Pilot Debrief

CESSNA 182L near Bonnerdale, AR — 2021-12-04

Final reportCEN22FA058
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Date
2021-12-04
Location
Bonnerdale, AR, USA
Aircraft
CESSNA 182L
Registration
N182NS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

The noninstrument rated pilot’s improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent impact with terrain.

NTSB narrative

The accident airplane was the lead airplane in a flight of two that departed for a cross-country flight. The non-instrument rated pilot of the second airplane stated that he took off behind the non-instrument rated accident pilot and described the weather as “already sketchy.” He was able to see the ground, but there was no forward visibility. About 20 minutes into the flight and prior to reaching a designated alternate airport, they were in instrument meteorological conditions (IMC). Both pilots were communicating via radio transmissions while in flight and they decided not to divert to the alternate because the accident pilot told him that he thought the clouds would clear up and they should continue to the destination. As the flight continued, both airplanes remained at the same altitude and the second pilot reported that he was “in full IMC.” He stated that he glanced down at his phone to check his flightpath and saw the track information from the accident airplane had turned and was on a southeast heading. Unable to reach the accident pilot on the radio, he continued ahead. About 30 seconds later, he received a 500 ft altitude warning and initiated an immediate climb with full power. Although the route of flight had both airplanes traveling on a northerly heading, the accident airplane impacted rising terrain from the north on a southeasterly heading. A postaccident examination did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation. Although toxicology testing detected Quetiapine, a prescription medication that can be potentially mentally and physically impairing, in the pilot’s liver and muscle tissues, detected concentrations were low, and it is likely that any blood concentration would have been well below therapeutic levels. Therefore, it is unlikely that effects from the pilot’s use of the medication contributed to the accident. Additionally, given the absence of ethanol in vitreous fluid and the detection of a low level of ethanol and methanol in only one tissue type, it is likely that the identified ethanol was from sources other than ingestion. Based on the wreckage fragmentation, which was consistent with a high-speed impact, and the chase pilot’s report of IMC, it is likely that the accident pilot experienced spatial disorientation and lost airplane control.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot should have diverted to alternate airport when IMC conditions were encountered.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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