- Date
- January 10, 2005, 20:10 local (Jan 11, 2005, 02:10 UTC)
- Place
- Monroe, LA
- Injuries
- 2 fatal
- Damage
- Destroyed
- Phase of flight
- Approach
- Aircraft
- N9474ECessna 182R
- Weather
- Instrument (IMC) · Night/dark
- Status
- Completed · report March 28, 2006
- Report
- Approved by Office Director
- Parties
- Cessna Aircraft Company, Teledyne Continental Motors, Baton Rouge FSDO
- Case key
- 60857
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On this page
Probable cause
The NTSB’s determination of the probable cause, and any contributing factors.
The failure of the pilot manipulating the controls to maintain aircraft control during a night missed approach in instrument meteorological conditions. Factors include a dark night and low ceilings.
Analysis
The two Civil Air Patrol pilots took off on a dark night in order to shoot a number of practice instrument approaches in VFR conditions. The pilot who was believed to be sitting in the left seat and shooting the approaches was not instrument current at the time. After shooting the first approach, and just after being cleared for the second, the crew was advised that the ceiling had become 900 feet broken and that the field was then IFR. When queried by the controller, the crew said they wanted to continue their series of approaches via an IFR clearance. During the second approach they had trouble intercepting the localizer, and although they had by that time decided to make the next landing a full-stop, because they could not get established on the localizer, they eventually had to execute a missed approach. During the next approach they again had trouble getting established on the localizer, and when advised that they had a C130 following them on an approach for landing, the crew requested another missed approach. During that missed approach, while making a climbing turn in order to be repositioned for another approach, the flying pilot lost control of the aircraft, which descended into the waters of a shallow water collection pond/swamp.
Factual narrative
The factual narrative1,335 words
History of flight
On January 10, 2005, approximately 2010 central standard time, a Cessna 182R, N9474E, impacted the shallow waters of a swampy collection pond about eight miles northeast of Monroe Regional Airport, Monroe, Louisiana. Both occupants, each of whom held a commercial pilot certificate, received fatal injuries, and the aircraft, which was owned and operated by the Civil Air Patrol (CAP), was destroyed by the impact sequence. The local CFR Part 91 instrument proficiency flight, which departed Monroe Airport about 65 minutes prior to the accident, was being operated in instrument meteorological conditions (IMC) at the time of the accident. While in flight, the pilot had received a local instrument clearance to the Monroe Airport. There was no report of an ELT activation.
According to individuals at the airport, the two occupants executed a number of practice instrument approaches in visual meteorological conditions, and then landed, took a short break, and prepared to take off for another set of practice instrument approaches. Although it could not be positively confirmed, representatives of the operator believe that prior to the second flight, the two pilot's switched places, and the pilot who had been sitting in the right seat and operating the radios during the first flight was the one who did the flying from the left seat during the second flight. The operator based this assumption on the fact that an observer saw who was in which seat at the beginning of the first flight, and it was determined that the person in the right seat had been making the radio transmissions during that flight, while the pilot in the left seat during the first flight was the one making the radio transmissions during the second flight.
Prior to their departure, the flight crew of CAP flight 1630 contacted Monroe Ground, advised the controller that they had Information Victor, and then stated that they wanted to do two ILS's ( Instrument Landing System) and one VOR/DME (Very-High Frequency Omnidirectional Range/Distance Measuring Equipment) "under VFR (visual flight rules) conditions." The controller told them to maintain VFR at 2,000 feet, assigned them a discrete transponder code, and gave them the departure control frequency. The crew then asked for, and received, a clearance to take off on Runway 14 and maintain runway heading. After takeoff, the crew was directed to turn left to a heading of 060 degrees, for vectors to an ILS final approach for Runway 22, and then given climbout (missed approach) instructions of a left turn to 140 degrees, maintain 2,000 feet. The pilot handling the radios correctly read back the clearance, except for stating that the climbout was "runway heading to 2,000." The controller corrected him, and he correctly read back "140 to 2,000." The controller gave the crew two more turns, and then told them they were seven miles from Baiyu (the initial approach fix and outer marker), to turn left to 250 degrees, intercept the localizer, track it inbound, and to stand by for a clearance. The crew started the read-back, but after getting as far as the heading to turn to, paused and stated "...I didn't get those instructions." The controller then gave them a traffic advisory for the position of another aircraft in the radar pattern, and then gave them a clearance for the ILS, to which the crew correctly responded. Soon thereafter, the controller asked the crew what the bases were, and they asked him to repeat his transmission. The controller then transmitted, "Is it clear, or are there layers below you?" And the crew responded with "Don't see any clouds where we are right now." The crew was then directed to contact Monroe Tower, which they did after responding with "Ah, it looks like we spoke too soon. There is a little layer below us." Then, after contacting the tower and completing a stop-and-go, they took off for the second approach.
After departure for the second approach, the crew contacted departure control and was given a heading of 070 degrees. After responding to that clearance, the crew transmitted "Going through a little cloud right now at 1,000 feet." After being given three more heading changes in order to position them northeast of the final approach course, they were cleared for a second ILS for Runway 22, and asked to maintain "max forward speed." Then about 15 seconds after clearing CAP 1630 for the approach, the tower announced "Attention all aircraft, information whiskey, altimeter 30.10, ceiling 900 broken, 4,700 broken." Then about five seconds later the tower transmitted "CAP Flight 1630, showing the field IFR now, ceiling 9,000 broken, say intentions." The crew responded with "Ah, that's affirmative, we're not in the clouds right now." The tower then responded with, "Correction, showing 900 broken, with 10 miles visibility," to which the crew responded "900 broken, 10 miles visibility." The tower controller then asked the crew if they would like "...an IFR clearance to the airport," and the crew responded with " Yeah, let's do IFR to the airport, and then can we do a VOR/DME after this under these conditions?" The tower controlled then said "You're going to have to stay IFR to do the approach. Is that alright with you?" The crew of CAP 1630 responded to this transmission with "IFR approach, CAP 1630." They were then given an IFR clearance to the Monroe Airport via radar vectors, and given a new discrete transponder code. Soon thereafter they were switched to the tower and "cleared for the option," whereupon they advised the tower they were going to execute a stop-and-go, and then would like to shoot a VOR/DME. Then about 20 seconds after CAP 1630's last transmission, the tower controller transmitted "CAP Flight 1630, I'm showing you slightly east of the ILS final approach course. Are you picking it up?" CAP 1630 responded with "We're just now trying to make the adjustment. We see our problem." Then about five seconds later CAP 1630 transmitted "Are we still East of the localizer?" The controller told them that was affirmative, and CAP 1630 responded with "It's coming in now, thank you." Almost immediately, the tower controller asked "Are you going to need to be vectored for another approach," and the crew responded with "Yes, we want a VOR/DME." The controller's response to that transmission was "I mean, are you going to need a vector now to reattempt the ILS to 22?" To that the crew stated "We have intercepted the ILS." Then about five seconds later, the crew said that because of the low ceiling they had decided that the approach would end in a full-stop landing. Then about five seconds after that transmission, the controller asked CAP Flight 1630 to say what their heading was, and the crew responded with "Ah, can we do a missed approach on this and try it again?" At that point the tower controller told them to turn right to 320 degrees, and to maintain 2,100 feet for vectors for resequencing. The crew read back that clearance, and was soon switched back to approach control for another attempt at the ILS.
After switching back to approach, CAP 1630 was vectored to a position northwest of the ILS final approach course, and then given a heading of 120 degrees (within 12 degrees of being perpendicular to the inbound course), and subsequently advised that they could expect vectors across the final approach course for spacing behind traffic that was 6 miles southeast of their position. The crew of CAP 1630 responded to that transmission with "We'll be looking. You have a lot of static on your radio. It's hard to understand." The controller then asked CAP 1630 to confirm that they were on frequency 118.5, and not 126.9, which they confirmed. The controller then transmitted again, and asked 1630 if the transmission was any better, to which they responded "Ah, no, 1630." The controller then advised them "That's all I got for now," but within five seconds told them to change to frequency 126.9, because that m
Sequence of events
NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.
Aircraft
- Registration
- N9474E
- Reported as
- Cessna 182R
- Category
- Airplane
- Serial number
- 18268418
- Airframe hours
- 3,843
- Engine
- Continental O-470-U, 2,320 horsepower, reciprocating
- Damage
- Destroyed
- Flight
- Personal · Part 91
- Registered owner
- Civil Air Patrol Inc.
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · October 1, 2004 · 76.6 hours before
- Departed
- KMLU · Monroe, LA
- Destination
- KMLU
- Flight plan
- IFR
- Airport
- KMLU · Monroe Regional Airport, runway 22, 7,500 × 150 ft
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew · 2
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 54
- Injuries
- Fatal
- Certificate
- Commercial
- Airplane ratings
- Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 2, With waivers/limitations
- Last flight review
- March 1, 2004
- Seat
- Left
- Toxicology
- Performed
- Flight hours
- 1,225 total · 37 in the last 90 days · 7 in the last 30 days · 1 in the last 24 hours
- Role
- Pilot
- Age
- 80
- Injuries
- Fatal
- Certificate
- Commercial
- Last flight review
- March 1, 2004
- Seat
- Right
- Flight hours
- 1,350 total
Weather
- Conditions
- Instrument (IMC) · Night/dark
- Wind
- 190° at 8 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- 900 ft overcast
- Temperature
- 64 °F, dew point 63 °F
- Altimeter
- 30.12 inHg
- Observed at
- KMLU, 8 nm away
Docket · 16
The files NTSB released with the investigation on December 20, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.1 MB in all.