WPR09FA385

The instrument-rated pilot’s loss of situational awareness and failure to follow the prescribed instrument departure clearance/procedure, which resulted in an in-flight collision with the terrain.

The instrument rated pilot was planning a cross-country flight from his home airport in low fog conditions. The pilot received an instrument flight rules (IFR) clearance about 15 minutes prior to departure from runway 18R. Witnesses reported observing the airplane pass directly over their work site at a very low altitude about 1 mile south of the airport. Recorded radar data disclosed that the airplane was airborne for about 1.5 minutes. Following departure, the airplane made a left bank while gradually increasing its altitude to 1,000 feet mean sea level (msl) to an easterly heading. The last two returns show an altitude of 900 feet msl and a slight change of direction back toward the south. The last radar return was located about 0.5 miles north of the accident site. The departure clearance dictated that the pilot was to continue straight on the runway heading of 180 degrees until intercepting a VOR radial about 6 miles from the airport. Thereafter, he was to make a left turn to join the radial and follow it to the first intersection on the departure route (about 10.25 miles south of the airport). The accident occurred during the hours of darkness with a full moon about 12.9 degrees above the horizon. A routine aviation weather report (METAR) disclosed that during the time of the accident there was an overcast cloud layer at 600 feet agl and 10 miles visibility. The pilot received an Instrument Competency Check several days prior to the accident and reportedly frequently flew with sole reference to the instruments. Ground scar analysis, impact signatures, and wreckage fragmentation patterns disclosed that the airplane impacted terrain in a near level attitude, with high forward velocity. There was no evidence of a pre-mishap mechanical malfunction or failure observed during the examination of the engine or airframe.

HISTORY OF FLIGHT On August 05, 2009, at 0431 Pacific daylight time, a Cessna 182S, N23750, impacted hilly terrain shortly after departing from Napa County Airport, Napa, California. Sierra Madre Corp. was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The commercial pilot, the sole occupant, was killed. The airplane was substantially damaged. The cross-country personal flight was originating from Napa with a planned stop in Bakersfield, California, and final destination of Santa Fe, New Mexico. Instrument meteorological conditions prevailed in the area surrounding the accident site. An instrument flight rules (IFR) flight plan had been filed and a clearance had been issued; the flight plan was never activated. During a telephone conversation with a Safety Board investigator, the pilot's spouse recalled that they had been planning a trip down to New Mexico. As for the trip's logistics, she stated that she was a timid flyer and therefore, opted to take a commercial flight; the pilot planned to fly the accident airplane, which was based at Napa County Airport. He had flown the airplane on this route about five times prior and usually chose to leave early to avoid any inclement weather. For this flight he planned to land in Bakersfield to refuel and then continue on to Santa Fe, where he would meet his wife later in the day. After leaving their residence in the San Francisco area, the pilot called his spouse about 0315 reporting that the weather was good. He again telephoned her around 0400, stating that he was at the airplane's hangar and preparing to depart. According to Federal Aviation Administration (FAA) records, at 1351 the day prior to the accident, the pilot contacted the Prescott Automated Flight Service Station (FSS). He requested to file two IFR flight plans, the first of which was from Napa to Bakersfield, and the latter was from Bakersfield to Santa Fe. He reported a planned departure time of 0430, and a cruising altitude of 7,500 feet at an airspeed of 130 knots. The pilot stated that he thought there was probably going to be "that morning fog IFR getting out of Napa." He called flight service the day of the accident at 0408 to open his flight plan and request a clearance. During the ensuing conversation, the pilot received an IFR clearance and correctly read back the following: cleared Napa to Bakersfield via the LIZRD3 departure, CROIT transition, on V108 and as filed, climb and maintain 7,000 feet. A contracting crew was pouring concrete the morning of the accident about 1 mile south of the airport [located about 2 miles west of the accident site]. The crew recalled that at about 0430 they witnessed an airplane pass directly over their work site at a very low altitude. They recalled that the area was foggy, but could not determine the height of the cloud layer. They witnessed a fire plume in the distance shortly after the airplane passed over them. Recorded radar data covering the area of the accident was supplied by the FAA in the form of a National Track Analysis Program (NTAP) printout from Oakland Air Route Traffic Control Center (ARTCC). The radar data was analyzed for time frame and proximity to the anticipated flight track of the airplane en route as dictated in his IFR clearance. The radar data consisted of approximately equidistant radar returns from 0429:17 to 0430:54, or about 1.5 minutes intervals. The data was consistent with the airplane making a shallow left bank following departure from runway 18R and gradually increasing its altitude towards the east. The target was first identified at a Mode C reported altitude of 100 feet mean sea level (msl). During the proceeding minute, radar returns disclosed a gradual ascent to 1,000 feet msl, corresponding to about 960 feet above ground level (agl). The last two returns show an altitude of 900 feet msl and a slight change of direction to the south. The last radar return was located about 0.5 miles north of the accident site. The LIZRD 3 departure description for runway 18R is as follows: The pilot is to depart and climb on a 180-degree heading. This heading will lead to the intercept of the Scaggs Island VORTAC radial-127 [located about 6 miles from the departure end of runway 18R], which the pilot is to follow until reaching the LIZRD intersection [located about 10.25 miles south of the runway]. The pilot is to cross the LIZRD intersection at or above 3,000 feet. The accident occurred during the hours of darkness, with civil twilight beginning at 0546, and sunrise at 0615. According to the United States Naval Observatory astronomical data, at the time of the accident the moon was 12.9 degrees above the horizon on an azimuth of 233 degrees, and was 100 percent illuminated with a full moon occurring on August 5, 2009. PERSONNEL INFORMATION A review of the airmen records maintained by the FAA disclosed that the pilot, age 67, held a commercial pilot certificate with airplane ratings for single and multi-engine land. The pilot received his instrument rating in April 2001. His most recent third-class medical was issued on July 22, 2008, with a limitation that he must wear corrective lenses to exercise the privileges of his certificate. The pilot's personal flight records were found at the accident site; the entirety of the contents could not be read, as they were partially burned. Only one page in the logbook contained flight entries, of which there were six entries dated from January 31, 2009, to August 02, 2009. The entries all indicated the flights originated and terminated in Napa and were conducted in the accident airplane. In pertinent part the entries were as follows: January 31: Instrument Competency Check, 2 hours (1.8 hours simulated instrument) March 28: Cross Country, 3.5 hours April 25: Cross Country, 3.1 hours May 29: Cross Country, 3.1 hours June 28: Cross Country, 8.4 hours (0.1 hours actual instrument) August 02: Instrument Competency Check, 1.8 hours (0.3 hours actual instrument) The totals at the bottom of the page were recorded as follows (excluding the times listed above): Night: 28.5 hours Actual instrument: 28.5 hours Simulated instrument: 162.1 hours Total time: 1,080.3 hours During an interview with a Safety Board investigator, the pilot's certificated flight instructor (CFI) stated that he had flown with the pilot for the duration of his instrument training (over about 2 years) and continuously since that time. He classified the pilot as being a "brilliant" aviator, and commented that he often flew his airplane with sole reference to instruments. He performed the pilot's instrument competency check a few days prior to the accident. During that time, they thoroughly discussed taking off in instrument meteorological conditions (IMC) at an uncontrolled airport, and specifically the departure procedures the pilot was executing on the day of the accident. The CFI further recalled that the pilot did not use the autopilot system, but did frequently use his Garmin GPS for backup reference. AIRCRAFT INFORMATION The Cessna 182S, serial number 18280452, was manufactured in 1999. The airplane's maintenance logbooks were found by a Safety Board investigator in the pilot's hangar. A review of the logbooks revealed that the most recent annual inspection of the airframe and engine was recorded as being performed on July 07, 2008, at a total time of 1,073.8 hours. A typed letter was found predominantly placed on top of the logbooks in the airplane's hangar. It was dated August 02, 2009, and was addressed to the airplane's mechanic from the pilot. It stated that he did not fly several days prior because he would have had to depart IFR, which he did not want to do with an airplane that had just undergone an annual inspection. During an interview with a Safety Board investigator, the airplane's mechanic indicated that he hadn't performed an annual