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NTSB investigation record

ERA22FA149

Completed

Cessna 182Q· N182XT

Date
March 9, 2022
Location
Panama City, FL
Conditions
IMC
Record
Published September 20, 2023

Primary finding

Probable cause

The pilot’s deviation from the final approach course during a night instrument approach with low instrument meterological conditions, which resulted in an impact with heavily wooded terrain. Contributing to the accident was the pilot’s decision to continue the approach after being warned of his flightpath deviations and his lack of experience in instrument conditions at night.

Investigator assessment

Analysis narrative

The pilot and passenger departed during the middle of the day for a nearly 7-hour instrument flight rules cross-country flight with one fuel stop. During the fuel stop, the pilot reported to an airport employee that he was trying to time his flight to arrive at the destination between two thunderstorms. The flight departed and entered the destination airport area at night without incident. Air traffic control cleared the pilot for a straight-in instrument landing system approach and advised him that the cloud ceiling was 200 ft above ground level, which was the decision height for the straight-in instrument landing system approach the pilot was about to perform. The pilot told the controller that the airplane was established on the final approach course. However, between the initial approach fix and final approach segment the airplane’s altitude and flightpath showed deviations, and the pilot was cautioned of those deviations by controller. Additionally, the airplane crossed the initial approach fix about 500 ft below the specified crossing altitude and about 700 ft below the expected altitude at the final approach fix. As the airplane continued in the final approach segment, continuous deviations to the left and right of course occurred. The airplane subsequently descended below the decision height for the approach and impacted heavily wooded terrain about 1.55 nautical miles from the runway threshold in a 18°-to-20° descent. The wreckage was highly fragmented, but all major components of the airplane were located in the debris path. No evidence indicated any preimpact mechanical malfunction or failure of the airplane. The evidence also indicated that the engine was producing power at the time of impact. Prior to the accident, the airplane had ongoing autopilot altitude-hold control issues despite several recent maintenance corrective actions. The pilot was aware that the autopilot issue persisted, and he told a friend a few days before the accident flight that he felt comfortable hand flying the airplane during the long cross-country flight. The investigation was unable to determine whether the autopilot was activated during the approach, and testing of the autopilot system could not be performed due to the significant impact damage to the airplane and autopilot components. Furthermore, a safety pilot who had flown with the accident pilot reported that it was typical of the pilot to turn off the autopilot for instrument approaches and hand fly the airplane. Thus, it is likely that the pilot flew the accident approach without the autopilot engaged. The weather observed at the destination airport had deteriorated significantly after the pilot departed for the last leg of the flight, and the weather was worse than the expected forecast conditions. During the approach, the controller advised the pilot of the low ceiling and visibility and advised that other nearby airports were reporting better weather conditions. The pilot responded that he would continue the approach. Review of the weather at the alternate airport for the flight, which was about 25 to 30 minutes away from the planned destination, found that visual flight rules conditions were occurring during the time surrounding the accident. It is likely that had the pilot discontinued the instrument approach and diverted to the alternate airport after the approach had become unstable, and after having been warned of his flightpath deviations, the accident would have been avoided. Review of the pilot’s logbook found that he had logged less than 2 hours of night experience during the 12 months preceding the accident and had logged no night flights in the 90 days before the accident. The pilot had logged 11 instrument approaches in the 6 months that preceded the accident. The pilot’s total actual instrument experience was 32 hours, but only 2.5 hours of this time was logged as night actual instrument experience. In addition, the pilot was disapproved twice when testing for his instrument airplane rating because he had become distracted and lost situational awareness and had a full-scale deflection on the glideslope during an instrument approach. Although the pilot was approved for an instrument rating on his third attempt, he likely did not possess the experience or ability to successfully complete the night instrument approach in low instrument meteorological conditions.

Source record

Factual narrative

According to a customer service employee at RNC, the pilot discussed that he was on his way to Florida and was trying to beat bad weather arriving at the ECP area. The pilot explained that he was trying to arrive between two lines of thunderstorms. The pilot appeared to be checking the weather and filing a flight plan on his personal iPad. According to ForeFlight archived records, the pilot filed an IFR flight plan from RNC to ECP with an alternate of Dothan Regional Airport (DHN), Dothan, Alabama. The flight plan was filed at 1028 eastern standard time (before the first flight leg of the day). The pilot received a standard preflight weather briefing as part of filing the flight plan. No records showed that the pilot received additional weather briefings later that day. A National Transportation Safety Board weather study reviewed National Weather Service forecast and observation data for ECP and surrounding airports. The weather at ECP at 1453 (while the pilot was on the ground at RNC) indicated the following: wind from 140° at 11 knots gusting to 19 knots, 7-statute mile visibility, and a broken ceiling at 1,800 ft agl. An AIRMET for IFR conditions was valid for the accident site at the accident time. The terminal aerodrome forecast issued for ECP at 1140 called for, between 1500 and 2000, visibility greater than 6 statute miles, scattered clouds at 2,500 ft, and broken clouds at 25,000 ft. At 2000, the forecast called for a visibility of 6 statute miles, mist, and overcast ceilings at 400 ft agl. At 1721, while the airplane was en route from RNC to ECP, another terminal aerodrome forecast was issued for ECP. The forecast called for, at 2000, a visibility of 1 statute mile, mist, and overcast ceilings at 500 ft agl. The ECP hourly weather observations showed that about 1700, IFR conditions were reported that continued to deteriorate throughout the evening. At 1756, about 45 minutes before the pilot’s approach into ECP, the weather conditions were visibility 4 statute miles, mist, ceiling broken at 400 ft agl, overcast at 800 ft agl; the remarks section indicated that the ceiling was variable from 300 to 700 ft agl. A special hourly weather observation, which was issued at 1827, indicated a visibility of 2 statute miles, mist, and an overcast ceiling at 300 ft agl; the remarks section indicated the ceiling was variable from 200 ft to 700 ft agl. The pilot’s alternate airport DHN, was about 60 nautical miles north of ECP, about a 25- to 30-minute diversion. The pilot’s route of flight from RNC to ECP resulted in the airplane passing about 28 miles west of DHN about 1815 (31 minutes before the accident occurred). The weather observations at DHN starting at 1753 included visual meteorological conditions with calm wind. Review of satellite imagery and model soundings found that an overcast cloud layer likely extended up to 3,250 ft msl. Review of astronomical information found that, for the accident area on the day of the accident, the sunset occurred at 1747, and civil twilight ended at 1811. The District Fourteen Medical Examiner, Panama City, Florida, performed an autopsy of the pilot. His cause of death was blunt impact to the head and neck. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected no drugs, carboxyhemoglobin, ethanol, or glucose in the pilot’s specimens. According to maintenance records and interviews with individuals who had spoken with the pilot before the accident flight, the airplane had a persistent autopilot problem. The autopilot, when engaged and selected to altitude hold mode (ALT HOLD), would begin an altitude oscillation that would eventually reach 1,500 ft per minute in climbs and descents. Disengaging the autopilot had not been an issue. Maintenance records showed autopilot discrepancies and corrective actions from October 2020 to January 21, 2022. The maintenance shop that worked on the autopilot thought that the issue had been corrected, and, on January 31, 2022, the pilot departed with his airplane. The oscillations still persisted, so the pilot brought his airplane back to the maintenance shop on February 14, 2022. The airport manager at IKW spoke with the pilot 3 days before the accident. She stated that, according to the pilot, he was “chasing an autopilot issue” that was still not fixed. She also stated that the pilot had indicated that he would be completing his planned trip to ECP without the autopilot operating. In addition to the original autopilot altitude porpoise issue, the pilot reported that he had performed autopilot/trim system troubleshooting, but he did not describe the specific actions he took to the maintenance shop manager. The pilot indicated that the programmer/computer for the autopilot displayed a fault but that the manual elevator trim wheel operation was normal. The pilot did not have an appointment for service, and the shop could not evaluate the airplane at that time; thus, the pilot decided to return to the shop at a later time. No record indicated any maintenance performed after January 2022. According to a friend of the pilot who spoke with him 3 days before the accident, the pilot stated that he was going to fly to Florida as soon as his airplane was fixed. The friend asked the pilot, “are you comfortable flying without autopilot and single pilot that far?” The pilot responded, “yeah I’ll be fine.” Review of the pilot’s logbook revealed that he had accumulated 691 hours of total flight time, of which 569 hours were in the accident airplane. He had logged a total of 35 hours of night flight experience and a total of 2.5 hours of night actual instrument flight experience. During the 12 months that preceded the accident, he had logged 13 hours of actual instrument experience; 1.5 hours of night flight experience, 0.5 hours of which was in actual instrument experience; and four night landings. During the 6 months before the accident, the pilot logged 11 instrument approaches. During the 90 days preceding the accident, he logged 51.3 hours of actual instrument flight experience and no night flights. His most recent flight review was competed on June 14, 2021. There was no record indicating that the pilot had landed at ECP within the 3 years before the accident. The pilot received his instrument airplane rating on June 27, 2019, on the third practical examination attempt. The pilot received a notice of disapproval during two separate practical examination flights (in May and early June 2019). The comments on the first notice of disapproval indicated that the pilot became distracted, lost situational awareness, and improperly managed tasks during partial panel operations. The comments on the second notice of disapproval indicated that the pilot had flown an ILS approach to a full-scale deflection on the glideslope. According to an individual who had flown with the pilot as a safety pilot during instrument training, the pilot would typically disengage the autopilot and hand fly approaches. On March 8, 2022, about 1846 central standard time, a Cessna 182Q airplane, N182XT, was destroyed when it was involved in an accident near Northwest Florida Beaches International Airport (ECP), Panama City, Florida. The private pilot and passenger were fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to a family member, the pilot and passenger (his wife) planned a cross-country flight departing from their home airport, Jack Barstow Airport (IKW), Midland, Michigan, with a final destination of Panama City, Florida. Review of Federal Aviation Administration (FAA) Automatic Dependent Surveillance–Broadcast (ADS-B) data revealed that the pilot completed a 10-minute local flight at IKW that concluded about 1118 (1018 eastern standard time). The pilot then initiated an instrument flight rules (IFR) cross-country flig

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