Primary finding
Probable cause
The pilot's loss of situational awareness and failure to maintain clearance from hilly terrain while flying in an area of a low cloud ceiling. Contributing to the accident was the pilot's decision to continue flight due to a self-induced pressure.
Investigator assessment
Analysis narrative
The purpose of the flight was for the pilots to attend a business meeting. The left-seated pilot, a private pilot, owned the airplane and the right-seated pilot held an instrument rating; it could not be determined who was the pilot-in-command at the time of the accident. The left-seated pilot had a self-induced stress of completing the flight and attending the meeting as he was concerned about his company's financial health. The right-seated pilot's pressure to depart likely stemmed from him dedicating over a year preparing items to be presented in the meeting. The left-seated pilot had great confidence in the right-seated pilot's flying ability and history in operating in inclement environments, which most likely contributed to his decision to depart in poor weather conditions. An audio recording of the airplane just prior to the accident revealed that the engine was producing high power and the airplane was traveling at an airspeed of about 130 knots. The airplane crashed into a hill bordering an interstate about 10 miles south of the departure airport and in the direction of the destination. The wreckage distribution was consistent with the airplane in a relatively level flight attitude during a high speed impact. An airline pilot, who departed about 30 minutes after the accident airplane, stated that the cloud layer was about 1,000 feet above ground level (agl). At the time of the accident, the departure airport's weather observation facility reported a broken cloud layer at 800 feet; an overcast layer at 1,500 feet and remarked that a cloud ceiling varied between 700 feet and 1,100 feet. Recordings between the Automated Flight Service Station (AFSS) and the left-seated pilot revealed that he was open to perform the flight as an instrument flight rules (IFR) operation, but opted not to. Just prior to the flight the AFSS briefer reiterated that visual flight rules (VFR) flight was not recommended. Post accident examinations revealed no mechanical anomalies with the airframe or engine that would have precluded normal operation.
Source record
Factual narrative
HISTORY OF FLIGHT On January 23, 2009, about 0655 mountain standard time, a Cessna 205, N8298Z, impacted a hill shortly after departing from Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, killing the two pilots. The private pilots, one of which was the owner, were operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The airplane sustained substantial damage. The cross-country business flight was originating from Flagstaff with a planned destination of Yuma, Arizona. Instrument meteorological conditions prevailed in the area surrounding the accident site; no flight plan had been filed. The National Transportation Safety Board investigator-in-charge (IIC) interviewed both of the pilots' spouses several days after the accident. They reported that the pilots had been planning to fly to Yuma to attend a business meeting. PERSONNEL INFORMATION Left-seated Pilot (owner) A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the left-seated pilot, age 47, held a private pilot certificate with airplane ratings for single-engine. His most recent third-class medical certificate was issued on March 12, 2007, with a limitation that he “must wear corrective lenses.” On his last application for a medical certificate, he reported a total flight time of 1,550 hours. The Safety Board IIC reviewed copies of the left-seated pilot’s personal flight logbooks. The last entries in the flight section were labeled as being complete in 2002, with a total flight time indicated of 960.9 hours. In the endorsement section of the logbook the last biennial flight review (BFR) was signed as being completed on February 06, 2006. Another entry was entered as the pilot having completed an instrument proficiency check on February 28, 2008; the same certificated flight instructor signed both these entries. The left-seated pilot did not hold an instrument rating. The left-seated pilot's spouse stated that her husband would take her on flights often and classified him as a very conservative and conscientious pilot; this was the second airplane he owned. He had planned this trip to Yuma with the right-seated pilot as they had an important meeting. He was excited about the meeting, as he had recently had numerous stressors about the financial health of his company with a downturn of the economy. The left-seated pilot's spouse further stated that her husband and the right-seated pilot had flown together before. On several occasions they also teamed up on different work related projects. Her husband had spoken highly of the right-seated pilot's flying ability. She noted that when flying with her husband to the south or west of Flagstaff, they would normally be to the east of Interstate 17. Right-seated Pilot According to the FAA airmen records, the right-seated pilot, age 57, held a private pilot certificate with airplane ratings for single-engine land and instrument flight. His most recent third-class medical certificate was issued on May 06, 2008 with the limitation that he must have glasses available for near vision. The pilot's personal flight records were not recovered. On his last application for a medical certificate, he reported a total flight time 2,500 hours. The right-seated pilot's souse stated that her husband was a seasoned pilot, with lineage of aviators in his family. He regularly flew in the harsh conditions of Alaska where they owned another home, although he frequently operated out of Flagstaff. She flew with him often and classified him as a conscientious pilot, always willing to cancel a flight for any reason, including poor weather conditions. Her husband had relayed to her that he was excited about the Yuma project. He had spent many years working on the job and the meeting was of high importance. The night prior to the accident he received about 6 hours of sleep, which was shorter than normal. She added that although he had his instrument rating, he rarely flew instruments, as he did not like to conduct such operations. AIRCRAFT INFORMATION The Cessna 205, serial number 205-0298, was manufactured in 1963. A review of the logbooks revealed that the most recent annual inspection was performed on May 16, 2008, at a total airframe time of 5,017.1 hours. The powerplant, a Teledyne Continental Motors IO-470-S, serial number 102781-3-S-1, last underwent a major overhaul on April 30, 2008; during the last annual inspection this engine was installed on the airframe. The maintenance records listed the last maintenance as occurring on July 08, 2008, where the owner performed preventative maintenance items, which included an oil change. The last known fueling occurred on January 13, 2009, where the owner added 48 gallons of fuel in Sedona, Arizona, filling the tanks to their full capacity. The flight time between the fueling and the accident is unknown. An Arizona Department of Public Safety commander was making a traffic stop near the accident site and radioing to dispatch when the accident airplane passed overhead. The audio recording was sent to the National Transportation Safety Board Vehicle Records Laboratory in Washington D.C., for examination. Based on the recording, it was estimated that the engine rpm was about 2,000 and the airplane was traveling at an airspeed of about 130 knots. METEOROLOGICAL INFORMATION The first officer of a Horizon Air flight 2497 recalled that on the morning of the accident he was preparing to fly from Flagstaff en route to Prescott, Arizona. Prior to departure, and while waiting for a clearance, he witnessed an airplane taxiing to runway 21. He subsequently observed the airplane depart off of runway 21, which he noted to be similar appearance to a Cessna 172. He further stated that around 0700 he departed from runway 03, complying with company procedures. The airplane entered the cloud layer before the facility-observed 1,600 feet, somewhere around 1,000 feet above ground level (agl). He added that the cloud layer and visibility seemed to be lower to the south of the airport. During the entire flight there was continuous light turbulence and light rime ice, until they eventually broke out of the cloud layer just before Prescott. At 0656, the weather observation facility at FLG reported calm wind; 10 statute miles visibility; scattered cloud layer at 800 feet; broken cloud layer at 1,500 feet; and an overcast layer at 2,200 feet; temperature 04 degrees Celsius; dew point 04 degrees Celsius; and an altimeter setting of 30.23 inches of mercury. At 0659, 3 minutes later, the same facility updated the cloud conditions to a broken cloud layer at 800 feet; an overcast layer at 1,500 feet; remarking that a cloud ceiling varied between 700 feet and 1,100 feet. An audio recording was provided by the Lockheed Martin Prescott Automated Flight Service Station (AFSS), of the owner requesting and receiving an outlook weather briefing at 1951 the night prior to the accident. He stated that he intended on departing from Flagstaff to Yuma at 0630 the next morning. The owner stated that the flight would take about 2 hours at an en route altitude of 8,500 feet mean sea level (msl). Immediately following his announcement of the planned altitude, he relayed that "we may have to go IFR (Instrument Flight Rules) in which case the altitude would change." The briefer informed the owner that from 2200 that night to 1900 the next day, the Flagstaff weather was forecasted with the following conditions: light rain showers; mist; visibility 2 miles; scattered clouds at 500 feet; and an overcast layer at 1,000 feet. He added that around Flagstaff there would be snow and mixed precipitation as well as other areas along the intended route. The briefer stated that for northern Arizona "outlook marginal VFR for ceilings, rain showers, and mist." The owner called the AFSS at 0611 the morning of the accident. He reque