Pilot Debrief

CESSNA T182 near Santa Barbara, CA — 2020-09-27

Final reportWPR20LA319
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Date
2020-09-27
Location
Santa Barbara, CA, USA
Airport
SBA
Aircraft
CESSNA T182
Registration
N157RC
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s loss of airplane control due to spatial disorientation after entering instrument meteorological conditions.

NTSB narrative

The pilot departed about 10 minutes after sunrise for the cross-country flight destined for her home airport. As instructed by air traffic control (ATC), she departed on a westbound heading over the Pacific Ocean. About 1 minute after departure, at an altitude of 1,300 ft mean sea level (msl), the pilot acknowledged ATC instructions to turn right to a heading of 255° and climb to 8,000 ft. The pilot acknowledged the instruction, and radar data indicated the airplane initiated a turn to the right (west), followed by a turn to the north and a rapid descent to the water. Examination of the airframe did not reveal any anomalies that would have precluded normal operation. Although the engine was not recovered, the damage to the airframe was consistent with a high-speed impact. The closest weather reporting station, located about 33 miles east-southeast of the accident location reported visibility of 7 statute miles and an overcast ceiling of 1,400 ft about 12 minutes before the accident. Additionally, an airman's meteorological information (AIRMET) for instrument flight rules conditions in mist and fog was active for the accident location and pilot reports (made in the area within a few hours of the accident) included references to instrument meteorological conditions (IMC) between 1,400 and 2,000 ft. As the airplane began its turn to the west, the low sun angle and mist would have restricted forward visibility and identification of a visual horizon while operating over the ocean, and it is likely that the airplane entered IMC during the turn. The recorded radar data (showing the turn continuing beyond the assigned heading, tightening, and being accompanied by a rapid descent) were consistent with the pilot experiencing the effects of spatial disorientation. Toxicology testing on the pilot revealed ethanol in postmortem cavity blood and spleen tissue; ethanol was not detected in urine, which is a specimen type that is generally less susceptible to postmortem microbial contamination and ethanol production. Although postmortem microbial activity does not always produce ethanol, in this case, the absence of ethanol in urine indicates that the ethanol detected in other specimen types did not likely come from ethanol consumption. Thus, ethanol was not likely a factor in the accident.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have aborted the flight due to worsening weather conditions.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • ADS-B / radar
  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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