Common Themes

Organizational Lapses

For approximately eight hours prior to the flight, the pilot repeatedly checked the weather in an attempt to stay up to date on local weather conditions and conditions along the planned route of flight. At each update, he was provided with information indicating that VFR conditions were persisting, and would remain as such for the planned duration of the flight. At approximately 90 minutes and again at approximately 45 minutes prior to takeoff, the National Weather Service issued two flash weather advisories indicating that conditions had significantly deteriorated along the route of flight, to conditions worse than those required for VFR flight.

Investigators could find no evidence that either advisory was drawn to the attention of pilot, even though there had been opportunities as late as during taxi prior to takeoff. Investigators believed that if the pilot had been made aware of these advisories, he might have cancelled or delayed the flight until conditions improved.

Unintended Effects

Investigators cited the pilot's unfamiliarity with a new attitude indicator, which provided a pitch display opposite that of the artificial horizon to which he was accustomed, as a contributing factor to the accident. Almost immediately after takeoff, investigators believed that the pilot would have encountered instrument meteorological conditions, and would have had to transition to reference to the attitude indicator for pitch information. Having very little experience with this attitude indicator installed on the accident airplane, investigators believed that he rapidly became confused by his pitch display and lost control of the airplane.

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