Primary finding
Probable cause
The pilot's improper decision to continue VFR flight into instrument meteorological weather conditions. Contributing to the accident were low ceilings, reduced visibility, and mountainous terrain.
Investigator assessment
Analysis narrative
The instrument rated commercial pilot departed under visual flight rules (VFR) for a planned cross-country flight. Shortly after departure, the pilot was receiving radar flight following for about 15 minutes. During this time, the controller advised the pilot that no one had successfully proceeded south VFR and that low ceilings and reduced visibility existed between her destination and her point of departure. Radar data revealed that the flight was initially on a southeasterly heading at an altitude of about 2,400 feet. About 18 minutes after departure, the flight initiated a descent to 900 feet while remaining on the southeasterly heading. As the flight approached an uncontrolled airport, radar data showed a slight climb to 1,400 feet, followed by a climbing 180-degree turn to the northwest, which was opposite the direction of her intended destination. Two minutes later the flight initiated a right turn to a northerly course, while continuing to climb. As the flight proceeded northward, radar data depicted a series of turns to the left and right with the altitude fluctuating between 1,500 feet and 2,900 feet before radar contact was lost. Wreckage and impact signatures were consistent with the airplane impacting trees and mountainous terrain at 2,250 feet msl within a heavily wooded area on an easterly heading. All major components of the airframe were located at the accident site. Review of recorded weather data revealed that instrument meteorological conditions prevailed in the area at the time of the accident, with restricted visibilities in rain showers, and overcast clouds with bases and tops at 1,900 and 10,000 feet, respectively. Examination of the recovered airframe revealed no mechanical anomalies that would have precluded normal operation. Examination of the engine revealed that the number four cylinder exhaust valve was stuck in the open position and was bent. The camshaft was intact and each of the camshaft cam lobes exhibited severe wear and spalling signatures. The corresponding tappets exhibited severe spalling on their respective camshaft contact surfaces. The engine exhibited signatures consistent with a high time engine.
Source record
Factual narrative
HISTORY OF FLIGHT On July 27, 2008, at 1439 Pacific daylight time, a Cessna 172N airplane, N75558, impacted trees and terrain while maneuvering near McMurray, Washington. The airplane was registered to Crest Airpark, Inc., Kent, Washington, and operated by the pilot, under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and two passengers were killed. The airplane was substantially damaged. Visual meteorological conditions prevailed at the time of departure and instrument meteorological conditions prevailed in the area at the time of the accident. No flight plan was filed for the personal flight. The cross-country flight originated from the Roche Harbor Airport (WA09), Roche Harbor, Washington, about 1402, with an intended destination of Auburn, Washington. A family member of the pilot reported the airplane missing to the Federal Aviation Administration (FAA) on July 27, 2008, after becoming concerned when the airplane had not arrived at its intended destination. The FAA subsequently issued an Alert Notification (ALNOT). The airplane was located by air units on July 27, 2008, approximately 2120, in a heavily wooded mountainous area about 6 miles east of McMurray. A witness who was flying in a Cessna 170 reported she intended to fly from Blakely, Washington, to Auburn. During the flight, they elected to return to Blakely due to lowering ceilings and decreasing visibility south of Port Townsend, Washington. During the return flight to Blakely, she was receiving traffic advisories from Whidbey Approach Control. The controller advised her about opposite direction traffic. The witness stated that she observed a Cessna that matched the accident airplane passing in front of her position on an eastbound heading. She added that during this time, the visibility to the east of her current position appeared to be "very poor." There were no known witnesses to the accident sequence. According to a family member of the pilot, the flight was destined for Auburn to drop off two passengers, pickup one passenger, return to WA09 to pickup two additional passengers, and return to Auburn. Review of radar data provided by the FAA revealed that a primary radar contact was initially obtained at 1404, about 5.2 miles southeast of WA09 at an altitude of 2,200 feet mean sea level (msl). The flight path of the airplane was generally on a southeasterly heading with at an altitude between 2,400 and 2,500 feet msl until 1420, where a gradual descent to 900 feet msl was observed. At 1427, a slight climb was initiated until approaching the vicinity of Arlington Airport, Arlington, Washington, at 1429. While in the vicinity of Arlington, radar data depicted the airplane initiated a left turn from a southeasterly course to a northwesterly course while climbing to an altitude of 1,700 feet msl. At 1431, the airplane initiated a right turn to northerly course until 1434, where the airplane performed a series of left and right turns with the altitude fluctuating between 1,500 feet msl and 2,900 feet msl. The last three radar returns were consistent with the airplane being in a descending right-hand turn. The last recorded radar return was at 1439, located 0.17 miles southwest of the accident site at an altitude of 2,200 feet msl. PERSONNEL INFORMATION The pilot, age 47, held an airline transport pilot certificate with airplane multiengine rating, and a commercial pilot certificate with airplane single-engine land and airplane single-engine sea ratings. In addition, the pilot held a turbojet powered rating and type ratings in various transport category aircraft. A first-class airman medical certificate was issued on November 26, 2007, with the limitations stated, "must wear corrective lenses, not valid for any class after." The pilot reported on her most recent medical certificate application that she had accumulated 14,200 total flight hours. Review of the pilot's rental records provided by Crest Airpark revealed the pilot had rented a Cessna 172 on seven separate occasions, totaling 12.3 hours of usage between July 5, 2007 and July 17, 2008. Of the seven rentals, six were conducted in a Cessna 172SP and one in a Cessna 172N. According to the rental record, the pilot had rented a Cessna 172SP and Cessna 172N within the previous 90 days to the accident. The total flight time for both rentals was 2.5 hours. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number (S/N) 17267807, was manufactured in 1977. It was powered by a Lycoming O-320-H2AD engine, S/N L-4858-76, rated at 160 horsepower and equipped with a McCauley two bladed fixed-pitch propeller. Review of copies of maintenance logbook records showed an annual inspection was completed on April 1, 2008, at a recorded tachometer reading of 2,609.8 hours; airframe total time of 9,935.4 hours; and engine time since major overhaul of 2,559.8 hours. At the time of the accident, the airplane had accumulated 105.2 hours since the time of the inspection. The engine was overhauled on June 19, 2001, at a total time of 4805.0 hours. According to an entry in the engine logbook, the number four cylinder and number four piston were replaced on August 30, 2007, due to low compression. According to the FAA inspector who interviewed the mechanic that performed the maintenance, the replacement cylinder was removed from another O-360-H2AD engine. Logbooks for the engine in which the cylinder was removed revealed that metal was found in the oil filter and oil suction screen in 2005. Review of Lycoming Service Instruction Number 1009AT, the recommended time between overhauls is 2,000 hours. The Service Instruction states for the O-320 engine, "if an engine is being used in a 'frequent' type service and accumulates 40 hours or more per month, and has been so operated consistently since being placed in service, add 200 hours to the TBO time." METEOROLOGICAL INFORMATION A review of recorded data from the automated weather observation station at Arlington Municipal Airport, Arlington, Washington, located about 11 miles southwest of the accident site reported at 1435; wind from 320 degrees at 7 knots; visibility 10 statute miles; scattered cloud layer at 500 feet above ground level (agl), broken cloud layer at 2,000 feet agl, and an overcast ceiling at 2,700 feet agl; temperature 15 degrees Celsius; dew point 13 degrees Celsius; and an altimeter setting of 30.05 inches of Mercury. The National Transportation Safety Board's staff meteorologist reviewed weather data and reported that the northwest portion of the National Weather Service (NWS) Weather Depiction Charts for 1200 depicted an area of instrument flight rules (IFR) conditions over Washington in the vicinity of the accident site. Surrounding that area was an area of marginal visual flight rules (MVFR) conditions over portions of western Washington, Oregon, and northern California. The closest visual flight rules (VFR) conditions were depicted over eastern Washington. MVFR conditions were depicted over the route of flight and the accident site, with IFR conditions in the immediate vicinity. The closest station model to the south of the accident site depicted MVFR conditions with a ceiling overcast at 1,900 feet agl. The northwest section of the NWS hourly Radar Summary Chart for 1419 PDT (2119Z) depicted a band of "light" intensity echoes associated with rain showers over the Cascade Range and Puget Sound area, and in the immediate vicinity of the accident site. The northwest section of the NWS hourly Radar Summary Chart for 1419 depicted a band of "light" intensity echoes associated with rain showers over the Cascade Range and Puget Sound area, and in the immediate vicinity of the accident site. According to the Skagit County Sheriff Deputy, who was located just north of the accident site, "spotty rain s