WPR09FA146

The pilot's failure to maintain proper altitude and glidepath while executing a night instrument approach. Contributing to the accident was the pilot's fatigue.

The pilot was executing an over-water instrument approach to Runway 14 on a dark night in an area of moderate to heavy precipitation and light to moderate turbulence. Based upon the airplane's descent profile, recorded radar data, local ocean currents, and the ultimate distribution of debris along the beach, the airplane impacted the ocean's surface about one-half mile offshore and about seven statute miles northwest of the Arcata Airport. In the forty-two hours immediately preceding the accident, the pilot had flown about twenty hours and forty-five minutes, and had crossed four time zones. There was no record of the pilot acquiring a weather briefing relating to his destination on the day of the accident.

HISTORY OF FLIGHT On March 1, 2009, about 2300 Pacific Standard Time, a Diamond DA-40, N521DS, impacted the waters of the Pacific Ocean while its pilot was executing an RNAV/GPS approach to Runway 14 at Arcata Airport, Arcata/Eureka, California. The commercial pilot and his passenger were killed in the accident sequence, and the airplane, which was owned by Mitchell Enterprises Inc., was destroyed by the impact. The Title 14 Code of Federal Regulations Part 91 personal pleasure cross-country flight, which was operating in night visual meteorological conditions (VMC), departed Bakersfield, California, at 1936. The pilot was on an instrument flight rules (IFR) flight plan, and had been issued a clearance for the approach into Arcata, Airport. There was no report of an emergency locator transmitter (ELT) signal. Debris from the wreckage was first discovered on a nearby beach four days after the accident. According to family members, the pilot spent a number of hours on Friday, February 28, 2009, looking on the internet and calling around his local area in an effort to locate an airplane to use on a cross-country flight from Florida to Les Vegas. Although his first choice was a twin engine airplane, he was not able to find one available. He first contacted the owner of N521DS about 1100, on that Friday. He inquired about renting the airplane for a multi-day cross-country flight, and arranged for a checkout by the owner's check pilot the next morning, and for rental of the airplane beginning on that same day (Saturday). On Saturday morning the pilot and his passenger arrived at Plant City Airport about 0800. The passenger stayed in the office area of the airplane's owner while the pilot went through the pre-rental process. That process included having his log books reviewed by the check pilot, undergoing 30 minutes of ground checkout, and an in-flight checkout lasting one hour. The pilot then completed the rental agreement, put $1,000.00 cash on deposit, and gave the owner his credit card number for billing the flight time beyond the $1,000.00 deposit. According to the owner, during the rental/checkout process, the pilot said that he was building time, and that he and his passenger were going to fly to Las Vegas, and would return on Tuesday, Wednesday, or Thursday, depending on the weather. According to the check pilot, the checkout went well, with the pilot displaying good knowledge of the airplane, as well as good piloting skills. The pilot and his passenger departed Plant City Airport about 1100 Eastern Standard Time, and arrived at Mobile Regional Airport, Mobile, Alabama, about 1340 Central Standard Time (CST), for a leg flight time of about three hours and forty minutes. They stayed on the ground at Mobile for about one hour and fifty minutes, and then departed there about 1530 CST. They arrived at Huntsville Municipal Airport, Huntsville, Texas, about 1920 CST, for a leg flight time of about three hours and fifty minutes. After landing at Huntsville, the pilot had 39 gallons of 100 low-lead aviation fuel added to the fuel tanks. According to the Huntsville Aviation employee who pumped the fuel, the pilot initially stated that after refueling they were going to continue on. But, according to that employee, during the refueling process the pilot and his passenger started discussing how tired each one of them was, and they eventually made the decision to stay in Huntsville overnight. The owner of Huntsville Aviation then drove them to a local hotel, arriving there about 2000 CST. As he was leaving them at the hotel, they mentioned that after they checked in, they were going to walk to one of the adjacent restaurants for dinner before returning to the hotel. On the second morning of the trip, about 0700 CST, when the first Huntsville Aviation employee arrived at the airport, the pilot and his passenger where already at the airplane. The pilot was observed performing his preflight inspection, after which he and his passenger came into the Huntsville aviation office, reportedly to get warm. They then went back out to the airplane, and the pilot began to taxi out for takeoff about 0715. The next known location of the airplane was in Sedona, Arizona, where later that day it took on 31.6 gallons of fuel, before departing that location about 1730 Mountain Standard Time (MST). Although the airplane's arrival time at Sedona (an airport without a control tower) could not be determined, the investigation did reveal that while at Sedona the pilot made a phone call to his mother, ate a meal, and filed two flight plans through the CSC DUATS system. The first flight plan, which was for a leg from Sedona, Arizona to Palmdale, California, was filed at 1607 MST. The second flight plan, which was filed at 1700 MST, was for a leg from Palmdale, California, to Arcata, California. Although the pilot had filed from Sedona to Palmdale, upon reaching Palmdale he continued on to Meadows Field, Bakersfield, California, which is located about 65 nautical miles northwest of Palmdale. He arrived there at 1841 Pacific Standard Time (PST), for a leg flight time of about two hours and fifteen minutes. Then, at 1900, the pilot took on 29.0 gallons of 100LL aviation fuel from an Atlantic Aviation fueling truck, and departed for Arcata at 1936 PST. An annotation at the top of the refueling slip indicated that the Bakersfield refueling was a "top off." After departing Bakersfield, the pilot picked up his instrument flight rules (IFR) clearance, whereupon he was cleared to his filed altitude of 8,000 feet, with a route clearance of direct to Arcata. At 2002 PST, while in the vicinity of Visalia, California, he contacted Oakland Flight Watch to inquire about some reports of turbulence that he overhead while airborne. Although the pilot only asked for the turbulence information, the Flight Watch briefer responded with a more expanded weather update. He informed the pilot that there were AIRMET's (Airmen's Meteorological Information) in effect for low level wind shears and moderate turbulence below 18,000 feet, with icing from the freezing level to 20,000 feet. The briefer further advised him that he was moving into an area of moderate precipitation, but that he would move into an area of isolated widely scattered precipitation once he passed Stockton, California. He also indicated that pilot reports were indicating icing in the central California area at an altitude range of about 15,000 to 18,000 feet. He also told the pilot that there was a pilot report of moderate turbulence at 4,000 feet about five miles southeast of Tracy, California. The briefer informed him that there was light rain north of Stockton, with clouds scattered to broken about 4,100 to 5,000 feet. He also informed the pilot that the current conditions in Arcata were light rain, winds from 150 degrees at 10 knots, gusting to 20 knots, visibility 9 miles, scattered clouds at 5,000 feet, a broken ceiling at 6,000 feet, and an overcast ceiling at 9,500 feet. At the end of the update the controller asked, "Is that what you needed, or can I help you with anything else?" The pilot then indicated that that was all he needed, and thanked the briefer for his help. The pilot then continued on direct to his destination. As the pilot proceeded into the northwest corner of California, he was advised to switch from Oakland Center to Seattle Center. When he first made contact with the Seattle Center, the pilot advised the controller that his transmissions were "broken up." In response the controller said that the Center transmissions should get better as the pilot continued on toward Arcata. About four minutes after the pilot's first contact with Seattle Center, the controller gave him the altimeter setting (29.67) and asked him what his altitude was. The pilot responded that he was indicating 9,300 feet, and the controller then reminded him that his last assigned altitude was 10,000 feet, and t