Abstract: The purpose of this study was to discover new themes in general aviation accidents involving a loss of control inflight in instrument meteorological conditions using accepted international investigation protocols that were not discovered in the original NTSB investigations. Twelve aircraft accidents previously investigated by the NTSB involving general aviation aircraft that experienced a loss of control inflight in instrument meteorological conditions were selected and qualitatively examined in a multiple case study approach. Each case was examined in a fine-grained manner consistent with accepted aircraft accident investigation protocols found in government and industry literature. Cross case analysis was performed on the twelve cases.

This research principally focused on the pilots of the accident aircraft and examined in detail their background, flight training history, interaction with instructors and other pilots, and operation of the subject aircraft. These accidents revealed themes not found in the NTSB accident reports or in the aviation safety literature. Eight major operational and training related themes and fourteen sub-themes were discovered, many of which crossed case boundaries and were found in multiple cases.

These themes included 1) training, 2) records, 3) automation, 4) non-compliance, 5) stabilized approaches, and 6) other pilots, 7) stabilized approach, and 8) aircraft. Sub-themes in the training area included: owner/ pilot training source; professional flying history; checkride failure; young flight instructor utilization; flight instructor complicity in poor training, improper endorsements and logbook fraud; transition or refresher training after return to flying after long breaks in flying history by pilots; recent flight training; and Part 142 transition and recurrent training. Sub-themes in the aviation records area included: expired flight reviews and instrument proficiency checks and logbook irregularities. Procedural Intentional Non-Compliance sub-themes included: aircraft limitations violations; checklist; weather briefs and preflight inspections and flying aircraft with airworthiness issues. Nine pilots displayed anti-authority attitudes and behavior. Autopilot over use and misuse of the autopilot systems was found in six cases.