WPR20LA319

NTSB accident investigation · Cessna T182 · Santa Barbara, CA · September 27, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
September 27, 2020, 07:03 local (14:03 UTC)
Place
Santa Barbara, CA · Pacific Ocean
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N157RCCessna T182
Defining event
Enroute-climb to cruise: VFR encounter with IMC
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Textron Aviation, Federal Aviation Administration
FAA report
20200927016219A
Case key
102050

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s loss of airplane control due to spatial disorientation after entering instrument meteorological conditions.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Effect on personnelCessna T182T: 1 caseAll aircraft: 108 cases
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna T182T: 1 caseAll aircraft: 1,269 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot departed about 10 minutes after sunrise for the cross-country flight destined for her home airport. As instructed by air traffic control (ATC), she departed on a westbound heading over the Pacific Ocean. About 1 minute after departure, at an altitude of 1,300 ft mean sea level (msl), the pilot acknowledged ATC instructions to turn right to a heading of 255° and climb to 8,000 ft. The pilot acknowledged the instruction, and radar data indicated the airplane initiated a turn to the right (west), followed by a turn to the north and a rapid descent to the water. Examination of the airframe did not reveal any anomalies that would have precluded normal operation. Although the engine was not recovered, the damage to the airframe was consistent with a high-speed impact. The closest weather reporting station, located about 33 miles east-southeast of the accident location reported visibility of 7 statute miles and an overcast ceiling of 1,400 ft about 12 minutes before the accident. Additionally, an airman's meteorological information (AIRMET) for instrument flight rules conditions in mist and fog was active for the accident location and pilot reports (made in the area within a few hours of the accident) included references to instrument meteorological conditions (IMC) between 1,400 and 2,000 ft. As the airplane began its turn to the west, the low sun angle and mist would have restricted forward visibility and identification of a visual horizon while operating over the ocean, and it is likely that the airplane entered IMC during the turn. The recorded radar data (showing the turn continuing beyond the assigned heading, tightening, and being accompanied by a rapid descent) were consistent with the pilot experiencing the effects of spatial disorientation. Toxicology testing on the pilot revealed ethanol in postmortem cavity blood and spleen tissue; ethanol was not detected in urine, which is a specimen type that is generally less susceptible to postmortem microbial contamination and ethanol production. Although postmortem microbial activity does not always produce ethanol, in this case, the absence of ethanol in urine indicates that the ethanol detected in other specimen types did not likely come from ethanol consumption. Thus, ethanol was not likely a factor in the accident.

Factual narrative

On September 27, 2020, at 0703 Pacific daylight time (PDT), a Cessna T182T airplane, N157RC, was destroyed when it was involved in an accident near Santa Barbara, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed Santa Barbara Municipal Airport (SBA), Santa Barbara, California, for a cross-country flight to Truckee-Tahoe Airport (TRK), Truckee, California. According to radar data and voice communications provided by the Federal Aviation Administration, about 0701, the pilot contacted SBA tower requesting departure instructions. The local controller issued the pilot the wind information and a takeoff clearance from runway 15L. The pilot acknowledged the instructions. When the airplane was approximately 0.5 nautical miles (nm) off the departure end of runway 15L, over the Pacific Ocean headed southbound, and at an altitude about 700 feet mean sea level (msl), the local controller instructed the pilot to contact departure control. The pilot acknowledged the instructions. About 0702, as the airplane was at an altitude of 1,000 ft msl, the pilot contacted departure control. The departure controller established radar contact and instructed the pilot to turn right heading 255° and climb to 8,000 ft. The pilot acknowledged the instruction, and radar data indicated the airplane was at an altitude of 1,300 ft msl when a turn to the right (west) was initiated, followed by a turn to the north and a rapid descent. About 0703, radar contact was lost, and the departure controller attempted to contact the pilot. No further transmissions were received from the pilot. The Los Angeles County Sheriff’s Department Dive Unit located the pilot and airplane wreckage at a depth of approximately 200 ft on Thursday, October 1, 2020. The wreckage was recovered and examined at a secure facility. The examination revealed the fuselage and wings were separated into multiple segments and highly compressed. Aileron control continuity was established from each flight control surface to the wing root where the cables were separated from tension overload. The cabin section of the aileron control cable system was not recovered. Elevator and rudder control continuity was established from the control surfaces to where the aft fuselage section was separated. The aileron control yokes, rudder pedals, firewall instrument panel and engine were not recovered. The fuel selector was observed in the BOTH position and both wing fuel tanks were breached. According to fuel receipts provided by personnel at SBA, the pilot purchased 40 gallons of 100LL fuel on the morning of the accident. The closest weather reporting station was an automated surface observing system (ASOS) located at Oxnard Airport (OXR), about 33 miles east-southeast of the accident location. At 0651 PDT, the OXR ASOS reported wind from 060° at 4 knots, visibility of 7 statute miles, ceiling overcast at 1,400 ft, temperature19° Celsius (C), dew point 17°C, and altimeter setting of 29.87 inches of mercury. At the time of the accident, an airman's meteorological information (AIRMET) for instrument flight rules conditions in mist and fog was active for the accident location. Additionally, pilot reports made in the Los Angeles area within a few hours of the accident included references to instrument meteorological conditions between 1,400 and 2,000 ft. According to the National Ocean and Atmospheric Administration, sunrise occurred at the accident location at 0651. At the time of the accident, the sun was about 1.9º above the horizon at an azimuth of 93º. An autopsy of the pilot was performed by the Santa Barbara County Coroner, which listed the cause of death as “multiple traumatic injuries.” At the request of the coroner, Ascertain Forensics performed postmortem toxicological testing of spleen tissue from the pilot. This testing detected ethanol at 0.05 g/dL, and presumptively identified (without confirmation) ß phenylethylamine. Toxicology testing performed at the FAA Forensic Sciences Laboratory detected ethanol at 0.024 g/dL in cavity blood and did not detect ethanol in urine (less than 0.001 g/dL). Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. However, consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can be produced by microbes in a person’s body after death. ß-phenylethylamine is another substance that can be produced by microbes in a person’s body after death. The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

Aircraft

Registration
N157RC
Reported as
Cessna T182 (T)
Category
Airplane
Serial number
T18208491
Built
2006
Engine
Lycoming TIO-540-AKIA, 350 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
None
Destination
TRK · Truckee, CA
Flight plan
IFR
Airport
SBA · Santa Barbara Municipal Airport

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Toxicology
Performed

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 4 knots
Visibility
7 statute miles
Lowest ceiling
1,400 ft overcast
Temperature
19 °F, dew point 17 °F
Altimeter
29.87 inHg
Observed at
OXR, 34 nm away

Docket · 16

The files NTSB released with the investigation on October 26, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 429 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.