Primary finding
Probable cause
The pilot's continued visual flight rules flight into instrument meteorological conditions, which resulted in a controlled collision with terrain.
Investigator assessment
Analysis narrative
The pilot, who held an instrument rating, was flying the airplane for the owner, who did not hold an instrument rating, from the departure airport, where instrument meteorological conditions (IMC) prevailed, to another airport, where visual meteorological conditions prevailed. Forecast weather conditions along the route of flight called for areas of mountain obscuration and precipitation, including snow. The pilot filed an instrument flight rules (IFR) flight plan, and he was issued an IFR clearance. About 44 minutes into the flight, the pilot canceled the IFR clearance and continued the flight under visual flight rules (VFR). About 16 minutes later, the pilot amended the flight’s destination to an airport that was along the route of flight, but closer than the original destination, and about 19 minutes after that, the air traffic controller told the pilot that radar service was terminated. About 1.5 hours after radar service was terminated, the airplane impacted mountainous terrain at an elevation of about 6,400 feet mean sea level (msl). The wreckage was confined to the impact area, and the damage was consistent with controlled flight into terrain. The accident site was located along the route of flight beyond the amended destination and about 20 miles short of the original destination, indicating that the pilot had over flown the amended destination and may have been attempting to reach the original destination. About 30 minutes before the accident, light rain and mountain top obscuration were reported in the vicinity of the original destination airport. At the time of the accident, the original destination airport was reporting cloud layers with bases about 6,300 and 6,800 feet msl. Given the forecast and reported weather conditions, it is likely that the pilot encountered IMC and was unable to see the terrain prior to the airplane colliding with it. The toxicology report for the pilot showed positive results for amphetamine, methamphetamine, and trimethoprim, an antibiotic used to treat infections. However, it could not be determined from available samples when the amphetamine and methamphetamine had been ingested, and, therefore, whether they would have impaired the pilot’s performance. Review of the pilot's medical records indicated that he had diabetes, and, one day prior to the accident, he had been treated for a skin infection. It is possible that the pilot was distracted by his medical condition and that this may have impaired his performance and contributed to his decision to continue the VFR flight into deteriorating weather conditions.
Source record
Factual narrative
HISTORY OF FLIGHT On May 28, 2011, approximately 1800 Pacific daylight time (PDT), N9831V, a Cessna R172K, collided with terrain about 4 miles north-northwest of Cold Springs, Nevada. The owner was operating the privately owned airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was substantially damaged. The instrument-rated private pilot, the airplane owner, who held a private pilot certificate, and a passenger, sustained fatal injuries. A combination of visual and instrument meteorological conditions existed along the route of flight. At the time of the accident, the pilot was not operating under a flight plan or visual flight rules flight following. The airplane departed Roseburg, Oregon, operating under an instrument flight rules clearance at 1507. According to personnel at the Roseburg fixed-base-operator (FBO), the airplane owner had likely flown to Roseburg on Friday, May 27. On Saturday, the airplane owner contacted the FBO to query whether or not there was an instrument-rated pilot that could fly the airplane from Roseburg to Albuquerque, New Mexico, and be reimbursed for expenses. The pilot was contacted, and arrived at the airport to check out the airplane prior to the flight. He also filled the fuel tanks to capacity. According to the personnel at the FBO, the pilot intended to fly the owner and passenger to Reno International Airport, Reno, Nevada, and then return to Roseburg, as weather conditions improved along the route of flight after Reno. According to the owner of Ocean Air, a flight school at Roseburg, the airplane owner needed a pilot with an instrument rating to fly the airplane out of Roseburg. He indicated that the aircraft owner likely arrived on Friday because when the owner arrived to work on Saturday morning, the airplane was parked on the ramp. The airplane owner contacted the owner of Ocean Air by telephone and asked if he knew of someone with an instrument rating that could fly the airplane to Albuquerque, New Mexico. The owner of Ocean Air put him in touch with the pilot. Prior to their departure, the pilot and aircraft owner flew around the pattern so that the pilot could become familiar with the airplane. The airplane was topped off with fuel prior to departure. According to the owner of Ocean Air, the pilot was not being paid for the flight, but being reimbursed for his expenses. He was building time for his commercial rating. The airplane was reported missing on May 31 by the pilot's family, and an Alert Notice (ALNOT) was issued. The wreckage was located at 1915 PDT on May 31. PERSONNEL INFORMATION Pilot The pilot, age 47, held a private pilot certificate for single-engine land and instrument. He held a second-class medical certificate issued on June 22, 2009, with the restriction that he must wear corrective lenses. The pilot was located in the left seat. According to a friend of the pilot, he was trying to accrue flight hours as he was working on his commercial certificate. A review of the pilot's logbook showed that he had 342 hours, with 12 hours flown in the last 30 days. The logbook showed 59.4 hours simulated instrument flight time, and 16.1 hours operating in actual instrument conditions. Owner The owner, age 41, held a private pilot certificate for airplane single-engine land. He also held a mechanic certificate for airframe and powerplant. The owner held a third-class medical certificate issued July 8, 2008, with no limitations. The owner was located in the right seat. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number (SN) R1722351 was manufactured in 1977. It was powered by a Continental Motors IO-360-K engine, and equipped with a McCauley 2A34C203/90DCA-14 propeller. The airplane was fueled to capacity on May 28, at the Roseburg airport. The maintenance records for the airplane were not located. A receipt from Crown Aviation, Everett, Washington, was located in the wreckage. It showed that the transponder, altimeter, and static systems were checked in December 2010. According to personnel at Crown Aviation, they did not perform annual inspections on the airplane. The tachometer time recorded during the December 2010 tests was 3,016.61 hours. WRECKAGE AND IMPACT INFORMATION The airplane impacted steep, rocky, mountainous terrain, at an elevation of approximately 6,400 feet mean sea level. The wreckage was confined to the impact area. The accident site was located at the following global positioning coordinates: N 39 degrees 44.037 minutes, W 119 degrees 59.57 minutes. The aircraft was on a heading of east-northeast. The nose of the airplane was on a heading of 080 degrees magnetic, and the empennage section to the aft cockpit was on a heading of 020 degrees magnetic. Airplane The wreckage was confined to the impact area. The cockpit area was compressed downward and the empennage remained intact. All control surfaces remained secured to their attach points. The right wing leading-edge was crushed aft and perpendicular to the longitudinal axis of the airplane from the wingtip inboard to the strut attach point. Tapering compression was evident and the crushing was more pronounced on the outboard section, and lessened as it moved inboard. The left wing sustained crush damage on the underside. The aileron and flap control surfaces remained attached to both wings, and the control cables remained connected at their attach points. The flap actuator measured 1.8 inches, which according to the Cessna representative, equates to a flap extension between 5-10 degrees. The empennage section was examined. The elevator and rudder control surfaces remained attached. The outboard right horizontal stabilizer and elevator were bent upward at the tips. All control cables remained attached at their respective connection points in the empennage. The elevator trim was extended 2.0 inches, which according to the Cessna representative, is beyond the maximum up limit of 25 degrees tab up (1.88 inches). All of the seats were separated from the floor assembly and the seat rails were fragmented. The front seats had compression damage. The rear seat also sustained compression damage. All occupants were wearing their respective restraint systems; 3-point restraint systems in the front seats and 2-point in the rear seat. The airplane was equipped with an ACK Technologies Inc. electronic locator transmitter (ELT), model E-01, SN 008831. The unit was found in the "off" position in the wreckage and did not activate. Tests of the unit following its removal were unsuccessful. Removal of the batteries showed corrosion. The housing of the ELT showed that the batteries were due for replacement in March 2011. Examination of the recovered airframe and flight control system components revealed no evidence of pre impact mechanical malfunction. The ELT was not armed for the flight, and the batteries were corroded and unable to supply power. Instruments The following instruments, or portions of them, were identified: • Tachometer (3059.38 hours) • Clock • Vertical speed indicator (face) • Altimeter (face), Kollsman window setting 29.73 • Airspeed indicator • Altitude indicator • Directional gyro • Automatic direction finder • Turn coordinator • Marker beacons • 1Apollo IImorrow FlyBuddy (Global Positioning System) The housing from a Honeywell Bendix King RoHS unit, PN 066-01207-0099, SN AA012011, was discovered loose within the wreckage. The housing was sent to the NTSB Recorder Laboratory, but due to the damage, no information was obtained. Two gyros were found loose within the wreckage and were disassembled. One was electric (turn coordinator), and the other was not (directional gyro). Rotational scoring was evident on each gyro. The attitude indicator gyro was also examined. Rotational scoring was identified. Examination of the recovered instruments revealed no ev