Primary finding
Probable cause
The pilot’s continued visual flight rules flight into instrument meteorological conditions, resulting in controlled flight into trees and terrain.
Investigator assessment
Analysis narrative
**This report was modified on June 23, 2021. Please see the public docket for this investigation to view the original report.** The pilot was conducting a personal, cross-country flight with one passenger onboard. The pilot received a formal preflight weather briefing, which warned of instrument and marginal visual meteorological conditions as well as mountain obscuration conditions due to clouds near the departure airport and along the airplane’s expected route of flight. Although the pilot had filed an instrument flight rules flight plan for the flight, he advised air traffic control at the departure airport that he would be departing under visual flight rules (VFR). Flight track and weather data showed that, after departure, the airplane proceeded toward mountainous terrain that was likely obscured by clouds. A witness near the accident site reported seeing the airplane flying below the clouds (fog) before losing sight of it behind trees and then hearing the impact. Postaccident examination of the airframe and engine revealed no evidence of any preaccident mechanical failures or malfunctions that would have precluded normal operation. Based on the damage signatures displayed by the wreckage and trees surrounding the accident site, it is likely that the airplane impacted trees and terrain in a relatively level, slightly right wing down flight attitude and that the engine was producing power at the time of the impact. Although the pilot held an instrument rating, he did not meet the necessary currency requirements to undertake an instrument flight rules flight. It is likely that, after departing, the pilot encountered deteriorating weather conditions that obscured the mountainous terrain, and resulted in the pilot’s controlled flight into terrain.
Source record
Factual narrative
The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. Review of the pilot’s application to join the flying club that operated the accident airplane, which was submitted to the flying club in June 2017, revealed that he had accumulated 563 total hours of flight experience, of which 523 were in the accident airplane make and model. He also noted that he had accumulated 79 hours of instrument flight experience. On the application the pilot stated that his most recent flight was in May 2011. The pilot subsequently completed 13 flights in the accident airplane, over the course of 20.7 flight hours, between August 2017 and April 2019. The pilot’s personal logbook recorded simulated instrument flight for a duration of 0.3-hour during a 1.0-hour-long flight for the purposes of a flight review in accordance with 14 CFR Part 61.56(a), on August 15, 2017, more than 20 months before the accident. He had logged a total of 13.5 hours and 66.0 hours of actual instrument flight time and simulated instrument flight time, respectively. Between the flight review date and the last logbook entry, dated April 18, 2019, he did not record any actual or simulated instrument flight experience, the completion of an instrument proficiency check, or any instrument approaches. According to members of the flying club, a flight instructor flew in the accident airplane with the pilot, about 1 month before the accident after it had undergone maintenance for an extended time, and during which two Garmin G5 electronic flight instruments and a Garmin GFC 500 autopilot were installed. The club had advised pilots to fly the airplane with an instructor to refamiliarize themselves with the airplane and for a proficiency check. The flight instructor who flew with the pilot stated that the proficiency flight covered loss of control, power-on and power-off stalls, steep turns, and emergency procedures. Because the instructor was not an instrument instructor, he did not cover topics that might have been addressed during an instrument proficiency check, but he did have the pilot fly for about 18 minutes using a vision restricting device. The flight instructor described that during that time, the pilot struggled to hold altitude, but he was within +/- 100 ft. The pilot mentioned that the likely reason he struggled to hold altitude was that the display format of the new electronic flight instruments were more responsive than the previously installed analog instruments. The pilot did not mention anything to him about his instrument flight experience or instrument currency. After the flight, flight instructor did not sign the pilot’s logbook, and he suggested he fly a few more times VFR to familiarize himself with the new electronic flight instruments. Following the airplane’s last annual inspection on March 15, 2019, a maintenance facility employee conducted a test flight and deemed it satisfactory during all phases of flight. He reported that he was impressed with the autopilot system. Club personnel estimated that, excluding the accident flight, the airplane had been operated about 20 hours since the annual inspection. The president of the flying club conducted a 1.0-hour flight on April 30, 2019, which was the last flight of the accident airplane before the accident flight. He reported no issues with either the G5 or autopilot. The only discrepancy he noted was a 20-second loss of the GPS signal. There was no record that the airplane was flown after the president of the club flew it and the accident pilot began his flight. The airplane’s altimeter, altitude reporting, and static system tests required by 14 CFR Part 91.411 and the transponder test required by 14 CFR Part 91.413 were last completed on November 14, 2018. The airplane impacted heavily wooded terrain on a ridgeline with a maximum elevation in that area of about 2,275 ft msl. During examination of the accident site, pieces of the airframe were found in trees and on the ground. The cockpit and cabin exhibited extensive impact and fire damage. Wreckage pieces not found near the cockpit and cabin did not exhibit fire damage. The first identified tree contact was about 20 ft agl at an elevation of 2,122 ft msl. The outer portion of the right wing was found along the energy path about 63 ft past the tree, and the first identified ground contact location, which is where the rudder counterweight was found, was about 80 ft from the right wing’s outer section. The farthest identified wreckage, which comprised the engine assembly and the attached propeller, one side of the horizontal stabilizer with attached elevator, the cockpit, and a section of wing were found at an elevation of 2,181 ft msl. All primary and secondary flight controls and primary structure were accounted for at the accident site. Examination of the airframe revealed that the fuselage was consumed by postcrash fire from the cockpit to about fuselage station 166. The left horizontal/elevator remained attached to the fuselage with the counterweight attached. The pitch trim actuator was extended about 1.25 inches, which equated to 0° or neutral. Both elevator and rudder control cables remained connected at their respective bellcranks. The elevator bridle cable was attached to the primary control cable and was wrapped around the autopilot trim capstan, which rotated freely. The outboard portion of the left elevator was partially consumed by fire. The vertical stabilizer’s main spar was attached, but it was fractured about 12 inches up from the attachment point. The right horizontal stabilizer had separated and exhibited a semicircular indentation about 37 inches outboard of the attachment point. The impact angle correlated to about a 18° right bank. The elevator counterweight was separated. The full span of the elevator trim tab remained connected to the elevator. The pushrod remained connected to the trim tab and elevator trim actuator but was fractured, and the actuator had separated. The rudder counterweight had separated. The elevator trim cable was separated from the chain; both cables were fractured in tension overload. Examination of the flight control cables for roll, pitch, and yaw revealed that, except for a section of the right aileron primary control cable near the control yoke, which was not found; cables that were cut for recovery; or cables that exhibited tension overload, revealed no evidence of any preaccident failures or malfunctions that would have precluded normal operations. No threads were extended at the flap actuator consistent with flaps retracted. Both wings were fragmented in multiple pieces and exhibited semicircular indentations on their leading edges consistent with tree contacts. The pitot tube opening was free of obstructions, and electrical wires were noted going to the pitot tube. Initial examination of the engine revealed that it remained attached to its respective engine mount, which remained attached to the firewall. The engine was covered in yellow fire-retardant residue and exhibited postimpact fire damage. The starter ring gear was fractured. One magneto remained attached to the engine, but the other was detached from the accessory section. The carburetor exhibited impact damage and was not attached to the engine, but it was held into its location via the throttle control cable. Further examination of the engine revealed impact damage to the rocker box covers on the Nos. 1 and 3 cylinders and bent and smashed pushrods on the exhaust side of the No. 1 cylinder. Both pushrods on the No. 4 cylinder were bent and smashed. The engine crankshaft was rotated about 60° through the vacuum pump accessory drive, but it could not be fully rotated. Inspection of the cylinders with a borescope revealed that some of the cylinders exhibited corrosion and debris, but all the valves were found intact. Examination of the crankshaft re