) about 3.5 minutes before the end of the data while the engine speed remained constant at 2,400 rpm. About 1 minute 20 seconds before the end of the data, the engine power reduced to 7” MAP and the engine speed also dropped to about 1,800 rpm. Exhaust gas temperatures on all cylinders were recorded above 950° F for the entire flight. The EMS recorded one fuel level quantity. At the start of the data for the accident flight the recorded fuel quantity was 16 gallons. There were times during the flight in which the fuel quantity indication remained steady for long periods. The initial fuel quantity indication indicated that the fuel quantity reading was for only one wing tank and that fuel was not being drawn from the indicated tank during those periods of steady fuel quantity indication. During the final 30