# NTSB CEN21LA121: Cessna 182Q, N4765N, Hackberry, LA, February 2, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: February 2, 2021, 17:44 local (23:44 UTC) - Place: Hackberry, LA - Coordinates: 30.009412, -93.330048 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.0094&lon=-93.3300&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 102590 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA121 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102590/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102590 - Page: https://openairdocs.org/ntsb/CEN21LA121 ## Probable cause The flight instructor did not maintain control of the airplane during training maneuvers, which resulted in a rapid, steep descent and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent rate](https://openairdocs.org/ntsb-findings/01062037): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 182Q, 1 case](https://openairdocs.org/ntsb-findings/01062037/cases.md?model=2072732), [All aircraft, 242 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 182Q, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2072732), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 182Q, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072732), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 182Q, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072732), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The private pilot, who had recently purchased a share of the accident airplane, and a flight instructor were conducting a local flight to practice maneuvers. Just before the accident, the airplane reached about 4,500 ft above ground level and the airspeed steadily decreased. The airplane began a slow descent, which increased rapidly until the final recorded point. In the last 18 seconds of recorded data, the airplane made a right turn and descended about 11,250 ft per minute. Witnesses close to the accident site but at different locations, reported that they observed the airplane come straight down, nose first to the ground. One witness reported that no smoke was coming from the airplane, and he never saw the cockpit. Both witnesses reported the engine was loud. The airplane impacted soft, muddy terrain and the main wreckage, including the engine, propeller, fuselage, and empennage, was embedded about 15 ft deep. A debris field that consisted of the wings and smaller airplane components extended about 40 yards from the crater. A postaccident examination of the engine and airframe did not reveal any preimpact anomalies, although the examination was limited due to the extensive damage. Due to the propeller damage and the high-speed impact with terrain, it is likely that the engine was operating at a high-power setting during the accident sequence. Due to the limited medical evidence, whether a medical condition or effects from a substance contributed to this accident could not be determined. ## Factual narrative The airplane was equipped with a Garmin GFC500 automatic flight control system (AFCS) autopilot, which featured electronic stability and protection (ESP). According to the Garmin AFCS manual, the ESP function provides a soft barrier to keep the airplane within the desired operating envelope when the autopilot is not engaged. When the AFCS senses that the airplane is near the defined operating limit in pitch attitude, roll attitude, high airspeed, or low airspeed, the ESP function will automatically engage one or more servos to nudge it back to the nominal operating envelope. While ESP utilizes the same sensors, processors, and actuators as the AFCS autopilot, it is a separate, mutually exclusive function. ESP can be easily overpowered by the pilot and can be disabled using the autopilot disconnect button. ESP is a feature that is intended to monitor the airplane and provide control input feedback when necessary to discourage operating the airplane at potentially unsafe attitudes and/or airspeeds. The GFC500 manual also states that level mode as activated by ESP is limited by altitude. ESP will not be able to activate level mode until the airplane climbs above 2,000 ft agl. ESP will be locked out of automatically activating level mode after the airplane descends below 1,500 ft agl. Also, level mode as activated by ESP is different than manually-selected level mode. Manually-selected level mode is not limited by altitude. ESP is enabled or disabled from the primary flight display (PFD) page menu, and the Garmin website states that ESP can be manually disabled to allow for intentional flight maneuvers. According to one of the other airplane owners, during practice stall maneuvers, the autopilot circuit breaker needed to be pulled in order to complete the maneuver. He added that, even if the auto pilot is not engaged, this autopilot safety feature is still in effect unless the circuit breaker is pulled. He stated that it might be possible to stall the airplane without pulling the circuit breaker, but “you would be really fighting the servos in the auto pilot.” On the day before the accident, when he was passenger in the back of the airplane, he observed the accident pilots pull the autopilot circuit breaker before completing maneuvers. On February 2, 2021, at 1744 central standard time, a Cessna 182Q airplane, N4765N, was destroyed when it was involved in an accident near Hackberry, Louisiana. The private pilot and flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. Recorded air traffic control (ATC) communications and automatic dependent surveillance–broadcast (ADS-B) data revealed that the airplane departed at 1713 and proceeded south toward the Gulf coast. Soon after takeoff, the pilots contacted ATC and reported their intentions to operate in the southwest practice area. About 1725, the pilots were instructed to remain at or above 2,500 ft above ground level(agl) for traffic. The pilot acknowledged the restriction and advised that his maneuver might cause a loss of altitude at their current position. ADS-B data showed that the airplane completed several circling maneuvers near the coast and descended toward an old airstrip. At 1736, the pilot advised that they were climbing back to 2,500 ft agl or above. ATC queried if they needed to descend below the restriction, and the pilot responded that they did not, until they returned to Southland Field Airport (UXL), Sulphur, Louisiana. The airplane proceeded north, and the altitude and airspeed increased. As the airplane reached about 4,500 ft agl, the airspeed decreased, and the airplane began to slowly descend before entering a rapid descent until the final recorded point. In the last 18 seconds of recorded data, the airplane made a right turn and descended at a rate of about 11,250 ft per minute. Figure 1 shows the end of the recorded flight track and the accident location. At 1745, radar contact was lost; no further radio transmissions were received from the accident airplane. Figure 1. The recorded flight track and accident location overlayed on Google Earth. Two witnesses, who were in close proximity to the accident site but at different locations, stated that they observed the airplane come straight down, nose first to the ground. One witness reported that no smoke was coming from the airplane, and he never saw the cockpit. Both witnesses reported the engine was loud. An autopsy of the pilot was performed by the Calcasieu Parish Coroner's Office, Lake Charles, Louisiana. The cause of death was multiple injuries sustained in an airplane crash. The brain was not available for examination due to the severity of injuries. An internal examination was completed, and no significant natural disease was identified. Toxicology testing performed on the private pilot’s heart tissue by the FAA’s Forensic Sciences Laboratory identified no evidence of impairing drugs. An autopsy of the flight instructor was performed by the Calcasieu Parish Coroner's Office, Lake Charles, Louisiana. The cause of death was multiple injuries sustained in an airplane crash. The autopsy was limited to an external examination only. A cursory internal examination of the organs was performed and did not identify any natural disease. Toxicology testing for the flight instructor was not possible because there were no suitable specimens. According to a co-owner of the airplane, the private pilot had recently purchased a share of the accident airplane and was in the process of receiving training for complex and high-performance aircraft endorsements. The day before the accident, one of the co-owners was in the back seat of the airplane when the two accidents pilots conducted a training flight. He stated that the pilot completed the flight maneuvers well and he did not notice anything of concern. According to the airplane broker, on the day of the accident, the pilot called to report that hehad just completed a 1-hour flight in the accident airplane to satisfy the insurance policy requirements. That flight departed from Southland Field Airport (UXL), Sulphur, Louisiana, about 1326 and terminated about 1436. The airplane impacted soft, muddy terrain. The initial impact crater was about 15 ft deep and contained a majority of the airplane, including the engine, propeller, fuselage, and empennage. A debris field that contained the wings and smaller airplane components extended about 40 yards from the crater. The wreckage was recovered to a secure storage facility, where an engine and airframe examination was completed under the supervision of a Federal Aviation Administration inspector. The wings had separated from the fuselage and were crushed aft to the rear wing spar. The empennage was crushed and distorted. Flight control cable continuity was established for all flight control surfaces through tensile overload separations in several locations. The fuel selector valve was found in the “both” position. The engine sustained significant impact damage and was saturated with mud. The crankshaft sheared aft of the propeller flange. Two of the propeller blades remained attached to the propeller hub and exhibited S-bending and curling. The crankshaft was unable to rotate due to the impact damage. Although the examination was limited due to the extensive impact damage, examination of the engine and airframe examination did not reveal any preimpact anomalies. ## Aircraft - Registration: [N4765N](https://openairdocs.org/deregistered/N4765N-2023-06-19), registration cancelled 2023-06-19, S/N 18267348, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 182Q - Registry model: [Cessna 182Q](https://openairdocs.org/model/cessna-182q) (registry code 2072732) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18267348 - Year built: 1979 - Airframe hours: 3114 - Engines: Continental Motors (Texas Skyways Conversion) IO-520-U/TS 285 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: D & S Aviation Inc - Registered owner: D & S Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 5, 2020 - Departed: KUXL, Sulphur, LA - Destination: KUXL, Sulphur, LA - Equipment: Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Stall warning system, ADS-B, Angle of attack indicator, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review January 15, 2021; seat: left; toxicology performed; flight hours: 80 total, 3 in this make and model, 10 as pilot in command - Flight instructor; age 55; injuries: fatal; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 2, 2020; seat: right; flight hours: 4,354 total ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Temperature: 55 °F, dew point 36 °F - Altimeter: 30.19 inHg - Observed at: KLCH, 9 nm away - METAR: KLCH 022353Z 20004KT 10SM CLR 13/02 A3019 RMK AO2 SLP230 T01330022 10167 20128 56004 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210202003309A](https://openairdocs.org/incident/20210202003309A), Feb 2, 2021: Cessna 182Q, Hackberry, LA, Destroyed, 2 fatal. The pilot recently became a [privacy data omitted]of this aircraft. The previous flight was conducted for insurance purposes. The pilot went with an instructor… ## Docket (15 files) The files NTSB released with the investigation on July 29, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102590. 246 MB in all. - NTSB investigation summary (item 1, PDF, 8 pages, 480 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13664793&FileExtension=pdf&FileName=Investigation%20Summary%20for%20docket-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 11 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11944687&FileExtension=pdf&FileName=6120%20-%20Co-owners-Rel.pdf - Sheriff's report with witness statements (item 3, PDF, 4 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13348217&FileExtension=pdf&FileName=Sheriffs%20Report_Redacted-Rel.pdf - FAA air traffic control summary (item 4, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349357&FileExtension=pdf&FileName=Pages%20from%20FAA%20ATC%20Accident%20Package%20for%20N4765N%2002-02-21-Rel.pdf - Correspondence - co-owners (item 5, PDF, 5 pages, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13662722&FileExtension=pdf&FileName=Correspondence%20-%20co-owners_Redacted-Rel.pdf - Correspondence - insurance representative (item 6, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13361895&FileExtension=pdf&FileName=ROC%20-%20AIG%20Insurance%20Scifres-Rel.pdf - Garmin GFC500 autopilot information (item 7, PDF, 10 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13663012&FileExtension=pdf&FileName=Garmin%20AFCS%20RSP%20info-Rel.pdf - Maintenance records (item 8, PDF, 60 pages, 182 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13362216&FileExtension=pdf&FileName=Airplane%20mx%20logbooks_Redacted-Rel.pdf - Photos (item 9, PDF, 16 pages, 12.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347375&FileExtension=pdf&FileName=Photos-Rel.pdf - Flight path depictions (item 10, PDF, 6 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13362365&FileExtension=pdf&FileName=Google%20Earth%20images-Rel.pdf - Private pilot logbook (item 11, PDF, 5 pages, 34.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13362088&FileExtension=pdf&FileName=Private%20pilot%20logbook_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 1 page, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13352975&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release(signed)_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11945000&FileExtension=pdf&FileName=Party%20form%20-%20Textron_Redacted-Rel.pdf - Toxicological report - private pilot (item 14, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12124433&FileExtension=pdf&FileName=Tox%20-%20private%20pilot_Redacted-Rel.pdf - Memorandum for record a�� medical and pathological information (item 15, PDF, 2 pages, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13664247&FileExtension=pdf&FileName=Memo%20-%20Medical%20and%20Pathological%20Information-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.