WPR22FA172

The pilot’s improper decision to continue a visual flight rules flight into an area of limited visibility conditions, which resulted in spatial disorientation and a loss of airplane control.

The non-instrument-rated private pilot and passenger departed their home airport with the intention of flying to an airport on the coast. About 20 minutes before the accident, the pilot contacted air traffic control and requested to perform sightseeing in the San Francisco Bay area before proceeding southwest toward the destination airport. The pilot was instructed to remain clear of the Class B airspace that overlaid the area at an altitude of 3,000 ft mean sea level (msl). About six minutes before the accident, the pilot requested to transition toward his destination. The controller acknowledged and instructed the pilot to remain outside of Class B airspace. About one minute later, the pilot again stated his intent to proceed to the destination, and the controller again acknowledged and instructed the pilot to remain clear of the Class B. The airplane then made a series of turns, climbs, and descents from an altitude of 2,100 ft msl and below over a period of several minutes before it impacted the ground in a nose-down attitude. Postaccident examination of the airframe and engine did not reveal any preimpact mechanical anomalies that would have precluded normal operation. There was no record of the pilot obtaining a weather briefing before departing on the flight. According to witnesses, surveillance video, and weather reports, the airplane flew from an area of visual meteorological conditions into instrument meteorological conditions (IMC) as it neared the accident location. These conditions were forecast and would have been apparent to the pilot as he proceeded toward the area of the accident site. Modeling of the conditions in the area of the accident site indicated that the low-lying clouds and fog began about 200 ft above ground level and likely extended up to an altitude about 2,800 ft above ground level. The pilot had received instrument flight training, but did not hold an instrument rating at the time of the accident. Logbook entries suggested that the pilot had previously operated under instrument flight rules in IMC without an instructor onboard the airplane. Autopsy of the pilot revealed a dilated, enlarged heart; however, it is unlikely that the pilot’s heart disease contributed to the accident. Although toxicology testing indicated that the pilot had used the cannabis products delta-9 THC and cannabidiol, no detectable psychoactive cannabinoids remained in the pilot’s postmortem blood, and it is therefore unlikely that effects of his cannabis use contributed to the accident. The reduced visibility conditions present at the time of the accident in the accident area and the pilot’s lack of instrument flight experience presented circumstances conducive to the development of spatial disorientation. The flight track data, which depicted the airplane’s erratic flight path before collision with terrain, was consistent with the effects of spatial disorientation. Based on the available information, it is likely that the pilot’s decision to proceed into an area of instrument meteorological conditions resulted in his spatial disorientation and a subsequent loss of airplane control.

An NTSB meteorological study was completed with supplemental photographs from the accident flight and surveillance footage from the Golden Gate Bridge to assess the environmental conditions at the time of the accident. Accident Site Conditions A model sounding was completed using data provided by the National Oceanic and Atmospheric Administration. The modeling showed multiple layers of clouds over the accident site area from 200 ft above ground level (agl) with tops near 2,800 ft agl and higher broken clouds at 7,000 ft and 20,000 ft agl. Conditions indicated a high potential for the formation of radiation fog and light low level wind shear at 407 ft msl. A cross section was created using model data and data from selected locations along the airplane’s route of flight to estimate the cloud clover during various segments of the accident flight. Cloud Cover A report of infrared satellite imagery for 1211 captured low stratiform clouds and/or fog with higher stratiform clouds above the accident site. The low stratiform clouds were noted from about 13 nm south of the accident site off the coast and north. (see Figure 2.) Figure 2: GOES-17 infrared image of cloud cover along route of flight at 1211 Weather Forecasts According to a National Weather Service Public Zone forecast for the coastal North Bay, issued at 1101, “REST OF TODAY…Mostly cloudy. Areas of fog. A chance of showers late in the morning. A slight chance of showers in the afternoon.” For the San Francisco Peninsula Coast, the forecasted conditions were “Mostly cloudy. Widespread dense fog in the afternoon.” A Graphical Forecast for Aviation (GFA) issued at 0901 and valid at 1100 depicted visibility less than 1 statute mile over the Pacific Ocean. The chart also depicted an AIRMET for IFR conditions over northwestern California and off the California coastal sections immediately bordering the accident site. A GFA cloud forecast issued at 0902 valid at 1100 showed broken to overcast clouds with bases near 300 ft and tops 4,000 ft msl with higher cirrus clouds above the accident site and clear conditions further inland. AIRMET Sierra for mountain obscuration extended over the accident site and over northern California. There were no SIGMETs, Convective SIGMETs, or Center Weather Advisories issued for the time of the accident flight over the San Francisco area or the accident pilot’s route of flight. Pilot Weather Research A review of records from Leidos Flight Service and Foreflight did not reveal any evidence that the pilot obtained weather information from either source. Although the pilot possessed an account with Foreflight, he had not viewed any weather imagery within the application prior to the accident flight. He had reviewed the terminal procedures for his originating and destination airports, which would have included METARs, TAFs, and NOTAMs for those stations. It could not be determined if the pilot used another source to obtain current inflight weather advisories, GFAs or any other weather products. Golden Gate Bridge Stillshots A still photograph from a camera located on the bridge’s north tower facing north showed dense fog that covered the coastline and northern end of the bridge. Another image was captured by a camera located 1.7 nm southeast of the accident near the south abutment overlook at the Golden Gate Bridge Vista Point South, which faced northwest. The image depicted fog advection with an estimated visibility between ¼ to ½ sm, as the south tower of the Golden Gate Bridge and suspension cables were not clearly identifiable in the image. Photographs Taken During Flight The passenger took several photographs during the accident flight that were provided by a family member. An image, taken about 10 to 15 minutes before the accident, showed a low band of stratiform clouds off the right side of the airplane near the Golden Gate Bridge and the accident site. Toxicology testing performed on a sample of the pilot’s blood by the Federal Aviation Administration Forensic Sciences Laboratory detected the cannabis metabolite 11-hydroxy-delta-9-THC at 13 ng/mL in the urine, but not in his aortic blood. Additionally, the cannabis metabolite carboxy-delta-9 THC was detected at 3.8 ng/mL in the aortic blood and at 18.1 ng/mL in his urine. Cannabidiol (CBD) and its metabolite 7-carboxy-CBD were detected in both the pilot’s aortic blood and urine at unspecified quantities. The CBD metabolite 7-hydroxy-CBD was also detected in the pilot’s urine, with inconclusive results in his aortic blood. Rosuvastatin and famotidine were detected in his aortic blood and urine. 11-hydroxy-delta-9-THC is a psychoactive metabolite of delta-9-THC, which is the primary psychoactive chemical in marijuana and hashish, derived from the cannabis plant. Carboxy-delta-9-THC is a non-psychoactive metabolite of 11-hydroxy-delta-9-THC. Delta-9-THC, which was not detected in this case, is the chemical commonly referred to as THC. The psychoactive effects of THC vary depending on the user, dose, and route of administration, and may impair motor coordination, reaction time, decision making, problem solving, and vigilance. THC is considered unsuitable for pilots by the FAA regardless of state laws. Rosuvastatin is a prescription cholesterol medication and famotidine is an over-the-counter stomach suppression medication. Neither medication is considered impairing. The autopsy report described the pilot’s heart as hypertrophic and markedly dilated. The pilot used a web-based service to maintain a record of his flight activities, which contained entries from March 16, 2016, to May 12, 2022. According to the record, the pilot flew from Sacramento, California, to HAF on five occasions before the accident. Four of these flights took place in 2021 and one flight took place three months before the accident. Listed in the “Additional Comments and Remarks” column of the first recorded flight to HAF, which occurred on January 23, 2021, included the following: “VFR flight to Half Moon Bay. Bay area traffic control. Requested and granted City Tour. Denied entry to Bravo. Flew under Bravo. Next time ask for bay transition. Communications and post flight.” According to the pilot’s logbook, he began training for an instrument rating about one month after he received his private pilot certificate in November 2020. The pilot did not possess an instrument rating at the time of the accident. The pilot’s instructor remarked that they flew together for about 40 hours to prepare for the pilot’s instrument practical test and noted that the pilot was proficient in conducting instrument approaches in the accident airplane. According to the instructor, about one year before the accident, while flying with another student he heard the accident pilot on the radio obtaining an instrument clearance while he was flying without his regular instructor, which concerned him. Entries made on May 17, 2021, and May 19, 2021, indicated that the pilot obtained an instrument clearance without a flight instructor onboard the airplane. The entry on May 17, 2021, stated “fly IFR was in IMC for about 30 min no issue.” The pilot’s flight instructor further recalled that the pilot was a “little pushy” in the cockpit and was accustomed to being “his own boss.” On May 6, 2022, about 1210 Pacific daylight time, an experimental, amateur-built Vans RV-10, N54MG, was substantially damaged when it was involved in an accident near Sausalito, California. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Flight track data was captured by both automatic dependent surveillance - broadcast (ADS-B) data and information downloaded from onboard avionics. Both sources were consistent for most of the flight, while the ADS-B coverage became intermittent after about 1205:10. The track data showed that the air