Primary finding
Probable cause
The pilot’s continued visual flight into instrument flight rules conditions, which resulted in his failure to maintain sufficient clearance from rising terrain.
Investigator assessment
Analysis narrative
Before beginning the cross-county flight under visual flight rules (VFR), the pilot received a weather briefing that reported VFR conditions at the departure and destination airports but included an airmen's meteorological information notice for instrument flight rules (IFR) conditions along the route of flight. About 8 minutes after departure, recorded radar data showed the airplane's altitude varying between 321 and 635 ft above ground level (agl) for about 1.5 minutes before the impact. Until about 30 seconds before impact, the airplane was tracking south on course along a valley, but it then began to deviate west toward rising terrain. The airplane then began a slow, descending right turn. The last recorded radar target showed the airplane about 0.2 miles from the accident site, at an altitude of about 410 ft agl. A postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of weather observations and satellite imagery indicated that IFR conditions prevailed in the vicinity of the accident site due to low clouds and restricted visibility. It is likely that the pilot was varying his altitude to remain clear of the clouds and subsequently entered an area where continued flight on course was not possible and initiated a right turn. During the turn, the airplane collided with rising terrain.
Source record
Factual narrative
A Garmin GPSMAP 396 unit was recovered from the wreckage and sent to the NTSB Vehicle Recorders Laboratory for examination. Track log data dated from May 18, 2009, to June 26, 2009, was recovered from the unit. No track log data was identified correlating with the date of the accident. The complete GPS report is appended to this accident in the public docket. A review of archived Air Traffic Control (ATC) radar data showed the airplane's altitude varied between 1,100 feet msl and 1,225 feet msl from 0849:08 until 0850:13, with a general south-east heading. The radar data was not shown from 0850:14 until 0855. At 0855:16, the airplane was depicted at 1,724 feet msl. From 0855:17 until 0856:12, the airplane's altitude varied between 1,625 feet msl (about 321 feet agl) and 1,774 feet msl (about 438 feet agl), with a south-west heading. At 0856:17, the heading changed to west, and the airplane started a climb. At 0856:38, radar data showed the airplane at 1,850 feet msl (about 635 feel agl). The airplane then began a slow descent with a slight right turn until the collision with terrain. The last observed target on the accident airplane was recorded at 0856:54 about 1,525 feet msl (about 410 feet agl). Radar data video and raw data are appended to this accident in the public docket. An autopsy was performed on the pilot May 26, 2015, by the Alameda County Sheriff's Office, Coroner's Bureau, Oakland, California. The cause of death was determined to be "extensive blunt trauma." The FAA Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology on specimens from the pilot. The specimen used to test for volatiles tested positive for ethanol in muscle but negative for ethanol in liver. The specimen used to test for drugs detected a presence of atorvastatin in liver. Tests for carbon monoxide and cyanide were not performed. Examination of the accident site revealed that it was located on the side of a hill, at an elevation of 1,237 feet msl. The airplane wreckage was spread along a 230-foot-long upsloping debris path through grass on an approximately heading of 044 degrees magnetic. The main wreckage came to rest at an elevation of about 1,257 feet msl. The first point of impact is a ground scar about 10 inches wide containing a piece of a green lens, and a piece of a wing structure. The ground scar extended about 17 feet into a large area of disturbed dirt. A propeller slash mark was found about 16 feet from the initial point of impact. About 43 feet northeast-east from the first point of impact were one of the airplane's propeller blade, and a right wing lift strut. Plexiglas, portions of engine cowling, engine mount structure, and fuselage debris were scattered across the ground beginning at the first point of impact, and extended to the main wreckage. Another propeller blade was located about 115 feet from the first point of impact. The terrain from the first point of impact to where the airplane's main wreckage came to rest was upsloping, at an angle of approximately 9 degrees. The main wreckage was located 145 feet from the first point of impact, and consisted of the airplane's engine, right wing, right landing gear, aft fuselage, and empennage. The fuselage came to rest upright on a heading of about 300 degrees. Those components were partially charred, melted, and damaged by the impact. The forward fuselage and the cabin were consumed by fire. A burned area of grass surrounded the main wreckage within about 10 feet. The left wing was located 165 feet from the first point of impact. The third propeller blade was located at 193 feet, and it was attached to the propeller hub. The horizontal stabilizer, elevators, vertical stabilizer, and rudder remained attached to the empennage. The bulkhead and the bottom of aft fuselage were bent inward. Front seats and center seats were found outside the main wreckage. The two rear seats remained attached to the airframe. The airplane wreckage was examined at the facilities of Plain Parts, Pleasant Grove, California, on May 24, 2015, by representatives from Textron Aviation, Continental Motors, Inc., and FAA under the supervision of the NTSB IIC. Examination of the recovered airframe, engine, and system components revealed no evidence of preimpact mechanical malfunction that would have precluded normal operation. The complete engine and airframe examination report is appended to this accident in the public docket. A NTSB staff meteorologist prepared a factual report for the area and timeframe surrounding the accident. The National Weather Service (NWS) Surface Analysis Chart for 0800 depicted a surface trough to the east of the accident site in central Nevada, and oriented from north to south into western Arizona with a surface low pressure center at 1005-hectopascals (hPa). The station models around the accident site and along the California coast depicted air temperatures in the low to mid 50's Fahrenheit (F), with temperature-dew point spreads of 2 degrees F or less, a west-to-northwest wind between 5 and 10 knots, cloudy skies, and areas of fog. The station models east of the accident site and in the central valley of California coast depicted air temperatures in the mid to upper 50's Fahrenheit (F), with temperature-dew point spreads of 8 degrees F or more, variable winds between 5 and 15 knots, and partly cloudy skies. The accident site was located in an area where the marine air was moving onshore and into the terrain helping to produce clouds and some precipitation. The area is favored for widespread low cloud cover. An Automated Surface Observing System (ASOS) located 2 miles west of Hayward Executive Airport (HWD), Hayward, California, elevation of 52 feet mean sea level (msl), reported at 0835, wind from 290° at 7 knots, 10 miles visibility, a broken ceiling at 800 feet above ground level (agl), overcast skies at 1,300 feet agl, temperature of 13 degrees Celsius (C), dew point temperature of 12 degrees C, and an altimeter setting of 29.95 inches of mercury. Remarks: automated station with a precipitation discriminator, rain began at 0822 and ended at 0831 PDT, ceiling varying between 600 and 900 feet agl, one-hourly precipitation of a trace, maintenance is needed on the system. At 0854, HWD reported wind from 280 degrees at 5 knots, 10 miles visibility, a broken ceiling at 800 feet agl, overcast skies at 2,500 feet agl, temperature of 14 degrees C, dew point temperature of 12 degrees C, and an altimeter setting of 29.95 inches of mercury. Remarks: automated station with a precipitation discriminator, rain began at 0822 and ended at 0831 PDT, ceiling varying between 600 and 1,400 feet agl, sea-level pressure of 1015.3 hPa, one-hourly precipitation of a trace, temperature 13.9° degrees C, dew point temperature of 12.2 degrees C, maintenance is needed on the system. At 0919, HWD reported wind from 270 degrees at 7 knots, 10 miles visibility, few clouds at 800 feet agl, a broken ceiling at 1,600 feet agl, overcast skies at 4,700 feet agl, temperature of 14 degrees C, dew point temperature of 12 degrees C, and an altimeter setting of 29.95 inches of mercury. Remarks: automated station with a precipitation discriminator, maintenance is needed on the system. The Livermore Municipal Airport (LVK), Livermore, California, was located 8 miles east of the accident site, at an elevation of 400 feet msl, also had an ASOS. At 0853, LVK reported wind from 240 degrees at 8 knots, 10 miles visibility, a broken ceiling at 1,500 feet agl, overcast skies at 2,000 feet agl, temperature of 15° C, dew point temperature of 10 degrees C, and an altimeter setting of 29.94 inches of mercury. Remarks: automated station with a precipitation discriminator, sea-level pressure 1013.8 hPa, temperature 15.0 degrees C, dew point temperature 10.0 degrees C. The closest sounding was from Oakland, California. The 0500 sounding indicated a relatively moist environment from the