Primary finding
Probable cause
The pilot's loss of control of the airplane due to spatial disorientation after inadvertently entering instrument meteorological conditions. Contributing to the accident were the pilot's inadequate preflight preparation, his en route decision-making, and his distraction due to a partial loss of engine power due to a restriction in a fuel injection nozzle.
Investigator assessment
Analysis narrative
The pilot, who was not instrument rated, intended to fly to his destination while remaining in visual meteorological conditions (VMC). While en route, he entered an area where the clouds started to close in on him. Although the air traffic controller whom he was communicating with advised the pilot that there was an airport with VMC a short distance behind him, the pilot elected to attempt to proceed to his destination. As he continued, weather conditions became such that the pilot elected to land at an alternate airport. While being vectored to the alternate airport, the airplane's engine began to run rough, which, according to recorded engine analyzer data, was due to a restriction of the fuel flow in the orifice of the no. 1 cylinder injector nozzle. While attempting to deal with the rough running engine and maneuvering toward the alternate airport, the pilot inadvertently entered the clouds, and most likely lost control of the airplane due to spatial disorientation. The airplane then descended near vertically into the terrain. There was no record of the pilot receiving a weather briefing either from an FAA-contracted Flight Service Station or from either Direct User Access Terminal Service (DUATS) provider.
Source record
Factual narrative
HISTORY OF FLIGHT On February 26, 2011, about 1730 mountain standard time, an experimental Neefjes Lancair 360 MK-II, N989TT, impacted the terrain about 6.5 five miles northwest of Milford, Utah. The private pilot, who was the sole occupant, received fatal injuries, and the airplane, which was owned and operated by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal cross-country flight, which departed Grand Junction, Colorado, about 1 hour and 40 minutes prior to the accident, was en route to Chandler, Arizona. The airplane was initially being operated in visual meteorological condition (VMC), but as the pilot continued en route he entered an area where instrument meteorological conditions (IMC) prevailed. The pilot did not file a flight plan prior to departure, but he did contact the Air Route Traffic Control Center (ARTCC) while en route for assistance in reaching his destination while operating under visual flight rules (VFR). After departing Grand Junction, the pilot contacted Denver ARTCC for VFR flight advisories and routing assistance. As he approached the boundary of Denver Center's airspace, the pilot advised the controller that he may need to divert from his planned route due to weather, and might head more to the west toward Cedar City, Utah. The controller therefore gave the pilot the current Cedar City weather, and soon thereafter, about 1600, handed him off to Salt Lake Center. Approximately two and one-half minutes after he contacted Salt lake Center, the pilot told the controller that he was trying to divert through a cloud cover, and that the clouds were starting to close in on him. He then asked for the weather for Carbon County Airport, which was north of his planned route. The Carbon County weather the controller gave the pilot included the fact that it had a 3,300 foot overcast ceiling and a visibility of 10 miles. The controller further advised the pilot that the best weather in his vicinity was at Canyonlands Airport (Moab, Utah), which had a 6,500 foot broken ceiling; and that everything else in the area had broken ceilings below 3,000 feet. The controller then told the pilot that the weather at Page, Arizona, looked really good, with no ceiling, but with winds at 17 knots gusting to 26 knots. At that point the controller also explained to the pilot that since his weather radar was very inaccurate that he did not know how to route him to Page. Then about five minutes later, the controller advised the pilot that he had checked the weather at Vernal, Utah, which was about 50 miles behind the pilot, and that the weather report there indicated clear skies. The controller then checked with the crew of another airplane that was about 100 miles in front of the Lancair pilot, in order to get a report on the tops of the cloud layer in that location. That crew reported that the tops in that location were about 15,000 feet, and the controller passed that information on to the pilot. As the pilot continued to the west, he advised the controller that it appeared that the cloud tops might be higher than the reported 15,000 feet. The controller therefore asked the aforementioned crew for an update on the cloud tops in their present location, which was about 20 miles north of the Lancair, and the report came back that they were around 17,000 feet. The controller passed that information on to the pilot, and then, in response to another question from the pilot, confirmed that previous reports indicated that the tops started to go down "a bit" toward the west. About 11 minutes later, the pilot advised the controller that he was going to try to divert to Torrance, California (his home base), and asked if the controller had any weather information between his present position and Torrance. About 2 minutes later, the controller advised the pilot that he had looked at the Tonopah, Nevada and Las Vegas, Nevada weather, and that Las Vegas had an 8,500 foot broken ceiling, with an overcast ceiling at 14,000 feet, and that Tonopah had a 5,500 foot broken ceiling, with no overcast above. The controller further advised the pilot that he did not show any precipitation in the Las Vegas and Tonopah areas, and that in the Los Angeles area (near Torrance) there was no ceiling, but only scattered clouds at 6,000 feet and 20,000 feet, with winds at 18 knots gusting to 25 knots. The pilot responded to that information by stating, "I think I will head in that direction." About 5 minutes later the pilot was switched to the next Salt Lake Center sector controller, and about 6 minutes after that, after an inquiry from the controller, the pilot confirmed that he was "currently" at 13,600 feet. About 3 minutes later the pilot asked for an update on the cloud tops in his area and in the Las Vegas area. The controller therefore checked in with two other airplanes operating in the area, and determined that the cloud tops near Milford, Utah, were between flight level 250 and flight level 270, and that in the area of Saint George, Utah, the tops were about flight level 195, with light to moderate turbulence in the area. The controller passed this information on to the pilot, along with the updated weather for Las Vegas, which indicated an 8,000 foot broken ceiling, a visibility of 10 miles, and winds of 19 knots gusting to 23 knots. The pilot then asked if there was any precipitation between his position and Las Vegas, and the controller informed him that there was one area of precipitation, but that on his present course he would not enter that area. Then about 18 minutes after the pilot had been handed off to the sector controller, the controller asked him if he was still planning on going to Torrance, or if he was changing his destination to Las Vegas. The pilot responded that he was changing his destination to Las Vegas. About one minute after advising the controller that he was changing his destination to Las Vegas (about 1718), the pilot reported that he was "losing" his engine, and was declaring an emergency. The controller responded by asking him his intentions, and the pilot stated that he would like to divert to the nearest airport. The controller advised him that Milford was 15 miles to his east, and that Cedar City was a little bit further away and to the south. The pilot chose Milford, and after receiving a vector heading from the controller, he asked for the Milford weather. The controller informed the pilot that Milford's weather included heavy snow, freezing fog, and a visibility of ¼ mile. The pilot therefore asked for the Cedar City weather, which included light snow, mist, a visibility of 1/2 mile, few clouds at 600 feet, a broken ceiling at 2,900 feet, an overcast layer at 4,200 feet, a temperature of 1 degree C, and a dew point of 0 degrees C. The pilot then advised the controller that his engine was running very rough, but that he was not losing altitude. The controller acknowledged that transmission, and then about 45 seconds later informed the pilot that Saint George was reporting a broken ceiling at 3,600 feet, with an overcast layer at 4,200 feet, with a visibility of 10 miles. The pilot responded by asking the controller to vector him there, and the controller gave the pilot a heading vector and provided him with the airport identifier (DXZ). About 2 minutes later the controller directed the pilot to contact the next sector controller on the frequency he provided. About 15 seconds after giving the frequency change instructions, the controller noticed that the airplane was heading north (away from Saint George). Assuming that the pilot might still be on his frequency, the controller asked the pilot if he was just heading north for cloud avoidance. The pilot did not immediately respond, but about 15 seconds later transmitted that he was losing control of the airplane. The controller then advised the pilot that Milford was at 077 degrees from his position at 5 miles, and then asked the