# NTSB ERA17FA073: Cessna 182, N1839X, Gatlinburg, TN, December 26, 2016

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: December 26, 2016, 16:02 local (21:02 UTC)
- Place: Gatlinburg, TN
- Coordinates: 35.651943, -83.458335 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.6519&lon=-83.4583&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report April 17, 2018
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Textron, CMI, FAA/FSDO
- NTSB case key (mKey): 94531
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17FA073
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94531/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94531
- Page: https://openairdocs.org/ntsb/ERA17FA073

## Probable cause

The non-instrument-rated pilot's intentional visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain. Contributing to the accident was the pilot's established anti-authority attitude.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182H, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072718), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Experience/qualifications: total instrument experience](https://openairdocs.org/ntsb-findings/02031030): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Cessna 182H, 2 cases](https://openairdocs.org/ntsb-findings/02031030/cases.md?model=2072718), [All aircraft, 66 cases](https://openairdocs.org/ntsb-findings/02031030/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 182H, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2072718), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna 182H, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2072718), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md)
- [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 182H, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2072718), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md)
- [Personality/attitude: personality](https://openairdocs.org/ntsb-findings/02021030): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 182H, 1 case](https://openairdocs.org/ntsb-findings/02021030/cases.md?model=2072718), [All aircraft, 8 cases](https://openairdocs.org/ntsb-findings/02021030/cases.md)
- [Personality/attitude: self confidence](https://openairdocs.org/ntsb-findings/02021010): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 182H, 1 case](https://openairdocs.org/ntsb-findings/02021010/cases.md?model=2072718), [All aircraft, 16 cases](https://openairdocs.org/ntsb-findings/02021010/cases.md)
- [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Cessna 182H, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=2072718), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 182H, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2072718), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)

## Analysis

The non-instrument-rated private pilot elected to conduct the cross-country flight over mountainous terrain without obtaining a weather briefing or filing a flight plan. As he approached his destination, the pilot requested a descent from his cruising altitude of 9,500 ft mean sea level (msl), which was approved by air traffic control. The controller instructed the pilot to maintain visual flight rules flight throughout his descent. Instead, the pilot descended the airplane into a cloud layer between 7,000 ft msl to 5,000 ft msl despite his instructions from air traffic control. Radar data and satellite weather imagery depicted the airplane in a steady-state descent inside a solid cloud layer which tracked north, directly toward the destination airport. The radar track ended at 5,400 ft. msl abeam a mountain peak at 6,500 feet elevation. The accident site was located at 5,400 ft in steep, mountainous terrain about 15 miles south of the destination airport at the same position as the last radar target. Examination of the wreckage revealed no pre-impact mechanical anomalies and signatures consistent with controlled flight into terrain. The pilot had a history of disregard for established rules and regulations. The pilot's airplane was about 2 months overdue for an annual inspection. He was counseled numerous times by an experienced flight instructor about his unsafe practice of operating the airplane in instrument meteorological conditions without an instrument rating, but he continued to do so over a period of 2 years and again on the accident flight. His contempt for rules and regulations was consistent with an anti-authority attitude, which is hazardous to safe operation of aircraft. The pilot had used the potentially-impairing stimulant phentermine at some time before the flight, but the samples available for testing were inadequate to quantify impairment. Therefore, it could not be determined if the pilot's use of phentermine contributed to this accident.

## Factual narrative

The owner/operator of the flight school at 42J where the pilot received his primary flight instruction was interviewed. According to the flight school owner, who was a flight instructor, the pilot "pushed his training as hard as he could and cut corners wherever he could." According to school records, the pilot scored a 73 on his FAA private pilot written exam. The pilot purchased the airplane as soon as he passed his practical exam. The pilot later built a hangar on his property and kept the airplane there, but he continued to fly in and out of 42J. The flight school owner said that he watched the pilot depart 42J with his family on multiple occasions in weather that was "below VFR minimums." He said that he counseled the pilot numerous times about operating the airplane VFR in instrument conditions. Most recently, he counseled the pilot 2 weeks before the accident. The flight school owner stated, "I've been flying for more than 40 years, and I tried to explain to him the history of pilots with an anti-authority attitude. It's an attitude that catches up with you. He was a low-time, flat-land pilot with no mountain experience. There was an AIRMET for mountain obscuration that day… there was plenty of information out there." When asked why he thought the pilot departed on the accident flight with those conditions along his route of flight, the instructor said, "I counseled him numerous times about taking instrument training and getting an instrument rating. Lots of us around here did. He couldn't be bothered. He would just draw… [the flight route] on his iPad and go." GKT was depicted on the Atlanta VFR Sectional Chart at 1,014 ft msl. The Maximum Elevation Figure (MEF) for the quadrant that contained both GKT and Mt. LeConte was 7,000 ft msl. Instrument approach procedure charts for GKT depicted the minimum sector altitude as 7,900 ft msl, which provided a minimum clearance of 1,000 ft above all obstacles within a 25nm radius of GKT. These charts were available to ForeFlight subscribers. The four-seat, single-engine, high-wing, fixed-gear airplane was manufactured in 1965 and equipped with a Continental O-470-R-series, 230-horsepower, reciprocating engine. According to the airplane's maintenance records, the most recent annual inspection was completed on October 3, 2015, at 2,595 total aircraft hours. On December 26, 2016, about 1602 eastern standard time, a Cessna 182H, N1839X, collided with mountainous terrain during descent for landing to Gatlinburg Pigeon Forge Airport (GKT), Sevierville, Tennessee. The private pilot and two passengers were fatally injured; the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed, and no flight plan was filed for the personal cross-country flight. The airplane departed Keystone Airpark (42J), Keystone Heights, Florida, about 1300. Information from the FederalAviation Administration (FAA) revealed that the airplane was receiving visual flight rules (VFR) flight-following services and was at 9,500 ft mean sea level (msl) when the pilot requested a descent into GKT. At 1554, the controller approved the descent, issued an altimeter setting, and directed the pilot to "maintain VFR." Radar data depicted a descent on a ground track of about 340° directly toward GKT at a groundspeed between 130 and 150 knots. At 1558, about 20 miles from GKT, the airplane descended below the minimum vectoring altitude of 8,000 ft msl. The airplane continued its descent on the same ground track and about the same speed. At 1602, the radar target was at 5,400 ft msl abeam the peak of Mt. LeConte, elevation 6,500 ft, when the radar track ended. At that time, the controller issued the airplane a radio frequency change to the GKT frequency and terminated radar services. No reply was received from the airplane, and no further attempts to contact the airplane were made. Local law enforcement was notified of the overdue airplane by concerned family members. A search was initiated, and the wreckage was located later that evening by helicopter at 5,400 ft in steep, mountainous terrain at the same position as the last radar target. The Regional Forensic Center, Knox County, Tennessee, performed the autopsy on the pilot. The cause of death was listed as multiple blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing for the pilot. Phentermine was detected in the liver at 0.167 ug/ml, in the spleen at 0.125 ug/ml, and in the kidney at 0.116 ug/ml. Phentermine is a prescription stimulant/appetite suppressant medication marked under various names including Adipex. It is a central nervous system stimulant, and side effects include overstimulation, restlessness, and dizziness. It carries the warning, "phentermine may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle; the patient should therefore be cautioned accordingly." The pilot had not disclosed use of this medication to the FAA. There is no known relationship between tissue levels and impairment for this drug. At 1615, the weather reported at GKT, located 15 miles north of the accident site, included few clouds at 4,600 ft and calm wind. The temperature was 18°C; the dew point was 13°C; and the altimeter setting was 30.30 inches of mercury. Airmen's Meteorological Information (AIRMET) Sierra for mountain obscuration was in effect along the airplane's flight route. Satellite imagery showed instrument flight rules (IFR) conditions with cloud tops between 6,000 and 7,000 ft msl in the area surrounding the accident site. Conditions north of the ridgeline that the airplane struck and at the destination airport were VFR. At 1545, about the time the airplane passed overhead, the weather reported at Macon County Airport (2,034 feetelevation), Franklin, North Carolina, about 25 miles south of the accident site included scattered clouds at 700 ft, a broken ceiling at 1,200 ft, and an overcast cloud layer at 2,400 ft. The visibility was 4 statute miles in fog. A pilot who transitioned through the area of the accident site around the time of the accident captured images and weather information near the site. He said that during the climb, his airplane entered a flat, stratus cloud layer at 5,000 ft and that the cloud tops were at 7,000 ft msl. According to this pilot, the cloud layer remained consistent throughout the en route and descent portions of his flight. A search of official weather briefing sources, such as Lockheed Martin Flight Service and the Direct User Access Terminal Service, revealed that no official weather briefing was received by the pilot from those sources. A search of ForeFlight weather information revealed that the pilot did not request a weather briefing, nor did he file a flight plan using ForeFlight mobile. However, at 1449, the pilot did enter route information from 42J to GKT in ForeFlight, but he did not view any weather imagery. It could not be determined if the pilot viewed weather observations or terminal area forecast information en route as Foreflight did not archive that information. The pilot held a private pilot certificate with a rating for airplane single-engine land. He was issued a third-class medical certificate on December 3, 2013, and he reported 12 total hours of flight experience on that date. The pilot was issued his private pilot certificate on April 1, 2014 at 45.3 total hours of flight experience. His pilot logbook was not recovered. On April 27, 2016, the pilot reported to his insurance carrier that he had accrued 272 total hours of flight experience, 219 hours of which were in the accident airplane. The wreckage was examined at the accident site by an FAA inspector. There was an odor of fuel, and all major components were accounted for at the scene. Because of the hazardous conditions at the site, a brief photo-documentation of the wreckage was performed before it was recovered by helicopter for further examination. During the subsequent examination, it was determined that two landing gear and a propeller blade were not recovered from the accident site. The airframe was segmented by both impact and cutting performed by the aircraft recovery technicians. Control continuity was established from the cockpit area, through several breaks and cuts, to the flight control surfaces. All breaks were consistent with overload failure or mechanical cutting during recovery. The leading edges of both wings were uniformly crushed. Examination of the instrument panel revealed that the instruments were destroyed by impact, and no useful data was recovered. The mixture, throttle, and propeller controls were all found in the full-forward positions. The fuel selector valve was in the "Right" tank position. The propeller, propeller governor,engine case, No. 6 cylinder, and the crankshaft forward of the No. 4 main bearing were separated by impact forces. The engine could not be rotated by hand due to impact damage. The oil sump was also separated, which allowed for visual inspection of the power section. Visual inspection and borescope examination revealed normal wear and lubrication signatures. The engine accessories were also separated from the engine due to impact. The magnetos could not be tested due to impact damage. Disassembly revealed normal wear and no pre-impact mechanical anomalies.

## Aircraft

- Registration: [N1839X](https://openairdocs.org/deregistered/N1839X-2018-03-20), registration cancelled 2018-03-20, S/N 18255939 (OpenAirDocs)
- Reported make and model: CESSNA 182 (H)
- Registry model: [Cessna 182H](https://openairdocs.org/model/cessna-182h) (registry code 2072718) (OpenAirDocs)
- Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 18255939
- Airframe hours: 2595
- Engines: CONT MOTOR O-470 SERIES 230 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, October 3, 2015
- Departed: 42J, KEYSTONE HEIGHTS, FL
- Destination: GKT, Gatlinburg, TN
- Airport: GKT, Gatlinburg-Pigeon Forge
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 41; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; toxicology performed; flight hours: 272 total, 219 in this make and model

## Weather

- Conditions: Instrument (IMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 64 °F, dew point 55 °F
- Altimeter: 30.29 inHg
- Observed at: GKT, 13 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 20161226023729A](https://openairdocs.org/incident/20161226023729A), Dec 26, 2016: Cessna 182H, Gatlinburg, TN, Destroyed, 3 fatal. Aircraft had VFR flight following. Pilot started descent to kgkt 15 miles from airport. Aircraft was in IFR conditions and descended into mountains. Aircraft…

## Docket (19 files)

The files NTSB released with the investigation on March 20, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94531. 21.2 MB in all.

- Weather study report (item 1, PDF, 33 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4714851&FileExtension=pdf&FileName=ERA17FA073_weatherstudySuffernfinal-Rel.pdf
- Weather attachment 1 (item 2, PDF, 1 page, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4714869&FileExtension=pdf&FileName=attachment1_foreflighrequestcheck_Redacted-Rel.pdf
- Weather attachment 2 (item 3, PDF, 1 page, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4714959&FileExtension=pdf&FileName=attachment2_foreflighrequestcheck2_Redacted-Rel.pdf
- Weather attachment 3 (item 4, PDF, 1 page, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6156706&FileExtension=pdf&FileName=attachment3_imagefromotherflight_Redacted-Rel.pdf
- Weather attachment 4 (item 5, PDF, 1 page, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6155745&FileExtension=pdf&FileName=attachment4_imagefromotherflight2_Redacted-Rel.pdf
- Witness interview summary (item 6, PDF, 1 page, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6052506&FileExtension=pdf&FileName=Memorandum%20for%20Record%20Robert%20Oehl-Rel.pdf
- Witness blog post (item 7, PDF, 2 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6053355&FileExtension=pdf&FileName=Witness%20Blog%20Post_Redacted-Rel.pdf
- FAA inspector's statement (item 8, PDF, 3 pages, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6052516&FileExtension=pdf&FileName=Inspector%20Statement%20N1839X%20(2)_Redacted-Rel.pdf
- Maintenance records excerpts (item 9, PDF, 2 pages, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6052928&FileExtension=pdf&FileName=Maintenance%20Excerpts_Redacted-Rel.pdf
- Toxicological report (item 10, PDF, 1 page, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6053462&FileExtension=pdf&FileName=Pilot%20Tox%202.0_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (Textron) (item 11, PDF, 1 page, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6053265&FileExtension=pdf&FileName=Textron%20Party%20Form_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (cmi) (item 12, PDF, 1 page, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6053160&FileExtension=pdf&FileName=Party%20Form%20CMI_Redacted-Rel.pdf
- Photos (item 13, PDF, 5 pages, 5 photos, 567 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6056132&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf
- ATC factual report (item 14, PDF, 8 pages, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6142578&FileExtension=pdf&FileName=ERA17FA073%20-%20ATC%20Factual%20Report%20-%20FINAL-Rel.pdf
- ATC factual report - attachment 1 (item 15, PDF, 14 pages, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6142921&FileExtension=pdf&FileName=ERA17FA073%20-%20ATC%20Factual%20Report%20-%20Attachment%201%20-%20FINAL-Rel.pdf
- ATC factual report - attachment 2 (item 16, PDF, 5 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6143122&FileExtension=pdf&FileName=ERA17FA073%20-%20ATC%20Factual%20Report%20-%20Attachment%202%20-%20FINAL-Rel.pdf
- Tys radar data (item 17, XLSX, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6171548&FileExtension=xlsx&FileName=ERA17FA073%20-%20TYS%20Radar%20Data-Rel.xlsx
- Release of aircraft wreckage, NTSB form 6120.15 (item 18, PDF, 1 page, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=6306348&FileExtension=pdf&FileName=Release%20of%20Aircraft%20Wreckage_Redacted-Rel.pdf
- Case revision memorandum (item 19, PDF, 9 pages, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17000646&FileExtension=pdf&FileName=ERA17FA073_Case%20Revision%20Memo_docket-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.