# NTSB DEN00FA053: Cessna 182E, N2988Y, El Prado, NM, February 25, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 24, 2000, 18:45 local (Feb 25, 2000, 01:45 UTC) - Place: El Prado, NM - Coordinates: 36.469818, -105.619224 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.4698&lon=-105.6192&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 4, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 48665 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN00FA053 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/48665/pdf - Page: https://openairdocs.org/ntsb/DEN00FA053 ## Probable cause The pilot's improper preflight planning/preparation in that he initiated flight into known adverse weather, and continued VFR flight into IMC to the point where remedial action was not possible. Factors were the weather conditions that included snow, low ceiling, and obscuration, a dark night, and his overconfidence in his abilities. **This case was modified on February 27, 2008.** ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - normal - preflight planning/preparation - improper, pilot in command (cause) - flight into known adverse weather - initiated, pilot in command (cause) - weather condition - snow (contributing factor) - weather condition - low ceiling (contributing factor) - light condition - dark night (contributing factor) - In flight collision with terrain/water, descent - vfr flight into imc - continued, pilot in command (cause) - overconfidence in personal ability, pilot in command (contributing factor) - use of inappropriate medication/drug, pilot in command - remedial action - not possible ## Analysis The instrument rated private pilot received an in-person abbreviated weather briefing from the Albuquerque Flight Service Station (FSS), and local weather reports from a friend who lived near the Taos Municipal Airport via telephone and aircraft radio. FSS advised the pilot that VFR flight was not recommended due to mountain tops being obscured, turbulence, and icing conditions. His friend said it was snowing at his home. The pilot then filed a VFR flight plan for the dark night cross country flight, and departed Albuquerque for Taos. Later, he radioed his friend and told him that the snow had moved in behind him, he had the airport in sight, but was having difficulty maintaining visual contact with the runway lights because he was 'in and out of snow showers.' The airplane impacted terrain 1.5 miles east of the airport. Toxicological tests revealed that the pilot, a psychiatrist, had recently taken fluoxetine (also known by the trade name Prozac), a prescription antidepressant medication not approved for flight. **This case was modified on February 27, 2008.** ## Factual narrative HISTORY OF FLIGHT On February 24, 2000, approximately 1845 mountain standard time, a Cessna 182E, N2988Y, owned and operated by the pilot, was destroyed when it collided with terrain while descending 1.5 miles east of the Taos Municipal Airport at El Prado, New Mexico. The private instrument rated pilot, the sole occupant aboard, was fatally injured. Instrument meteorological conditions prevailed, and a VFR flight plan was filed for the personal flight being conducted under Title 14 CFR (Code of Federal Regulations) Part 91. The flight originated at Albuquerque, New Mexico, approximately 1758. According to a friend of the pilot's, he was contacted at home by the pilot who inquired as to the weather conditions at Taos. The friend said he told him that it was snowing, and that he "should not even think of flying." The pilot then received an in-person abbreviated weather briefing from the Albuquerque Flight Service Station (FSS). He was advised that VFR (visual flight rules) flight was not recommended (VNR) due to mountain tops being obscured, turbulence, and icing conditions. This information was based on Doppler radar and the Taos AWOS (Automated Weather Observation System). The pilot's friend said that about 45 minutes later, the pilot telephoned a second time and told him that it would be possible to make the flight VFR because the Taos AWOS was reporting 10 miles visibility and ceiling of at least 10,000 feet. His friend told him that it was still snowing where he lived (about 25 miles west of the airport and 8,200 feet above sea level). The pilot said he was going to attempt the flight anyway, citing his friend living "right at the edge of the snow level." The pilot took off and established radio contact with the Albuquerque Air Route Traffic Control Center (ARTCC) at 1806. At 1818, the pilot requested and was given permission to leave the frequency momentarily. He contacted a friend at his home on (Unicom) frequency 122.75 MHz, and told him he had just passed Santa Fe and wanted to know what the weather was like at Taos. His friend, using a hand-held radio, looked outside and told him that the weather was clear in Taos, but snow was falling over the mountains. The pilot reestablished radio contact with Albuquerque ARTCC at 1823. Shortly thereafter, the controller told the pilot that his filed flight plan went only as far as the Taos VORTAC (Very High Frequency Omnidirectional Radio Range Tactical Air Navigation), and asked if he planned to land at Taos. The pilot said he did, but was considering turning back and landing at Santa Fe. At 1831, radar contact was lost and at 1832, the pilot's request for a frequency change was approved. The pilot again contacted his friend and told him he had passed Espinola, and that the snow had moved in behind him. His friend said it was now snowing at Taos, too. The next contact with the pilot was when he reported being 5 miles southwest of the airport. Then the pilot said he had the airport in sight, but was having difficulty maintaining visual contact with the runway lights because he was "in and out of snow showers." His friend asked him what his altitude was, and the pilot replied he was at 7,600 feet (airport elevation is 7,091 feet). The pilot then said he was "picking up ice" and "[thought he was] in trouble." This was the last contact with the pilot. The pilot's friend telephoned the airport manager, who went outside his home and noted that it was "snowing chicken feathers" (wet snow, large flakes, heavy downfall). At 1859, the pilot of a Beech 200, N444MT, advised Albuquerque ARTCC that he was receiving an ELT (emergency locator transmitter) signal. At 2027, the pilot of an Air Force C-130 agreed to fly to Taos in an attempt to locate the source of the ELT signal using a DF (directional finder) steer. At 2108, C-130 pilot reported picking up a strong ELT signal southwest of Taos and provided the controller with latitude and longitude coordinates. At 2151, the C-130 pilot executed an NDB (nondirectional beacon) runway 4 instrument approach to Taos in an attempt to get below the overcast. At 2202, he reported no success in acquiring visual contact. The wreckage was located by ground search teams approximately 2230. The accident occurred during the hours of darkness at a location of 36 degrees, 44.532 (36/26.779) minutes north latitude, and 105 degrees, 6448 minutes (105/38.688) west longitude. PERSONNEL INFORMATION The pilot, a psychiatrist, maintained a practice and residence in both Taos and Los Angeles, California. He was also on the faculty at UCLA Medical Center, serving as associate clinical professor in the psychiatry and biobehavioral science departments. According to FAA documents and two logbooks found in the wreckage, the pilot started taking flying lessons on January 7, 1991. Nine months later, he purchased N2988Y and continued his training in that airplane, earning his private pilot's license on November 24, 1991. On October 13, 1995, he received an instrument rating His most recent biennial flight review was dated October 9, 1999. The last entry in his logbook was dated February 17, 2000. (For a summary of the pilot's flight time, see docket exhibits). As a result of a flight that occurred on August 5, 1997 (logbook entry attached, see docket exhibits), FAA initiated a certificate enforcement action against the pilot, alleging that he "entered into IFR conditions without prior clearance, failed to maintain assigned altitude, and departed airway contrary to ATC clearance." Specifically, the pilot was charged with violating FAR (Federal Aviation Regulation) 91.13(a), 91.123(a), and 91.173. According to the enforcement action, the pilot reportedly inadvertently entered a thunderstorm somewhere in the vicinity of Santa Fe, New Mexico, became disoriented, and was given a flight assist by Albuquerque ARTCC. FAA documents indicate the pilot was offered and accepted "remedial training." The training consisted of additional instrument flight instruction given by a certified flight instructor and monitored by FAA's accident prevention specialist. AIRCRAFT INFORMATION N2988Y (s/n 18253988), a model 182E, was manufactured by the Cessna Aircraft Company in February 1962. It was equipped with a Continental O-470-R engine (s/n 83474-2-R), rated at 230 horsepower, and a McCauley 2-blade, all-metal, constant speed propeller (m/n 2A36C). The airplane's maintenance records were never located. According to a mechanic for Taos Aviation, however, he performed an annual inspection on the airplane on June 13, 1999. At that time, the tachometer registered 76.4 hours, and he computed the airframe total time to be 4,050.58 hours. At the accident site, the tachometer registered 1,800 rpm and recorded 0134.1 hours. METEOROLOGICAL INFORMATION Weather observations at the Taos Municipal Airport are made by AWOS (automated weather observation system) without precipitation discriminator (A01). The following weather observation was recorded at 1840, or about 5 minutes before the accident, to wit: WIND 300 DEGREES AT 12 KNOTS; VISIBILITY 9 STATUTE MILES; FEW CLOUDS AT 1,200 FEET, 1,900 FEET SCATTERED, CEILING 3,400 FEET BROKEN, TEMPERATURE 2 DEGREES CELCIUS, DEW POINT -6 DEGREES CELCIUS; ALTIMETER 29.70 INCHES OF MERCURY. Twenty minutes later, at 1900, the following weather observation was recorded: WIND 290 DEGREES AT 3 KNOTS; VISIBILITY 1 STATUTE MILE; CEILING 100 FEET OVERCAST; TEMPERATURE 1 DEGREE CELCIUS, DEW POINT -5 DEGREES CELCIUS; ALTIMETER 29.70 INCHES OF MERCURY. The Flight Service Station specialist told the pilot that VFR flight was not recommended due to mountains being obscured, turbulence, and icing conditions. These advisories were contained in AIRMETs (Airmen's Meteorological Information) Tango, Zulu, and Sierra (attached, see docket exhibits). In addition to describing accident weather conditions a ## Aircraft - Registration: [N2988Y](https://openairdocs.org/deregistered/N2988Y-2000-12-07), registration cancelled 2000-12-07, S/N 18253988 (OpenAirDocs) - Reported make and model: Cessna 182E - Registry model: [Cessna 182E](https://openairdocs.org/model/cessna-182e) (registry code 2072712) (OpenAirDocs) - Category: Airplane - Serial number: 18253988 - Airframe hours: 4108 - Engines: Continental O-470-R 230 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Richard M. Rosen - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 13, 1999, 58 hours before - Departed: ABQ, ALBUQUERQUE, NM - Destination: SKX, TAOS, NM - Flight plan: VFR - Airport: SKX, Taos Municipal, runway 22, 5,798 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 732 total, 630 in this make and model, 666 as pilot in command, 17 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 280° at 11 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 4,100 ft broken - Temperature: 39 °F, dew point 21 °F - Altimeter: 29.00 inHg - Observed at: SKX, 270 nm away ## 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 20000224003179A](https://openairdocs.org/incident/20000224003179A), Feb 24, 2000: Cessna 182E, Taos, NM, Destroyed, 1 fatal. The instrument rated private pilot received an in-person abbreviated weather briefing from the albuquerque flight service station (fss), and local weather… 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.