# NTSB ERA19FA179: Cessna TR182, N6123T, St. Simons Island, GA, May 25, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 25, 2019, 09:23 local (13:23 UTC) - Place: St. Simons Island, GA - Coordinates: 31.2325, -81.354721 - Nearby events: https://openairdocs.org/map.md?lat=31.2325&lon=-81.3547&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 99478 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA179 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99478/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99478 - Page: https://openairdocs.org/ntsb/ERA19FA179 ## Probable cause The pilot's loss of airplane control during approach for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna TR182, 5 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2072735), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna TR182, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072735), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna TR182, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072735), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The cross-country flight proceeded uneventfully in good weather conditions until the airplane was about 5 miles from the destination airport. The airplane had descended gradually from an en route altitude of 4,000 to 1,700 ft mean sea level (msl) over a period of about 4 minutes. However, between 1,700 ft and the second-to-last radar target at 1,300 ft msl, and between that radar target and the final target at 900 ft msl, the airplane descended 400 ft in about 4 seconds between the targets. The airplane subsequently impacted terrain in a wooded area. The tree scars and the lack of a debris path at the accident site were consistent with a near-vertical descent. Examination of the wreckage revealed no preimpact mechanical malfunctions that would have precluded normal operation. The 80-year-old pilot had high blood pressure and high cholesterol, which would not be considered impairing. Some plaques were found on the pilot's thoracic aorta during his autopsy, but, due to the pilot's extensive injuries, his heart was not available for examination to determine if he had any coronary artery disease. Thus, the investigation of this accident could not determine if the pilot's medical conditions contributed to the accident. Ethanol was detected in the pilot's muscle tissue. Given the lack of ethanol in the pilot's lung tissue and the presence of n-propanol in his muscle tissue, it is likely that some or all of the identified ethanol was from sources other than ingestion. Thus, the identified ethanol did not contribute to this accident. ## Factual narrative The four-seat, high-wing, retractable tricycle landing gear airplane was manufactured in 1982. It was powered by a Lycoming O-540, 235-horsepower engine equipped with a three-blade, constant-speed Hartzell propeller. A turbocharger was subsequently installed via a supplemental type certificate. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on January 17, 2019. At that time, the airframe had accumulated a total of 5,363.2 hours, and the engine had accumulated 79.9 hours since major overhaul. On May 25, 2019, about 0923 eastern daylight time, a Cessna TR182, N6123T, was destroyed when it impacted terrain during a visual approach to McKinnon–St. Simons Island Airport (SSI), St. Simons Island, Georgia. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan was filed for the cross-country flight, which originated from Savannah/Hilton Head International Airport (SAV), Savannah, Georgia, about 0859. According to information from the Federal Aviation Administration (FAA), at 0919, the flight was cleared for the visual approach to runway 22 at SSI, and the pilot was instructed to switch the radio frequency to the SSI common traffic advisory frequency, which the pilot acknowledged. Review of recordings of the common traffic advisory frequency at SSI revealed that the pilot reported the airplane was 9 miles north of, and on a straight-in approach to, runway 22. No further communication from the pilot was received, and radar contact with the airplane was lost at 0923, when the airplane was about 5 miles northeast of SSI at an altitude of 900 ft mean sea level (msl). (That altitude is usually where radar coverage is lost in that area.) Further review of the radar data revealed that the airplane made a gradual descent from an en route altitude of 4,000 to 1,700 ft msl. The final two radar targets, at 1,300 and 900 ft msl, each indicated that the airplane descended 400 ft in about 4 seconds (between 1,700 and 1,300 ft msl and between 1,300 and 900 ft msl). A witness subsequently observed a fire in a wooded area of a sparsely populated section of a residential development and notified law enforcement, who found the airplane wreckage about 5 miles north of SSI, near the last radar target. The Division of Forensic Sciences, Georgia Bureau of Investigation, Savannah, Georgia, performed an autopsy on the pilot. His cause of death was multiple blunt force trauma. The autopsy examination was limited by the pilot's extensive injuries, and the brain and heart were not available for examination. Atherosclerotic plaques were noted in the thoracic aorta. Toxicology testing performed at FAA Forensic Sciences Laboratory identified ethanol and n-propanol in the pilot's muscle tissue; no ethanol was detected in the pilot's lungtissue. Diltiazem was detected in the pilot's lung and muscle tissues. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant and impairs judgment, psychomotor functioning, and vigilance. After absorption, ethanol quickly and uniformly distributes throughout the body's tissues and fluids. Ethanol can also be produced postmortem. Diltiazem is a nonsedating high blood pressure medication. According to the FAA medical case review, on his application for BasicMed, the pilot listed the following medications: diltiazem, losartan, and furosemide, which are high blood pressure medications; rosuvastatin, a cholesterol-reducing medication; vitamin B9-folic acid; and aspirin.. At his most recent medical certificate examination (March 1, 2017), the pilot reported the same medications as those listed on his BasicMed application. The recorded weather at SSI at 0853 was wind from 260° at 10 knots, visibility 10 miles, clear sky, temperature 27°C, dew point 17°C, and altimeter 30.15 inches of mercury. The pilot, age 80, held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA second-class medical certificate, which was expired at the time of the accident, was issued on March 1, 2017, with the limitation that he have glasses available for near vision and use hearing amplification. At that time, the pilot reported a total flight experience of 4,600 hours. The pilot had a BasicMed dated February 27, 2018. The pilot's logbook was not recovered. Review of an insurance application, dated October 24, 2016, revealed that the pilot reported a total flight experience of 4,671 hours, of which 378 hours were in the accident airplane make and model and 30 hours were flown during the previous 90 days. The airplane came to rest nose down in a crater that was about 3 ft deep, and the airplane was oriented along a magnetic heading of 210°. Most of the airplane was consumed by postcrash fire. Two tree strikes were observed immediately above the wreckage. No debris path was observed. The engine and forward fuselage remained in the crater. The landing gear was partially extended;, but the preimpact position of the landing gear could not be confirmed. The left wing was folded inverted near the crater. The left flap remained attached and was partially melted. The left aileron had partially separated and melted. The right wing sustained more fire and impact damage than the left wing. The right flap separated and sustained impact and thermal damage. The right aileron separated and sustained impact and thermal damage. Measurement of the flap actuator corresponded to a flaps retracted position. The left elevator separated, and the right elevator melted near the elevator trim jackscrew. Measurement of thejackscrew corresponded to a 20° tab up (nose-down) elevator trim position, but the actuator had separated from the airframe, and the elevator trim cable exhibited a broom straw separation. The rudder separated and was fragmented. Flight control continuity was confirmed from the elevator and rudder bellcranks to the cabin area. Continuity was confirmed from the left aileron to the left wing root, and control cables from the right wing were identified but had been partially consumed by fire. The engine was recovered from the crater and separated from the airframe for examination. The propeller had separated from the engine and was also recovered from the crater. One propeller blade exhibited s-bending and leading-edge gouges, another propeller blade exhibited tip curling and bending, and the remaining propeller blade sustained a tip separation. The valve covers and top spark plugs were removed from the engine; the spark plug electrodes were intact and gray in color. The rear engine accessories were also removed. The single-drive dual magneto sustained impact damage and could not be tested. The engine-driven fuel pump and propeller governor also sustained impact damage and could not be tested. The fuel strainer screen was recovered, and no debris in the screen was observed. The carburetor sustained impact damage; its float was removed, which revealed that it had also sustained impact damage. The front section of the engine had sustained impact damage, and the crankshaft could not be manually rotated via an accessory gear drive; borescope examination of all six cylinders did not reveal any preimpact mechanical malfunctions. ## Aircraft - Registration: [N6123T](https://openairdocs.org/deregistered/N6123T-2022-02-05), registration cancelled 2022-02-05, S/N R18201910, built 1982 (OpenAirDocs) - Reported make and model: Cessna TR182 (No Series) - Registry model: [Cessna TR182](https://openairdocs.org/model/cessna-tr182) (registry code 2072735) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: R18201910 - Year built: 1982 - Airframe hours: 5363.2 - Engines: Lycoming O-540 235 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 17, 2019 - Departed: SAV, Savannah, GA - Destination: SSI, St. Simons Isla, GA - Flight plan: IFR - Equipment: Electronic multifunction display, Electronic primary flight display, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 80; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: basicmed, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 4,671 total, 378 in this make and model, 30 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 30.14 inHg - Observed at: SSI, 5 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 20190525005149A](https://openairdocs.org/incident/20190525005149A), May 25, 2019: Cessna TR182, Saint Simons Is, GA, Destroyed, 1 fatal. N6123T was on visual approach into ssi and approved to change to advisory frequency. The aircraft disappeared from radar at 0923 EST at approximately 1,300… ## Docket (11 files) The files NTSB released with the investigation on March 19, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99478. 5.3 MB in all. - Fuel Receipt (item 1, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481354&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Excerpt From Insurance Application - Pilot Flight Experience (item 2, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481355&FileExtension=.PDF&FileName=Excerpt%20From%20Insurance%20Application%20-%20Pilot%20Flight%20Experience-Master.PDF - Excerpts From Maintenance Records (item 3, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481356&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Records-Master.PDF - Weather Report (item 4, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481357&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Radar Plots With Communication Inforrmation (item 5, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481358&FileExtension=.PDF&FileName=Radar%20Plots%20With%20Communication%20Inforrmation-Master.PDF - CTAF Recording 1 (5 seconds long in .wav format, 172KB) (item 6, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481359&FileExtension=.PDF&FileName=CTAF%20Recording%201%20(5%20seconds%20long%20in%20.wav%20format,%20172KB)-Master.PDF - CTAF Recording 2 (2 seconds long in .wav format, 86KB) (item 7, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481360&FileExtension=.PDF&FileName=CTAF%20Recording%202%20(2%20seconds%20long%20in%20.wav%20format,%2086KB)-Master.PDF - Photo Array (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481361&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Toxicological Report (item 9, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481362&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 674 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481363&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481364&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.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.