WPR22FA210

The pilot’s spatial disorientation and loss of airplane control after entering instrument meteorological conditions shortly after takeoff.

The instrument-rated pilot planned to fly to his home base. The departure airport was enveloped in marine layer conditions with low visibility, mist, and clouds tops between 400 and 1,600 ft. The pilot received this weather information during a briefing about 30 minutes before departure, during which he filed an instrument flight rules (IFR) flight plan with a visual flight rules (VFR)-on-top clearance. The pilot was unfamiliar with the airport. After making a wrong turn, the pilot was given taxi instructions to the departure runway. The engine run-up and takeoff appeared uneventful, and the pilot’s communication with the control tower was routine. Shortly after takeoff, the airplane likely entered the clouds, and the pilot was instructed to contact the departure controller. Although the pilot acknowledged the instruction, he did not contact the departure controller. A short time later, a witness who was driving along a freeway parallel to the departure runway saw a low-flying airplane that was traveling perpendicular to the takeoff direction. The airplane did not appear to have any trailing smoke or vapors. The airplane then impacted the ground just past the freeway. A video from the witness’ dashboardmounted camera captured the flames from the impact and showed the fog and low clouds enveloping the area. The reported weather observations matched the weather conditions observed in both the security camera video and the dashboard camera video. Engine and propeller evidence and the associated propeller ground scars indicated that the engine was producing high levels of power at impact. The airplane was equipped with conventional vacuum and electrically powered flight instruments. Although the autopilot and flight instruments were destroyed due to impact and thermal damage, the vacuum pump, which had recently been installed, was recovered and found to be operational. Also, evidence within the wreckage indicated that the airplane was configured appropriately for the initial takeoff climb, with the landing gear retracted and the trim set for takeoff. Thus, the loss of control did not occur due to a loss of engine power, a preimpact mechanical malfunction or failure, or pilot error in configuring the airplane for takeoff. The pilot’s logbook showed only the flight time required to meet Federal Aviation Administration (FAA) currency requirements; and based on his entries, while he had undergone a flight review the year prior, it appeared that he was not instrument current at the time of the accident. The airport area is provided with radar and automatic dependent surveillancebroadcast (ADS-B) coverage that starts between 250 and 500 ft above ground level (agl), but neither system tracked the airplane. Thus, the airplane likely did not reach an altitude that would allow the airplane to be tracked after it entered the clouds. The pilot was required to make a slight right turn after departure; however, the airplane’s rapid change in direction after takeoff along with its high impact speed (as shown by ground scar and video evidence) are consistent with the pilot encountering spatial disorientation in the clouds, resulting in a loss of airplane control. It is possible that that the pilot might have been distracted as he configured the airplane for the initial climb and reached over to switch to the departure controller’s frequency. The pilot had cardiovascular disease, including moderate coronary artery disease, an implanted pacemaker/defibrillator, and mitral valve replacement. The pilot’s medical certificate had expired 6 years before the accident. In 2019 he began flying under the provisions of BasicMed, which is an alternate way for pilots to fly without holding an FAA medical certificate. The pilot’s history of mitral valve replacement would have required a special issuance medical certificate for BasicMed. No such issuance was obtained; therefore the pilot did not possess valid medical certification for the flight. The pilot’s cardiovascular disease was associated with an increased risk of sudden impairment or incapacitating cardiovascular event such as ventricular arrhythmia, heart attack, or stroke. No forensic evidence indicated that such an event occurred. However, such events do not leave reliable autopsy evidence if the event occurs just before death, and no data were available from the pilot’s implanted pacemaker/defibrillator. Thus, the investigation was unable to determine if sudden incapacitation or impairment was a factor in this accident.

CMA is located within a coastal basin about 7.5 miles from the Pacific Ocean. The area is affected by marine layer weather patterns, particularly during the early summer months. A terminal aerodrome forecast for CMA issued at 0506 on the day of the accident indicated persistent marine layer conditions throughout the morning and early afternoon with a 3-knot wind, 6-mile visibility, mist, and a broken ceiling at 600 ft agl. A forecast issued at 0713 indicated that these conditions would worsen between 0700 and 0900 with expected variable wind at 3 knots, 1/2mile visibility, fog, and an overcast ceiling at 200 ft agl. Area PIREPs surrounding the time of the accident indicated cloud tops between 400 and 1,600 ft. A Graphical Forecasts for Aviation issued before the accident flight, which was valid at the accident time, indicated broken cloud coverage with bases at 300 ft and tops at 2,100 ft. As previously stated, weather information was relayed to the pilot during his 0724 call to Leidos Flight Service. No evidence indicated what, if any, additional weather information the pilot received before or during the accident flight. The weather observations surrounding the accident time were consistent with low IFR to IFR conditions. Low IFR is defined as ceilings below 500 ft agl and/or visibility less than 1 statute mile. The Medical Examiner of Ventura County, State of California, performed an autopsy on the pilot. According to the autopsy report, the pilot’s cause of death was blunt trauma. The pilot had evidence of an enlarged heart, 60% narrowing of a coronary artery, a localized area of scarring of the heart, a mitral valve replacement, and an implanted cardiac pacemaker/defibrillator. The autopsy report stated that a representative from the pacemaker/defibrillator manufacturer attempted to download recorded data from the damaged device but was unsuccessful. As previously stated, the pilot was operating the airplane with BasicMed provisions, which allow pilots who meet certain requirements to fly without current medical certification. Among those requirements are the following: a pilot must have completed a BasicMed Course within 24 calendar months and must have had a medical examination with a state-licensed physician using the CMEC within 48 months. Pilots with certain medical conditions, including heart valve replacement, may not exercise BasicMed privileges unless they have completed the process for obtaining an FAA Authorization for Special Issuance of a Medical Certificate for the relevant conditions. The accident pilot had not completed this process for his mitral valve replacement. FAA records indicated that the pilot purchased the airplane in 2006. The airplane was fueled to capacity at a CMA fixed-base operator shortly after the airplane landed on the day before the accident. The fuel supplier tested the fuel after the accident, which yielded nominal results. The airplane was equipped with an autopilot. The roll servo was repaired on March 11, 2021. and an overhauled vacuum pump was installed on March 8, 2022. The pilot’s most recent flight review occurred on May 22, 2021. The NTSB’s attempts to reach the flight instructor who provided the pilot with his most recent flight review were unsuccessful. FAA regulations require that for a pilot to act as pilot in command under IFR conditions they must maintain currency by performing and logging within a 6-calendar month period preceding the flight, at least; 6 instrument approaches, holding procedures and tasks, and intercepting and tracking courses through the use of navigational electronic systems. The procedures should be performed in actual weather conditions, or under simulated conditions using a view-limiting device. The pilot’s last logbook showed that he generally documented the specific flights required as part of flight currency and proficiency, such as instrument approaches and flight reviews. The remaining flight time was entered in block entries covering periods of time that often coincided with engine oil changes. An entry dated March 31, 2022, indicated the pilot had performed an unknown number of RNAV (area navigation) instrument approaches during a round-trip flight from DVT to Hayward, California. A review of publicly available flight data for the accident airplane revealed that its last eight flights from May 4 to June 9, 2022, were not documented in the pilot’s logbook. An entry dated June 6, 2022, noted that the pilot had performed two instrument landing system approaches at Casa Grande Municipal Airport (CGZ), Casa Grande, Arizona. The first logbook entry, dated July 11, 2012, indicated that the pilot’s total previous flight experience was 1,672 hours. The remaining 11 pages showed that the pilot had flown about 787 hours, 80 hours of which were in actual instrument conditions. The logbook had four references to “VFR on top,” the last of which occurred in May 2019. The pilot’s most recent FAA medical certification examination was in 2014, and his third-class medical certificate expired in 2016. According to FAA records, the pilot completed a BasicMed Course on May 6, 2019, and reported completing the BasicMed comprehensive medical examination checklist (CMEC) the same day. No CMEC form was found with the pilot’s logbook or was otherwise recovered during the investigation. Records were requested from and provided by the physician who the pilot indicated had performed the CMEC examination. These records did not include a CMEC examination or a record of an examination on May 6, 2019. (The FAA does not require a physician to retain records related to a BasicMed examination, and CMEC forms are not routinely submitted to the FAA.) The pilot’s wife stated that he had previously flown in actual instrument conditions and that he might have flown in such conditions during a trip to Alameda, California, in February 2022. She stated that he had no appointments, meetings, or compelling reason to return home on the day of the accident. On June 10, 2022, about 0800 Pacific daylight time, a Mooney M20K, N305L was destroyed when it was involved in an accident near Camarillo, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot had flown from his home base of Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, to Camarillo Airport (CMA), Camarillo, California, on the day before the accident, and the accident flight was to be the return trip. The pilot’s wife stated that he called her at 0600 on the day of the accident to tell her that he would delay the departure because of cloudy weather. About 0724 the pilot contacted Leidos Flight Service and requested an abbreviated weather briefing. The briefer stated that a marine layer was present in Camarillo, and the pilot responded that it was “socked in.” The pilot requested cloud top information and was provided with a pilot report (PIREP) that indicated 700-ft cloud tops along the coast about 40 miles to the southeast at Los Angeles International Airport, Los Angeles, California, in the adjoining Los Angeles Basin. The pilot responded, “there you go.” After receiving information on a local temporary flight restriction, the pilot asked how he should file a VFR-on-top flight plan with the briefer. The briefer stated that he would need to file an IFR flight plan with a VFR-on-top clearance and that they could do it immediately. The weather at the time included calm wind, a visibility of 4 miles, a 300ft agl overcast ceiling, and mist. After the flight was plan filed, the pilot contacted the CMA tower controller. The controller provided the pilot with an IFR clearance to DVT with instructions to turn right to 275° after departure for radar vectors, climb and maintain 3,000 ft, and expect 7,000 ft 5 minutes after departure. The pilot replied but omitted the initial 3,000-ft