Flight Preparation
Before departure, the pilot of a turbo-propeller-equipped, single-engine airplane and a student pilot-rated passenger seated in the right front seat attempted to enter a flight plan into the airplane's integrated flight management system. They did not complete this task prior to takeoff, with the pilot remarking, "we'll get to it later."
In-Flight Events
The pilot departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and requested visual flight rules (VFR) flight following services and an IFR clearance to the destination. From shortly after leveling off through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the flight management system, as evidenced by his comments recorded on the cockpit voice recorder (CVR). He also attempted to navigate around restricted airspace that the airplane had entered.
During the final 10 minutes of the flight, the pilot was unsure of the spelling of a fix needed for the instrument approach and expressed frustration and confusion while programming the system. As the pilot fixated on programming and changing the altimeter setting, the airplane's pitch attitude increased to 10° nose up, and airspeed decayed to 109 knots. The stall warning system activated and the autopilot disconnected. The airplane began climbing and turning right, then left, before entering a steep descending right turn that continued until impact with the ocean about 3 miles from the coast.
Warnings and Systems
For the final 2.5 minutes of the flight, the pilot received stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. Examination of recovered sections of the airplane revealed no evidence of mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation.
Spatial Disorientation and Contributing Factors
The instrument meteorological conditions present at the time were conducive to spatial disorientation. The airplane's erratic flight track in the final two minutes, culminating in a rapidly descending right turn, was consistent with known effects of spatial disorientation. It is likely that the pilot's inadequate preflight planning and subsequent distraction while unsuccessfully attempting to program the flight management system resulted in his failure to adequately monitor airspeed, leading to activation of stall protection systems as the airplane approached and entered an aerodynamic stall. The sudden autopilot deactivation, combined with inattention to flight attitude and speed, likely surprised the pilot. He ultimately failed to regain control, likely due to spatial disorientation.
Medical and Medication Information
The pilot had a history of mantle cell lymphoma in remission, with maintenance treatment over 60 days prior. He also had back pain treated with steroid injections and nonsteroidal anti-inflammatory drugs, and reported using oxycodone for pain management; frequency and use on the accident day are unknown. While oxycodone can cause fatigue, dizziness, and impaired reaction time, the CVR did not indicate these side effects. A few weeks prior, the pilot reported COVID-19 and took hydroxychloroquine and ivermectin; enough time had elapsed that no adverse effects were expected. There is an increased risk of sudden cardiovascular events in recovered COVID-19 patients, but the pilot had no underlying cardiovascular disease, and the CVR showed no evidence of sudden incapacitation. It could not be determined if his medical conditions or medications were contributing factors.