# NTSB WPR20LA319: Cessna T182, N157RC, Santa Barbara, CA, September 27, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: September 27, 2020, 07:03 local (14:03 UTC) - Place: Santa Barbara, CA · Pacific Ocean - Coordinates: 34.388, -119.84 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3880&lon=-119.8400&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 102050 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA319 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102050/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102050 - Page: https://openairdocs.org/ntsb/WPR20LA319 ## Probable cause The pilot’s loss of airplane control due to spatial disorientation after entering instrument meteorological conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna T182T, 3 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2072738), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna T182T, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=2072738), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Cessna T182T, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2072738), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Cessna T182T, 22 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072738), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Cessna T182T, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2072738), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute-climb to cruise: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Cessna T182T, 1 case](https://openairdocs.org/ntsb-events/402/sequence.md?model=2072738), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Enroute-climb to cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna T182T, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072738), [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 T182T, 14 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072738), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N157RC-2021-12-04), registration cancelled 2021-12-04, S/N T18208491, built 2006 (OpenAirDocs) - Reported make and model: CESSNA T182 (T) - Registry model: [Cessna T182T](https://openairdocs.org/model/cessna-t182t) (registry code 2072738) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AK1A](https://openairdocs.org/engine/lycoming-tio-540-ak1a) (registry code 42005, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: T18208491 - Year built: 2006 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: fatal; 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 ## 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 20200927016219A](https://openairdocs.org/incident/20200927016219A), Sep 27, 2020: Cessna T182T, Santa Barbara, CA, Destroyed, 1 fatal. Airplane departed runway 15L on an IFR flight plan from Santa Barbara (sba) to truckee-tahoe airport (trk). Aircraft departure control and turned to a heading… ## Docket (16 files) The files NTSB released with the investigation on October 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102050. 429 MB in all. - Medical factual report (item 1, PDF, 3 pages, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14492409&FileExtension=pdf&FileName=WPR20LA319_MedicalFactualReport-Rel.pdf - Meteorology specialist's factual report (item 2, PDF, 9 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11541747&FileExtension=pdf&FileName=WX_WPR20LA319_Specialists_Factual-Rel.pdf - Air traffic control (item 3, PDF, 6 pages, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14432108&FileExtension=pdf&FileName=ATC%20Specialist%20Report%20WPR20LA319-Rel.pdf - Air traffic control attachment 1 a�� FAA certified ATC radar data (item 4, PPB, 130 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14337541&FileExtension=ppb&FileName=FAA%20ATC%20RADAR%20DATA-Rel.ppb - Air traffic control attachment 2 a�� audio recording of sba tower local control (lc) position (item 5, WAV, 139 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14337659&FileExtension=wav&FileName=N157RC-LC%201-Rel.wav - Air traffic control attachment 3 a�� audio recording of sba elcap (ec) departure control position (item 6, WAV, 120 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14336867&FileExtension=wav&FileName=N157RC-EC%201-Rel.wav - Air traffic control attachment 4 a�� aircraft accident package (item 7, PDF, 48 pages, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14340548&FileExtension=pdf&FileName=ATTACHMENT%204%20-N157RC%20Accident%20Package_Redacted-Rel.pdf - Recorded air traffic control radar data (plot) (item 8, CSV, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14409038&FileExtension=csv&FileName=N157RC-Rel.csv - Summary of findings Textron aviation (item 9, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14359110&FileExtension=pdf&FileName=Summary%20of%20Findings%20Textron%20Aviation_Redacted-Rel.pdf - Witness statements plus fuel receipt (item 10, PDF, 3 pages, 545 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13610926&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - Excerpt airplane log (item 11, PDF, 2 pages, 19.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13610519&FileExtension=pdf&FileName=Eccerpt%20Airplane%20Log_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 1 page, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14403698&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 2 pages, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14406422&FileExtension=pdf&FileName=WPR20LA319%20Wreckage%20Release_Redacted-Rel.pdf - Toxicological report (item 14, PDF, 1 page, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14406872&FileExtension=pdf&FileName=tox%20DNicholson_Redacted-Rel.pdf - Video file (item 15, MP4, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14408845&FileExtension=mp4&FileName=N157RC-Rel.mp4 - Photos (item 16, PDF, 2 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14359575&FileExtension=pdf&FileName=Photos_Redacted-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.