WPR16FA059

The pilot’s failure to maintain airplane control during an instrument approach in night instrument meteorological conditions, which resulted in a collision with terrain. Contributing to the accident was the pilot’s lack of recent experience in night instrument meteorological conditions.

The commercial pilot and his wife departed on a visual flight rules cross-country flight to their home airport. About 46 nautical miles from the destination airport, the pilot requested an instrument flight rules clearance and was subsequently cleared for an instrument landing system (ILS) approach at the destination airport. GPS data indicated that the airplane followed a straight course with minimal variation during its cruise flight in a manner consistent with use of the autopilot. The airplane's course movements became more erratic when the airplane neared the destination airport, which suggests that the pilot began to hand-fly the airplane. A combination of radar data, GPS data, and air traffic control audio showed that the pilot complied with the controller's instructions. After the pilot intercepted the glideslope, he maintained a shallow descent rate until the final approach fix. The pilot subsequently crossed the final approach fix 1,000 ft above the intercept altitude on a heading track to the right of the localizer. The tower controller reported multiple deviations over the radio to the pilot, but the pilot did not make appropriate corrections. Radar data showed the airplane enter progressively steeper descent rates after passing the final approach fix, and the airplane began to deviate to the left of the localizer. In the final moments of the flight, the airplane turned to the right about 50°, crossed the localizer, and then immediately began a 60° steep left turn at an approximate 1,200-fpm descent rate. Debris path signatures indicated the airplane was in a high-speed, steep left turn with a nose-down attitude when it impacted a field about 1.5 nautical miles south of the runway approach end. The proximity of the accident site to the final GPS data point and the similarity between the impact signatures and the track shown by the last few GPS data points indicates that the last data points closely represent the airplane's final movements before impact. Examination of the wreckage and of engine analyzer data did not reveal any evidence of preimpact anomalies with the airframe or engine. Circumferential scoring from the gyros was found on the case of the heading indicator and both attitude indicators, which indicates that these instruments were likely functioning normally at the time of impact. The pilot obtained weather information from an online service about 24 hours before the flight; however, the forecasts he received were not valid at the time of his departure. In his communication to an Air Route Traffic Control Center (ARTCC) controller, the pilot asked, "what are they doing for approaches?" which indicated that he was aware of possible instrument meteorological conditions (IMC) at the destination airport. The pilot's audio transmissions to ARTCC did not indicate that he had received current Airport Terminal Information System weather. Further, the ARTCC controller did not provide the pilot with the current weather as required by Federal Aviation Administration (FAA) procedure, and the airport tower controller had not been disseminating pilot reports, also required by FAA procedure. The pilot's flight instructors commended his aeronautical decision-making skills; however, the investigation was unable to confirm if the pilot obtained current weather and if knowledge of the low-visibility weather conditions would have altered his decision to continue the flight despite his desire to return home that night. Two months before the accident, the pilot completed an instrument proficiency check and made a night flight to fulfill the night currency requirement. Other than these two events, the pilot had no recent instrument or night flight experience. Further, the pilot's flight records did not show any evidence that he had completed a flight in night IMC in nearly 3 years. Given the pilot's lack of recent experience in night IMC, he was most likely overwhelmed by the complexity of hand-flying the airplane on an ILS approach in night IMC. Once the pilot crossed the final approach fix, he doubled his descent rate to correct for his high crossing altitude and then deviated from the localizer course line. The airplane's final movements suggest that the pilot likely lost control of the airplane during the large heading adjustment he made to correct his course and was not able to regain control.

48-Hour History The pilot contacted a friend in Palm Springs 2 days before the accident to inform him that he planned to fly to PSP for an overnight trip with his wife to retrieve some belongings. His friend picked up the pilot and his wife at the airport about 2015 on Wednesday, January 27, at which time he heard the pilot instruct the fixed based operator to fill each of the four fuel tanks on the accident airplane. According to the pilot's friend, they spent the night at his house that evening. The pilot's wife and the pilot awoke at 0700 and 0800, respectively and appeared rested. After they ran their errands and ate lunch, their friend took them to the airport where they departed on the accident flight. The pilot's friend offered his home to the pilot and his wife for another night, but the pilot was anxious to return home for work and to be present for his daughter who had recently broken her leg and was scheduled for surgery the following week. The friend further stated that they did not discuss weather with the exception of forecasted rainfall at the pilot's home airport. ATC Communication A review of the communications between the Oakland ARTCC controller and the pilot revealed that the controller did not issue current destination weather to the accident pilot as required by FAA Order JO 7110.65, which requires ATC personnel to transmit weather information to pilots when conditions are below a 1,000 foot ceiling or the highest circling minimum, whichever is higher, or less than 3 miles visibility for the corresponding airport. Additionally, the Oakland ARTCC controller had not been disseminating pilot reports (PIREPs). According to FAA Order JO 7110.65, controllers are required to relay pertinent PIREP information to concerned aircraft in a timely manner. The STS airport tower controller received a PIREP from a landing aircraft that arrived shortly before the accident airplane after completing an RNAV approach and reported the weather "right at minimums." The controller was required to enter the PIREP into the national airspace system as prescribed by FAA Order JO 7110.65; however, the controller did not do so, and he did not report any PIREPS to the accident airplane. An autopsy was performed on the pilot by the Sonoma County Coroner, Santa Rosa, California. The autopsy report indicated the cause of death as "total body trauma." A toxicological test on specimens recovered from the pilot was performed by the FAA Bioaeronautical Sciences Research Laboratory. A carboxyhemoglobin saturation test revealed no evidence of carbon monoxide in the pilot's cavity blood. The pilot's toxicology results were negative for ethanol, but positive for atenolol and chlorthalidone. Atenolol, sometimes marketed under the brand name Tenormin, is a prescription beta blocker medication used alone or in combination with other medications to treat high blood pressure. Chlorthalidone, marketed under the names Hygroton and Thalitone, is a diuretic prescription medication used to treat high blood pressure and fluid retention caused by various conditions including heart disease. It may also be used to treat patients with diabetes insipidus and certain electrolyte disturbances and to prevent kidney stones in patients with high levels of calcium in their blood. The pilot had reported both medications during previous airmen medical examinations. Atenolol is an FAA approved medication and chlorthalidone is not considered impairing. STS was equipped with an automated surface observation system, which transmitted Meteorological Aerodrome Reports (METARs) and special reports surrounding the period of the accident. The observations indicated that VFR weather conditions prevailed at STS in the early afternoon, followed by a deterioration to IFR from the pilot's time of departure until the time of the accident, followed by low IFR (LIFR) conditions about 4 minutes after the accident. LIFR conditions are defined as a ceiling less than 500 ft and/or visibility of 1/2 mile or less. Multiple special reports for STS were issued throughout the period of the flight, all indicating decreasing visibility and ceilings. The final special report issued before the accident was at 1853 and indicated calm winds, 2 1/2 miles visibility, mist, scattered clouds at 400 ft, an overcast ceiling at 900 ft,and a temperature and dewpoint of 12°C. A special METAR was issued about 4 minutes after the accident that indicated calm winds, visibility 2 1/2 miles, mist, an overcast cloud layer at 400 ft, and a temperature and dewpoint of 12°C. Forecasts The area forecast for the northern California area at the time of the accident included broken clouds at 2,000 ft msl with tops to 6,000 ft msl and isolated rain showers with an outlook of instrument meteorological condition ceilings. AIRMETs (airmen's meteorological information) for the accident period revealed that the accident site was located within an area covered by an advisory for mountain obscuration and near the border of an active AIRMET for IFR conditions. A terminal area forecast (TAF) that was issued on the morning of the accident for STS indicated deteriorating weather up until the time of the accident; however, the forecast was not for IFR conditions. At the time of the pilot's departure, the TAF reported marginal VFR to IFR conditions for the hours that followed the pilot's estimated arrival time. Weather Briefing The pilot retrieved weather information from the online service, ForeFlight.com, about 24 hours before he departed on the flight. According to Lockheed Martin Flight Services, the weather information provided to the pilot included TAFs, AIRMETs, area forecasts, METARs, and Notices to Airmen (NOTAMs). The area forecast report for Northern California, valid until the morning of the flight, indicated VFR conditions. The TAF for STS, valid to midnight, showed deteriorating conditions with low ceilings and low visibility. The United States Naval Observatory reported the moon phase as a waning gibbous moon with 79% of the moon's visible disk illuminated. The moonset for Santa Rosa, California, was at 0948 and moonrise was at 2215. The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. He held a second-class medical certificate issued on October 22, 2015, at which time he reported 1,278 total flight hours of which 50 hours were within the previous 6 months. The medical certificate included one restriction: "must have available glasses for near vision." A copy of a spreadsheet the pilot used to record his flight time was furnished by the pilot's friend. According to this flight record, the pilot's last instrument proficiency check (IPC), which was his last instrument flight experience was completed in 1.3 hours on November 6, 2015. The IPC instructor reported that the pilot demonstrated good aeronautical decision-making during their discussion of weather planning but struggled in performance, as he kept his airspeed too high during approaches, which resulted in steeper turns. The spreadsheet showed that the pilot had accumulated a total of 93.6 hours of actual instrument flight experience. Before his most recent IPC, the pilot had accrued 4 hours of actual instrument experience and 3.4 hours of simulated instrument experience in the previous year, most of which was in May 2015. The spreadsheet indicated that the pilot had not accumulated any simulated or actual instrument experience between November 6, 2015, and January 2, 2016, the last recorded entry in the spreadsheet. The spreadsheet showed that he had accrued 0.5 total hours of night flight experience in the preceding 2 years. In his most recent night flight entry, dated November 2015, he noted the flight as "Night Current." His most recent experience flying in night instrument meteorological conditions was documented on March 27, 2013. The pilot's most recent biennial flight