CEN16FA042

The pilot's continued visual flight into instrument meteorological conditions, which resulted in spatial disorientation and a loss of control.

The instrument rated pilot did not receive a weather briefing nor file a flight plan prior to departing on a VFR cross-country flight. Radar data showed that the airplane proceeded west on course after departure. As the airplane neared a north/south-oriented mountain range, it deviated from the direct course to the destination, turning to the southwest and then to the north. Overlaying the airplane's flight path on a weather radar image showed that the airplane began the deviation as it approached an area of precipitation. Additionally, photographs taken by a passenger during the flight indicated that the airplane was flying above a solid overcast. As the airplane flew north parallel to the eastern slope of the mountain range, the pilot contacted the destination airport's air traffic control tower and reported that he was descending out of 13,000 ft, that he was between cloud layers, and that he wanted to perform an instrument landing system approach to the airport . He reported being 5 miles east of the airport; however, radar data indicated that the airplane was about 25 miles east and on the other side of the mountain range from the destination airport. The pilot then said the situation was "pretty hairy . . . I can see the ground . . . I'm just trying to maintain visibility right now," and, a few minutes later, "we are really having a tough time trying to get out of this [*mess]." Radio contact was lost shortly thereafter. Radar data indicated an erratic flight path and a varying groundspeed during the last 4 minutes of the flight. Radar contact was lost, and the airplane impacted heavily wooded mountainous terrain in a near vertical attitude. Examination of the wreckage revealed no evidence of any anomalies that would have precluded normal operation of the airplane. In addition to the precipitation indicated by the weather radar imagery, satellite imagery showed cloud cover over the accident area with tops about 28,000 ft. The weather imagery, the pilot's statements, the erratic flight path, and the airplane's impact attitude are consistent with the airplane entering instrument meteorological conditions and the pilot developing spatial disorientation and losing control. Toxicological testing revealed 0.326 (ug.mL, ug/g) sertraline, a prescription antidepressant, in the pilot's heart blood and desmethylsertraline, a metabolite of sertraline, in the pilot's liver and heart blood. The pilot's medical records indicated that he was being treated for depression with sertraline, and, several months before the accident, the pilot's health care provider noted that the pilot's depression was well controlled.. Therefore, it is unlikely that effects from the pilot's depression or use of sertraline contributed to the accident.

The Office of the Medical Examiner, University of New Mexico Health Sciences Center, in Albuquerque performed an autopsy on the pilot. According to the autopsy report, the pilot's cause of death was blunt trauma. No significant natural disease was identified by autopsy. The FAA's Bioaeronautical Sciences Research Laboratory in Oklahoma City, Oklahoma, conducted toxicology tests on samples from the pilot. According to the toxicology report, no carbon monoxide was detected in cavity blood, and no ethanol was detected in vitreous. Cyanide testing was not performed. An unknown quantity of sertraline was detected in the liver, and 0.326 (ug ml, ug/g) sertraline was detected in heart blood. Desmethylsertraline was detected in the liver and heart blood. According to FAA's forensic toxicology drug web page, sertraline (Zoloft®) is a prescription antidepressant used for a variety of conditions including depression, obsessive compulsive disorder, panic attacks, posttraumatic stress disorder, and social anxiety disorder. Sertraline is not generally considered to be impairing, although it carries a warning about performance. Desmethylsertraline is the predominant active metabolite of sertraline. and is substantially less active than sertraline. It was learned that the Veterans Administration Hospital in Wichita Falls had prescribed the drug to the pilot for the treatment of his depression. NTSB's medical officer reviewed the pilot's medical file. According to her report, "The 35 year old male pilot had reported no medical problems and no medications to the FAA. According to the autopsy performed by the University of New Mexico, Office of the Medical Investigator, the cause of death was blunt trauma and the manner of death was accident. No significant natural disease was identified by autopsy. The pilot's personal records revealed a history of cervical spine surgery and major depression treated with sertraline around the time of the accident. Toxicology testing identified sertraline and its metabolite desmethylsertraline in liver and heart blood. The level of sertraline in the heart blood was 0.326 ug/ml. Sertraline is not generally considered to be impairing, although it carries a warning about performance. A few months before the accident, the pilot's health care provider felt his depression was well controlled." The following Meteorological Terminal Aviation Routine Weather Report (METAR) was recorded at KABQ at 1252: Wind, 290° at 21 knots, gusts to 27 knots; visibility, 10 miles; sky condition, few clouds at 500 ft, 4,100 ft broken, 11,000 ft overcast; temperature, 4° C.; dew point, -1° C.; altimeter setting, 29.62 inches of mercury; remarks: site is automated and has a precipitation sensor, peak wind 260° at 36 knots at 1200, rain ended at 1223, sea level pressure 1010 millibars, mountains obscured northeast through southeast. The following METAR was recorded at KAEG at 1235: Wind, 260° at 20 knots, gusts to 32 knots; visibility, 2-1/2 miles, snow; sky condition, few clouds at 1,500 ft, 4,200 ft scattered, 5,000 ft broken; temperature, 3° C.; dew point, -2° C.; altimeter setting, 29.61 inches of mercury. Geostationary Operational Environmental Satellite (GOES)-15 visible and infrared imagery from 1300 was reviewed. The GOES-15 visible imagery identified cloudy conditions over the accident location, and the infrared cloud-top temperatures were about -39°C over the accident site, which corresponded to a cloud-top height of about 28,000 ft. The cloud-top temperatures varied in the region, with some satellite-derived temperatures reaching 0°C, suggesting cloud top heights from near ground level to 28,000 ft (or possibly below higher tops of terrain in the Albuquerque region). A regional weather radar composite reflectivity mosaic at 1300 showed a wide area of light precipitation over the accident region. Overlaying the airplane's flight path on a weather radar image from 1259:22 showed that the airplane began to deviate from its west course as it approached the area of precipitation. The rear seat passenger took cell phone photos while en route, and sent them to friends in Wichita Falls before the accident. Two of those photos were obtained from KOB-TV, Albuquerque. It could not be determined where the airplane was when the photographs were taken. The first photo showed the airplane flying in VFR conditions but there were clouds in the distance. The second photo showed the airplane flying over a solid overcast. The pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument ratings, and a second class airman medical certificate with no restriction or limitations. He also held a mechanic's certificate with airplane and powerplants ratings and an inspector authorization. The pilot was a former U.S. Marine Corps aviation mechanic. A review of the pilot's logbook revealed entries from October 8, 2008, to September 28, 2015. According to the logbook, the pilot had logged the following flight hours: Total Time: 700.1 Pilot-in-Command: 648.8 Dual Instruction: 60.5 Cessna 182G: 33.3 Airplane Single Engine Land: 498.3 Airplane Multiengine Land: 205.2 Cross-country: 577.4 Night: 95.6 Actual Instruments: 45.0 Simulated Instruments: 75.6 Instrument Approaches: 79 The pilot had logged only one biennial flight review, which occurred on February 16, 2011. Between May 13, 2015, and the day of the accident, in addition to 45 hours of flight in actual instrument conditions, the pilot had logged 11 instrument approaches. The on-scene wreckage examination was conducted on November 17, 2015. The airplane had impacted heavily wooded mountainous terrain intact. Ground scars and damage to the airplane were consistent with an acute nose-down (about 90°) impact attitude, and the airplane came to rest in a near vertical attitude. The top of a nearby tree was severed, and branches were scattered around on the ground. Between the rear cabin and the empennage, the fuselage was buckled forward about 30°. All major airplane components were located and identified. Flight control continuity was established. Both the left and right wing leading edges displayed accordion-type crush damage. The fuel selector faceplate indicated that the right main tank had been selected. Due to the position of the airplane and the snow, the engine was not examined on site. Examination of the flight instruments revealed the following: Altimeter: 1,980 ft Kollsman window: 29.90 inches of mercury Tachometer: 850 rpm Recorder: 4,969.98 hours Directional gyro: 074° Clock: 1023 Examination of the lower left switch panel revealed the following: Master switch: On Ignition switch: Left magneto Standby vacuum: Off Pitot heat: Off Navigation lights: Off Rotating beacon: On The airplane, serial number 182-55540, was manufactured by the Cessna Aircraft Company (now Textron Aviation) in 1964. It was equipped with a 275-horsepower Continental/P. Ponk O-470-50 engine, driving a 3-blade, all metal, constant speed Hartzell PHC-G3YF-1RF propeller. According to the bill of sale, the airplane was purchased by Moore Aviation on August 1, 2013. Aircraft maintenance records revealed that the last annual inspection was completed on June 19, 2015, at a tachometer and airframe total time of 4,926.76 hours. On that date, the engine, which had accrued 3,145 total hours, was overhauled and converted from a Continental IO-520-E to a Continental/P. Ponk O-470-50. At the accident site, the tachometer read 4,969.98 hours. The last pitot-static system, altimeter, and transponder-encoder checks were conducted on September 6, 2012, at a tachometer reading of 4,870.13 hours. On November 16, 2015, at 1259 mountain standard time (mst), a Cessna 182G, N2440R, impacted wooded mountainous terrain in Sandia Park, New Mexico. The commercial pilot and the two passengers were fatally injured. The airplane was destroyed. Th