VFR into IMC · NTSB CEN18FA216

CESSNA T182T — Monroe, WI

4 fatal High-time pilotIMC
DateJune 10, 2018
LocationMonroe, WI
AircraftCESSNA T182T
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceUncontrolled descent Collision with terr/obj (non-CFIT)
Pilot age81
Pilot total time4,600 hrs · High time
Time in type90 hrs
Fatalities4

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.

NTSB findings

  • Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Pilot - C
  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Effect on operation - C
  • Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - F
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Below VFR minima-Decision related to condition - F

What happened

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.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →