WPR17FA045

The non-instrument-rated pilot's improper decisions to begin and to continue a flight under visual flight rules into instrument meteorological conditions, which resulted in controlled flight into terrain.

The non-instrument-rated private pilot departed his home airport with three family members on a cross-country visual flight rules (VFR) flight over mountainous terrain. The forecast weather conditions called for instrument meteorological conditions (IMC) and mountain obscuration due to clouds, precipitation, and mist along the route of flight and at the accident site. The co-owner of the airplane, who held an instrument rating, had reviewed the pilot's flight plan and the forecast weather conditions two days before the accident and informed the pilot that he should drive to his destination as the weather would not allow for VFR flight. However, the pilot elected to proceed with the flight contrary to the co-owner's recommendation. The pilot entered the flight route into the Foreflight mobile application but did not receive any weather briefings from flight service or the mobile application before departure.GPS data recovered from an electronic display device installed in the airplane showed that the airplane departed, entered a climb on a northerly heading, and maintained this direction for the remainder of the flight. After the airplane reached a peak altitude of about 8,000 ft above mean sea level (msl), it descended to 7,000 ft msl and then gradually descended to about 6,000 ft msl, where it remained until near the end of the flight. The airplane subsequently impacted the tops of trees on the rising face of a cliff about 6,600 ft msl. The orientation and length of the wreckage path were consistent with a controlled flight into terrain impact. Track data from the GPS showed that the airplane maintained a straight course after its departure all the way to the mountain rim, which had a published elevation between 6,700 feet msl and 8,000 feet msl. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures. A medical study revealed that each of the 4 fatally injured occupants sustained severe traumatic injuries that would have been rapidly fatal. Furthermore, the study showed there was no evidence to suggest that faster identification of the accident or earlier medical attention would have changed the outcome. Although the autopilot switch was found in the "ON" position at the accident site, the autopilot was likely not engaged as the airplane's ground track and altitude varied, consistent with the pilot hand flying the airplane. A weather study revealed that the airplane departed in visual meteorological conditions (VMC) and likely entered a combination of VMC and IMC after it climbed above 7,000 ft. Minutes later, the airplane encountered IMC and did not return to VMC for the remainder of the flight. The pilot's descent from 8,000 ft to 7,000 ft and then to 6,000 ft, occurred after the airplane entered IMC and indicates that he may have been attempting to return to VMC by descending, but was unsuccessful. Upon encountering IMC, the pilot could have turned around and returned to VMC, but he elected to continue and descend about 750 feet below the lowest peak terrain elevation in the area. The airplane's altitude increased rapidly by about 500 ft just seconds before the airplane impacted terrain suggesting that the pilot may have been alerted by the onboard terrain awareness warning system, which had been successfully tested by the co-owner, or observed the terrain and maneuvered to avoid the impact.

Weather Conditions at Time of Accident At 0935, the weather conditions recorded at Payson Airport (PAN), Payson, Arizona, elevation 5,157 feet, located about 11 nm south of the accident site, included wind variable at 4 knots with gusts to 10 knots, visibility 10 statute miles, overcast ceiling at 300 ft above ground level (agl), temperature 2°C, dew point 1°C, and an altimeter setting of 30.11 inches of mercury. Visible satellite imagery showed extensive cloud cover over the accident site with the clouds moving from west to east. Sounding data and infrared satellite imagery were used to determine the likely cloud cover that the airplane encountered along the route of flight. Figure 1, which depicts the cloud cover and the airplane's flight track, shows that the airplane departed in visual meteorological conditions (VMC) and entered a combination of IMC/VMC when it climbed above 7,000 ft. The airplane then entered IMC when it crossed over the Mazatzal Mountains, about 20 nm south of the accident site, and remained in IMC for the rest of the flight. Figure 1 – Cloud Cover with height (Color Fill) and Accident Flight Track (Line) A pilot weather report made near the time of the accident reported cloud tops at 11,000 ft about 40 nm west of the accident site. Another report made about 1 hour after the accident reported cloud bases between 5,900 ft and 6,400 ft and cloud tops about 8,000 ft about 50 nm northwest of the accident site. Pilot reports of light rime icing were made about 90 minutes after the accident took place and 45 nm northwest of the accident site. Weather Forecasts Airmen's meteorological information (AIRMET) advisories SIERRA and TANGO were issued at 0745 and were valid for the accident site at the time of the accident. AIRMET SIERRA forecasted IMC and mountain obscuration conditions due to clouds, precipitation, and mist, and AIRMET TANGO forecasted moderate turbulence below FL180. An area forecast issued at 0445 and valid at the time of the accident called for a broken to overcast ceiling at 9,000 ft with cloud tops at 10,000 ft and a south wind gusting to 25 knots. Sedona Airport, located 35 nm west-northwest of the accident site at an elevation of 4,830 ft, issued a terminal aerodrome forecast (TAF) at 0433 that was valid at the time of the accident. The TAF called for wind from 180° at 11 knots with wind gusts to 20 knots, greater than 6 miles visibility, light rain showers, scattered clouds at 200 ft agl, a broken ceiling at 400 ft agl, and overcast skies at 1,200 ft agl. The National Weather Service office in Flagstaff, Arizona, issued an area forecast discussion (AFD) at 0343 that discussed the likelihood of IFR conditions along south- and west-facing higher terrain. The AFD specifically mentioned that the Mogollon Rim was likely to have scattered light snow, rain, and rain shower conditions. Weather Briefing There was no record of the pilot receiving a weather briefing from Lockheed Martin Flight Service (LMFS), the Direct User Access Terminal Service (DUATS), or ForeFlight Mobile before departure. The pilot did not file a flight plan with ForeFlight Mobile but did enter route information at 0826 for a trip from SDL to Telluride Regional Airport. The pilot did not look at any weather imagery before or during the flight using ForeFlight, LMFS, or DUATS. It is unknown whether the pilot retrieved weather graphics or text weather information from other internet sources. Two days before the accident, the pilot asked the co-owner to research the weather forecast and cross-check it against the pilot's flight plan to Telluride. After reviewing his flight plan and researching weather, the co-owner informed the pilot that Sunday and Monday, the day before and the day of the accident, were not options and suggested that the pilot drive to Telluride. The co-owner, who was an instrument-rated pilot, stated that he would not have personally flown this route because of the weather forecast. For further meteorological information, see the weather study in the public docket for this investigation. The pilot held a private pilot certificate with an airplane single-engine land rating. He did not hold an instrument rating. The pilot's most recent third-class medical certificate was issued on April 10, 2015, with no limitations. At the time of the exam, the pilot reported that he had accumulated 295 total flight hours of which 14 hours were in the previous 6 months. The last recorded flight in the pilot's logbook was dated August 28 with the remark "Flight Review," but the logbook did not indicate the year the flight took place. An entry in the back of the logbook showed that the pilot's most recent flight review was conducted on May 11, 2016. His previous flight review was dated August 27, 2014. According to FAA records, the pilot purchased the airplane in 2011. In February 2014, the pilot sold 50% of the ownership to an individual who responded to an advertisement that he posted on an internet website. This individual stated that he developed a friendship with the pilot through their co-ownership of the airplane. He stated that the accident pilot sometimes flew with him as a safety pilot when he practiced instrument approaches, but he did not believe that the accident pilot had aspired to become instrument rated. According to the co-owner, the accident pilot made less than five total cross-country flights each year, and his local flying normally took place ahead of his cross-country flights and was for the purpose of maintaining his currency to carry passengers. The pilot's business partner flew with the pilot on three occasions and observed him watching a moving map on an iPad during one of the flights. According to FAA records, the airplane was manufactured in 1970 and registered to N9402M Aviation, LLC on July 22, 2011. The airplane was powered by a turbocharged, direct-drive, air-cooled, 310-horsepower Continental TSIO-520R engine. A review of the airplane's logbooks revealed that the airplane's most recent annual inspection was completed on October 21, 2016, at a tachometer time and total time of 4,307 hours. The engine logbook indicated that a 100-hour inspection was completed on October 21, 2016, at which time the engine had accrued 311 flight hours since major overhaul. At the time of the accident, the tachometer time was 4,323 hours. A fuel receipt obtained from Signature Flight Support at SDL showed that the pilot purchased 42 gallons of 100 LL aviation grade gasoline at 0845 on the day of the accident. The co-owner reported that he was the last person to fly the airplane before the accident flight. He returned the airplane with about 44 gallons of fuel onboard about 4 days before the accident. The owners installed a Garmin 750 GPS that was equipped with a Terrain Awareness Warning System (TAWS) and an engine analyzer in April 2016. The co-owner routinely updated the GPS databases and tested the TAWS system. An estimate of the airplane's weight and balance was computed using the occupants' weights reported by the medical examiner. The baggage weight was determined by adding the weight of the baggage recovered by the medical examiner to the weight of the baggage that remained with the wreckage. The center row left seat had been removed from the airplane, and two weight and balance scenarios were computed. The first scenario (labeled "Graph no. 1" in the "Weight & Balance Computation" document in the NTSB public docket) assumed that the 218 pounds of baggage was split between the center and aft rows, and the second scenario (labeled "Graph no. 2" in the in the "Weight & Balance Computation" document in the NTSB public docket) split the same baggage weight between the center row and the baggage compartment. Computations showed the airplane's center of gravity within the moment envelope for both scenarios. The airplane came to rest on the south face of the Mogollon