Pilot Debrief

CESSNA T182T near Monroe, WI — 2018-06-10

Final reportCEN18FA216
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Date
2018-06-10
Location
Monroe, WI, USA
Airport
EFT
Aircraft
CESSNA T182T
Registration
N1880B
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Approach

Probable cause

Spatial disorientation resulting in a loss of control during the missed approach conducted in instrument meteorological conditions. Contributing to the accident was the pilot's decision to execute an instrument approach in weather conditions that were below the approach minimums.

Contributing factors

Contributing to the accident was the pilot's decision to execute an instrument approach in weather conditions that were below the approach minimums.

NTSB narrative

The commercial pilot was conducting a personal, cross-country flight. Upon arrival at the destination airport, air traffic control (ATC) cleared the pilot for a GPS approach. The controller instructed the pilot to change to the airport common traffic advisory frequency after passing the initial approach fix. The pilot acknowledged, after which point no further communications were received. The available ATC data depicted the airplane tracking the final approach course until radar contact was lost less than 2 miles from the runway due to routine radar coverage limitations. Radar contact with the airplane was not regained. Low instrument meteorological conditions prevailed, and the cloud ceiling was below the minimum descent altitude for the approach. A witness heard the airplane immediately before the accident and described the sound as similar to an airplane performing aerobatic maneuvers. She subsequently observed a "fireball" through an opening in the tree line behind her home and immediately heard an explosion. The accident site was located about 1/2 mile north of the runway departure threshold. Postaccident airframe and engine examinations did not reveal any anomalies consistent with a preimpact failure or malfunction. The investigation was unable to determine whether the autopilot was engaged during the flight. However, the precise flight track and course intercepts depicted by the position data are consistent with extended portions of the flight, including the initial portion of the approach, being flown by the autopilot. While the published missed approach procedure included a left turn, the location of the accident site in relation to the runway indicated that a right turn was executed during the missed approach. This revealed that the pilot was not using the course guidance from the autopilot and was either using the autopilot in heading mode or was flying the airplane manually. Based on the witness description of an airplane performing aerobatics, it is likely that the pilot was flying the airplane manually. Furthermore, it is probable that the airplane remained in instrument meteorological conditions during the approach and missed approach phases of the flight. Therefore, it is likely that the pilot became spatially disoriented during the missed approach which resulted in a loss of airplane control and impact with the trees and terrain.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have opted for a missed approach instead of continuing in IMC.

NTSB coding

Evidence available

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

Docket documents22

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