Thursday, March 8, 2018

Cessna 182T Skylane, N784CP: Fatal accident occurred February 01, 2016 near Mobile Regional Airport (KMOB), Alabama

 2nd Lt. Phil J. Dryden of Gulf Shores, Alabama

Maj. David R. Mauritson of Fairhope, Alabama


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Vestavia Hills, Alabama
Lycoming; Williamsport, Pennsylvania 
Textron Aviation; Wichita, Kansas
Civil Air Patrol; Montgomery, Alabama 

Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N784CP

Location: Mobile, AL
Accident Number: ERA16FA100
Date & Time: 02/01/2016, 1945 CST
Registration: N784CP
Aircraft: CESSNA 182
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Positioning 

Analysis 

The airline transport pilot and non-instrument-rated private pilot were conducting a three-leg Civil Air Patrol (CAP) "compassion flight" to transport a passenger from Florida to Louisiana. The pilots departed the CAP squadron's home base in Alabama and flew to Florida, where they encountered a 2 1/2-hour delay while waiting for the passenger to arrive. After picking up the passenger, they subsequently transported her to her destination in Louisiana. The pilots then departed on the 1-hour return flight in dark night conditions to their home base, where a squadron meeting was scheduled for that evening. All three flights were conducted under instrument flight rules (IFR).

During the accident flight, the weather at the destination airport deteriorated from visual meteorological conditions to instrument meteorological conditions, with low cloud ceilings, reduced visibility, and fog; these conditions had been forecasted to develop. The mission pilot should have been aware of both the forecast and actual weather conditions, as he had received an electronic weather briefing, filed an IFR flight plan, and had filed an alternate destination in the event of poor weather at the intended destination. However, the airport the pilot selected as an alternate was located only 10 nautical miles northwest of the destination airport and was affected by the same weather conditions; both airports reported 1/2 statute miles visibility and vertical visibility about 200 ft about the time of the accident.

As the flight approached the destination, the pilot elected to divert to the alternate airport and received vectors for an instrument landing system (ILS) precision approach. The investigation was unable to determine why the pilot chose to divert. About 300 ft agl (100 ft above the decision height where the runway environment must be visible), the pilot initiated a missed approach procedure. Radar data showed that, rather than completing the prescribed climb to 2,000 ft on runway heading, the airplane entered a shallow right turn and continued to descend until radar contact was lost. The airplane impacted trees and terrain and was destroyed by a postcrash fire. Examination of the airplane and its systems identified no engine, airframe, or avionics anomalies that would have precluded normal operation. Additionally, no medical factors were identified that could explain the sequence of events.

CAP required that all flight activities obtain a flight release before departure. As part of the flight release process, pilots were required to consult with a flight release officer (FRO), who in part ensured the pilot was qualified in the airplane and met currency requirements and input the route of flight into an electronic log system. A CAP member could become qualified as an FRO by completing a one-time online course; they were not required to be rated pilots, FROs were not required to flight follow a flight, and were not responsible for the actual conduct of the flight. The FRO who released the accident flight had a phone conversation with the pilot before the first leg of the trip to cover all three legs. They discussed the pilot's health and readiness to fly, the clouds at altitude that would require the pilot to file an IFR flight plan on each leg and assessed that the operational risk management for the flights was low.

While the risk assessment completed on the morning of the accident may have been accurate at that time, the delay encountered in picking up the passenger resulted in a significant change in the circumstances of the flight, introducing the risk factors of deteriorating weather conditions at the destination, a longer duty day, and the pressure to return in time for the squadron meeting. It could not be determined whether the pilot completed a risk assessment specifically for the accident flight taking these factors into account, but even if he had, he was not required to discuss the risk assessment with the FRO or otherwise obtain explicit approval to depart on the accident flight.

The pilot's alternate airport choice was likely one of convenience rather than one that was chosen with operational considerations in mind. Additionally, the selected alternate did not meet the legal minimum weather requirements to be filed as an alternate. At the time of departure, the airplane had about 5 hours of fuel onboard, well in excess of IFR-required fuel reserves. This gave the pilot the flexibility of selecting other alternate airports that may have been farther away but were experiencing better weather conditions. A witness at the departure airport stated that, although the pilots had expressed some concern about the weather conditions before departing, they indicated that they wanted to return before conditions deteriorated and so that they could attend their squadron meeting. It is likely that the pilot was affected by "get-there-itis" as he made the decision to continue to his planned destination even though there were choices available that were significantly less risky, such as staying overnight and completing the flight the next morning or diverting to an airport that was not affected by the widespread coastal fog at the destination and alternate airports.

The pilot's logbooks were not recovered and his total instrument experience, recency of experience, and experience in the accident airplane could not be determined.. The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion. During this illusion, the vestibular system indicates a climb even though, in fact, the airplane is level. The sensation typically occurs when there are few visual cues (flying away from an airport at night in poor weather) and the airplane is accelerating, such as during a missed approach. Because a somatogravic illusion occurs within the vestibular system and antihistamines may affect the functioning of the vestibular system, it is possible that the pilot's use of doxylamine contributed to the illusion; however, without a blood level to indicate the amount of the drug remaining in the pilot's system, whether it contributed to the accident could not be determined.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's loss of airplane control during a missed approach in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot's inadequate preflight and inflight weather planning which resulted the pilot's selection of an unsuitable alternate airport, and the Civil Air Patrol's inadequate flight release procedures and inadequate oversight of the flight.

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Spatial disorientation - Pilot (Cause)
Weather planning - Pilot (Factor)
Decision making/judgment - Pilot (Factor)

Environmental issues
Ceiling/visibility/precip - Effect on operation (Cause)

Organizational issues
Oversight of operation - Operator (Factor)

Factual Information

History of Flight

Prior to flight
Preflight or dispatch event

Approach-IFR final approach
Other weather encounter

Approach-IFR missed approach
Loss of control in flight (Defining event)
Collision with terr/obj (non-CFIT)

On February 1, 2016, about 1945 central standard time, a Cessna 182T, N784CP, was destroyed when it impacted trees and terrain during a missed approach to Mobile Regional Airport (MOB), Mobile, Alabama. The air line transport pilot and private pilot were fatally injured. The airplane was registered to and operated by the Civil Air Patrol (CAP) under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Dark night instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the positioning flight, which departed from Louisiana Regional Airport (L38), Gonzales, Louisiana, about 1830, and was destined for Mobile Downtown Airport (BFM), Mobile, Alabama.

The accident flight was the final leg of a 300-nautical mile (nm), three-leg "compassion flight;" the purpose of the flight was to transport a passenger from Florida to her home in Louisiana. The pilots departed BFM about 0930 on the day of the accident and flew to Northwest Florida Beaches International Airport (ECP), Panama City Florida. While at ECP, the pilot contacted the flight release officer (FRO) to inform him that their departure would be delayed about 2 1/2 hours due to a problem with the airplane that was delivering the passenger to ECP. After the passenger arrived, the flight departed ECP for L38 about 1500.

According to the owner of the fixed base operator (FBO) at L38, who was also a CAP member, he saw the pilots in the lobby of his FBO. Noting that they were in CAP uniforms, he introduced himself, asked where they were from and their purpose at L38, and learned they were from Mobile, Alabama. About 1 hour earlier, the FBO owner had returned from a flight along the southeastern coast of Louisiana. He told the accident pilots that he had encountered several patches of sea fog moving inland from the coastal area between the mouth of the Mississippi River and Galliano, Louisiana. He noted it was unusual weather for Louisiana; most of the area was clear with visibility greater than 10 statute miles (sm), and the fog he encountered was very low to the ground with tops about 600 ft above ground level (agl) with no other associated weather. He described the fog patches as "wooly blankets" slowly moving across the ground.

The FBO owner was concerned about the accident pilots flying at night given the potential for fog and offered them a courtesy car and assistance with obtaining accommodations for the night. The crew acknowledged his concern about the weather but wanted to return to BFM in time for their CAP meeting and before the fog set in. At 1833, the flight which was operating under the call sign "CAP 184," departed L38, contacted air traffic control (ATC), and was issued an instrument flight rules clearance to BFM.

About 1924, the pilot indicated to ATC that he wanted to change the flight's destination to MOB. ATC cleared the flight to MOB and issued the flight incremental descents from its cruise altitude.

About 1931, the approach controller verified that the pilot had received the current weather conditions at MOB. About 1935, the controller issued the airplane a right turn to intercept the localizer course and cleared the flight for the ILS RWY 15 approach.

At 1936, the approach controller issued alternate missed approach instructions to climb to 2,000 ft and maintain runway heading. The pilot acknowledged, and the controller subsequently instructed the pilot to contact the MOB tower controller. The pilot checked in with the tower controller, who issued the runway visual range (RVR) for runway 15 and cleared the flight for landing. The pilot acknowledged, and the tower controller issued the wind conditions and updated runway 15 RVR.

At 1937, the approach controller advised the tower controller that the pilot had been assigned to fly runway heading in case of a missed approach, and stated that, "he sounds a little shaken so just be careful with him."

At 1944, the pilot declared a missed approach. Radar data indicated the airplane was at an altitude of about 500 ft msl, (300 ft agl) about that time and had begun a slight right turn away from the localizer course. The tower instructed the pilot to maintain 2,000 ft and verified that the flight had been instructed to fly runway heading in the event of a missed approach. The pilot responded, "affirmative." The tower controller subsequently noticed that the airplane was not climbing and reissued instructions to climb to 2,000 ft; the pilot acknowledged; no further transmissions were received from the accident airplane. The airplane continued the right turn and descended to an altitude about 300 ft msl (about 100 ft agl), then climbed to 400 ft msl. The final radar return, at 1944:45, showed the airplane about 300 ft msl.

At 1945, the tower controller informed the approach controller that radar contact with the airplane was lost.

An airline pilot reported that he was operating a "turn" into and out of MOB on the night of the accident. He stated that MOB was under visual conditions when his flight landed; however, during the 23 minutes his airplane was at MOB before its subsequent departure, conditions deteriorated to about 2,000 ft RVR. His flight was cleared to taxi to the runway without visual contact from the tower, and visibility was between 2,000 and 2,400 ft when the flight departed runway 15. After departure, he reported to the control tower that the top of the fog layer was 500 ft msl, above which were visual conditions.

After contacting the departure controller, he could hear CAP 184 being vectored for the ILS 15 approach at MOB. Reaching 10,000 ft, he elected to monitor the approach/tower frequency to listen to CAP 184. He monitored every radio transmission up to the missed approach by CAP 184, followed by several short static transmissions on the tower frequency. 

Pilot Information

Certificate: Airline Transport; Flight Instructor; Commercial
Age: 67, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Glider; Gyroplane; Helicopter
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Glider; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 10/14/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 06/29/2015
Flight Time: (Estimated) 11000 hours (Total, all aircraft) 

Other Flight Crew Information

Certificate: Private
Age: 66, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 11/05/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 80 hours (Total, all aircraft) 

Composition of CAP aircrew varied in number and qualifications depending upon the assignment. A typical aircrew was made up of a mission pilot, mission observer, and mission scanner.

According to CAP, both pilots were members of the Alabama Wing's Mobile Composite Squadron. The airline transport pilot was acting as the mission pilot (pilot-in-command), and the private pilot was acting as mission scanner (additional crew member).

Mission Pilot

According to Federal Aviation Administration (FAA) and CAP records, the 67-year-old mission pilot held an airline transport pilot certificate with a rating for airplane multiengine land, with commercial privileges for airplane single-engine land and sea, airplane multiengine sea, rotorcraft helicopter, rotorcraft gyroplane, and glider. He also held a flight instructor certificate with ratings for airplane single- and multiengine, instrument airplane, rotorcraft helicopter, rotorcraft gyroplane, and glider. Additionally, he held a ground instructor certificate with a rating for ground instructor instrument.

He joined CAP in September 1991 and held the rank of major. He was qualified as a CAP examiner, check pilot, instructor, command pilot, and tow pilot, and was qualified to operate several models of airplanes within CAP. His most recent application for an FAA second-class medical certificate was dated October 14, 2015, with a restriction to have available glasses for near vision. Records indicated that he had accrued about 11,000 total hours of flight experience, about 120 hours of which was in the previous 6 months. The pilot's logbooks were not recovered for review.

Mission Scanner

According to FAA and CAP records, the mission scanner held a private pilot certificate with a rating for airplane single-engine land. He joined CAP in November 2015 and held the rank of second lieutenant. He was qualified in general emergency services and as a mission scanner. His most recent application for an FAA third-class medical certificate was dated November 5, 2015. Records indicated that he had accrued about 80 total hours of flight experience. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N784CP
Model/Series: 182 T
Aircraft Category: Airplane
Year of Manufacture: 2006
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 18281784
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 11/20/2015, Annual
Certified Max Gross Wt.: 3100 lbs
Time Since Last Inspection: 61 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2082.6 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C126 installed, activated, aided in locating accident
Engine Model/Series: IO-540-AB1A5
Registered Owner: CIVIL AIR PATROL
Rated Power: 230 hp
Operator: CIVIL AIR PATROL
Operating Certificate(s) Held: None 

The accident airplane was a single-engine, high-wing airplane of conventional metal construction. It was powered by a fuel-injected, normally aspirated, air-cooled, six cylinder, 230 horsepower, Lycoming IO-540-AB1A5 engine, driving a three-bladed constant speed McCauley propeller.

Aircraft Information File

According to CAP, the aircraft information file (AIF) was normally carried in the airplane. The AIF contained all applicable inspections, equipment evaluations, and worksheets. The AIF was not recovered from the wreckage and was likely consumed in the postimpact fire. Computerized records provided by CAP indicated that an overhauled engine was installed on October 6, 2015, at 2,000.3 total hours of operation. The most recent annual inspection was completed on November 20, 2015, at 2,021.9 total hours of operation. After the airplane's most recent flight on January 31, 2016, it had accrued 2,082.6 total hours of operation.

Avionics and Flight Instrumentation

The airplane was equipped with a Garmin G1000 avionics suite that comprised of two liquid crystal displays; one acted as the primary flight display (PFD), and the other acted as a multifunction display (MFD). It also included an integrated communications panel mounted between the two displays.

The PFD showed the basic flight instruments, such as the airspeed indicator, altimeter, heading indicator, and course deviation indicator. A small map called the "inset map" could be enabled in the corner. When an instrument approach was loaded and activated, the PFD would display glide slope and localizer information. The PFD could also be used for entering and activating flight plans, and had a "reversionary mode," which was capable of displaying all information shown on the MFD. This capability was provided in case of an MFD failure.

The MFD typically showed a moving map on the right side and engine instrumentation on the left. Most of the other screens in the G1000 system were accessed by turning the knob on the lower right corner of the unit. Screens available from the MFD other than the map included the setup menus, information about nearest airports, navigational aids, Mode S traffic reports, terrain awareness, flight plan programming, GPS RAIM (receiver autonomous integrity monitoring prediction), and XM radio which was capable of providing on-board weather information. Around the time of the accident however, the Alabama Wing had not requested a subscription renewal from CAP Headquarters, so onboard weather, would not have been available from the G1000 system onboard the accident airplane.

A secondary power source would power the G1000 instrumentation for a limited time in the event of a failure of the aircraft's alternator and primary battery. The G1000 integrated cockpit also had a redundant airspeed indicator, altimeter, attitude indicator, and magnetic compass. In the event of a failure of the G1000 instrumentation, these analog backup instruments would become primary.

The airplane was also equipped with a rate-based, Bendix King KAP 140 autopilot, which included a wing leveler, heading select, and VOR/LOC intercept and tracking. It could be coupled to GPS and RNAV. The turn coordinator provided roll rate information, while pitch axis information came from a pressure sensor and accelerometer. Pitch axis features included vertical speed, glideslope and altitude hold along with altitude preselect. The KAP 140 Autopilot System operated independent of other sources, thus retaining roll stabilization and all vertical modes in the event of source failure. Internal monitors would keep track of the KAP 140's status and would automatically shut down the autopilot or trim system in the event of a malfunction.

No recorded flight and engine data was obtained from the G1000 system, as the secure digital (SD) card required to record such data was destroyed in the postcrash fire. 



Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: MOB, 218 ft msl
Observation Time: 0156 UTC
Distance from Accident Site: 2 Nautical Miles
Direction from Accident Site: 180°
Lowest Cloud Condition: Unknown
Temperature/Dew Point: 18°C / 18°C
Lowest Ceiling: Indefinite (V V) / 200 ft agl
Visibility:  1.5 Miles
Wind Speed/Gusts, Direction: 7 knots, 140°
Visibility (RVR):
Altimeter Setting: 29.93 inches Hg
Visibility (RVV):
Precipitation and Obscuration: Moderate - Fog
Departure Point: Gonzales, LA (L38)
Type of Flight Plan Filed: IFR
Destination: Mobile, AL (BFM)
Type of Clearance: IFR
Departure Time: 1830 CST
Type of Airspace: Class C

Synoptic Conditions

The National Weather Service (NWS) Surface Analysis Chart for 1800 depicted a stationary front extending east to west across northern Alabama and Mississippi, into southern Arkansas, into northern Texas, where the front joined into a triple point associated with an occluded front with a low-pressure system at 995-hectopascals (hPa). The resultant pressure pattern resulted in southerly winds of warm, moist air from the Gulf of Mexico streaming into the system. The station model for Mobile, Alabama, indicated wind from the south-southeast at 5 knots, visibility unrestricted, scattered clouds, temperature 67°F, dew point 66°F, and a sea level pressure of 1013.0 hPa. Multiple stations east and west of Mobile were indicating visibility restrictions in fog at the time.

A review of the Low-level Significant Weather Prognostic Chart also indicated that the 12-hour forecast depicted an extensive area of IFR conditions expected over the Gulf coast region.

National Weather Service (NWS) Forecast Discussion

The NWS Area Forecast Discussion, issued at 1610, indicated the onset of dense fog along the coast spreading inland from the shore of Alabama to Northwest Florida through the evening and overnight hours. A dense fog advisory was in effect for coastal areas, including Mobile. The aviation section of the forecast indicated mostly IFR to low IFR (LIFR) ceilings and visibilities through the next morning, with widespread low stratus and fog.

An updated forecast discussion was issued at 1840 indicated that ceilings and visibilities were expected to drop into the LIFR category overnight.

Pilot Reports

At 1644, a pilot flying at 15,000 ft msl about 40 sm southeast of the accident site reported coastal fog along the beach.

Soundings

An upper air sounding from the Slidell, Louisiana, NWS site, located about 85 sm west of the accident site, depicted a moist low-level environment with saturated conditions from 500 ft agl to 6,000 ft with a capping inversion. The freezing level was identified at 14,700 ft. The wind profile indicated calm surface wind with wind from the south-southeast veering to the southwest and west through 18,000 ft. A low-level wind maximum or low-level jet was identified near 5,000 ft at 215° at 25 knots, with winds less than 10 knots below 1,000 ft agl.

Destination Airport Observations

The automated observation at BFM at 1900 included wind from 160° at 6 knots, visibility 1/2 sm in fog, vertical visibility 200 ft agl, temperature and dew point 18°C, altimeter 29.94 inches of mercury (inHg).

Diversion Airport Observations

MOB, the flight's diversion airport, was equipped with an ASOS that was augmented by a certified observer. The following observations were reported surrounding the time of the accident:

At 1856, wind from 130° at 6 knots, visibility 9 sm, a few clouds at 2,800 feet agl, ceiling broken at 6,000 ft, temperature and dew point 18°C, altimeter 29.93 inHg.

At 1909, wind from 130° at 7 knots, visibility 1/2 sm in fog, vertical visibility 200 ft agl, temperature and dew point 18°C, altimeter 29.93 inHg.

At 1956, wind from 140° at 7 knots, visibility 1/2 sm in fog, vertical visibility 200 ft agl, temperature and dew point 18°C, altimeter 29.93 inHg.

MOB Terminal Aerodrome Forecast (TAF)

The MOB TAF that was provided to the pilot through electronic means for preflight planning was issued at 1728. The forecast expected marginal visual flight rules (VFR) conditions to prevail with a southerly wind from 180° at 6 knots, visibility greater than 6 sm, scattered clouds at 400 ft agl, ceiling broken at 1,700 ft, and overcast at 6,000 ft. A temporary condition of LIFR was expected between 2000 and 2400, with visibility 1/2 mile in fog and a broken ceiling at 400 ft agl, with the fog continuing into the morning hours.

The TAF was amended at 1808 for the better, expecting VFR conditions to prevail through 2000, with a temporary period of fog thereafter. The forecast was again amended at 1918, just before the accident, to include LIFR conditions with 1/2-mile visibility in fog and ceiling at 200 ft agl.

A dense fog advisory was valid for MOB from 1610 through the following morning.

Satellite Imagery

The GOES-13 infrared image at 1945 depicted low fog and stratus over the region.

Astronomical Conditions

At the time of the accident, both the sun and moon were more than 15° below the horizon, resulting in dark night conditions. According to the US Naval Observatory Astronomical Applications department, sunset occurred at 1728 and the end of civil twilight occurred at 1753.

Moonrise did not occur until 0119 on the following day. 

Airport Information

Airport: MOBILE RGNL (MOB)
Runway Surface Type: Asphalt
Airport Elevation: 218 ft
Runway Surface Condition: Unknown
Runway Used: 15
IFR Approach: ILS
Runway Length/Width: 8502 ft / 150 ft
VFR Approach/Landing: None 

Destination Airport

BFM was a publicly-owned, tower-controlled airport located 3 miles south of the central business district of Mobile, Alabama, at an elevation of 26 ft msl. The airport was served by a total of 8 instrument approaches, with two runways oriented in a 14/32 and 18/36 configuration. Runway 14/32 was asphalt and concrete. It was grooved and in good condition. The total length was 9,618 ft long and 150 ft wide. It was marked with precision markings in good condition. Runway 32 was equipped with an Instrument Landing System.

Diversion Airport

MOB was a publicly-owned, tower-controlled airport located 10 nautical miles (nm) northwest of BFM at an elevation of 218 ft msl. The airport was equipped with 8 instrument approaches, with two runways oriented in a 15/33 and 18/36 configuration.

Runway 15/33 was asphalt, grooved, and in good condition, measuring 8,502 ft long and 150 ft wide. It was marked with precision markings in good condition. The runway was equipped with a precision approach path indicator, high intensity runway edge lights, and a medium intensity approach lighting system with runway alignment indicator lights. It was equipped with an ILS approach. 



Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  30.678611, -88.263611 

The airplane was found about 1 nm mile west of MOB at 0200 on February 2, 2016, after search personnel tracked the airplane's emergency locator transmitter (ELT) to the accident site.

Examination of the accident site and wreckage revealed that the airplane initially impacted the top of a pine tree about 90 ft agl. The right wing and a section of the left wing came to rest about 50 ft from the base of the pine tree. The debris path was about 150 ft long and was oriented on a magnetic heading about 150°. The main wreckage, which comprised the fuselage, rudder, vertical stabilizer, left horizontal stabilizer, left elevator panel, and a section of the left wing, came to rest on its right side on a magnetic heading about 140°.

A postimpact fire consumed most of the cockpit, cabin, and baggage area. The cockpit, instrument panel, and avionics were destroyed by fire.

The left wing separated between the wing flap and the aileron. The section from the wing root to the separation remained attached to the fuselage. The left wing fuel tank was fire damaged. The entire right wing was separated from the fuselage. The right wing was also separated between the wing flap and the aileron.

The rudder and elevator flight control cables were continuous from their respective cockpit bellcranks to the rudder horn and the elevator rear bellcrank. Aileron control cable continuity was confirmed from the cockpit to each wing flight control surface through several separations that exhibited signatures consistent with tensile overload.

Elevator trim control cable continuity was confirmed from the cockpit to the elevator trim jack location through cable separations that exhibited signatures consistent with tensile overload. The elevator trim control cable was separated from the elevator trim actuator. The elevator trim actuator remained attached to the separated right horizontal stabilizer. The right elevator was separated from the right horizontal stabilizer.

The fuel selector valve was thermally damaged. The left wing fuel tank was thermally damaged. The right wing fuel tank was breached.

The ELT antenna was separated from the fuselage.

The propeller spinner was partially separated but remained attached to the propeller. All three propeller blades remained attached to the hub; the No. 3 blade was loose in the hub. Blade No. 1 was bent aft toward the non-cambered side near the root. Blade No. 2 exhibited S-bending/twisting from its mid-span to the blade tip. About 3 inches of the tip of blade No. 3 was bent aft toward the non-cambered side.

The engine remained attached to the airframe through the tubular mount and lay on its right side. The firewall and the rear-mounted accessories were discolored consistent with exposure to post-impact fire. The exhaust system was partially crushed. The engine was partially disassembled for further examination. The engine was rotated via the vacuum pump drive pad, and continuity of the crankshaft to the rear gears and the valve train was confirmed. Compression, suction, and valve movement were observed from each cylinder. The interiors of the cylinders were observed with a lighted borescope and displayed no anomalies.

The fuel injector servo remained attached to the engine and was impact damaged. The throttle control cable remained attached to the servo throttle arm; the arm was in a position consistent with about 1/3 throttle applied. The mixture control cable remained attached to the servo mixture control arm and was in the full rich position. The cockpit throttle and mixture controls were fire damaged and their positions could not be confirmed.

The servo was removed and partially disassembled. Fuel was observed in the servo. The rubber diaphragms were intact, and the servo fuel inlet screen was free of debris.

The flow divider remained attached to the engine and was undamaged. It was partially disassembled, and the rubber diaphragm was intact. A small amount of fuel was observed in the flow divider.

The fuel injector nozzles remained attached to the engine and displayed no damage. All six nozzles were unobstructed.

The engine-driven fuel pump remained attached to the engine and was discolored consistent with exposure to the postimpact fire. The pump was removed and partially disassembled. The diaphragms and the internal check valves were undamaged.

Liquid with an odor consistent with that of aviation gasoline was observed in the fuel return line from the servo to the firewall.

Both magnetos remained attached to the engine and were fire damaged. The left magneto could not be rotated; the right magneto rotated but produced no spark. The right magneto distributor block cover was removed and the block was melted.

The vacuum pump remained attached to the engine. The drive coupling was melted. The pump was removed and partially disassembled, and the carbon rotor and vanes were intact.

The engine contained oil. The oil suction screen and the oil filter media were absent of metallic debris. The oil cooler and associated hoses were fire damaged. The hoses remained attached to the oil cooler and accessory case. 

Medical And Pathological Information

Mission Pilot

According to the FAA medical case review, the mission pilot reported at his last aviation medical examination high cholesterol and the use of atorvastatin (a cholesterol lowering drug also called Lipitor), as well as regular use of aspirin (an over-the-counter fever and pain medication that can also help prevent heart attacks).

The Alabama Department of Forensic Sciences, Mobile, Alabama, performed an autopsy of the mission pilot; the cause of death was multiple blunt force injuries and the manner of death was accident. In addition to his injuries, the autopsy identified severe coronary artery atherosclerosis with multifocal areas of plaque, including an area of 80% stenosis in the proximal portion of the left anterior descending coronary artery. There was no evidence of scarring from a previous heart attack and the remainder of the heart was unremarkable.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing that identified doxylamine in liver and heart tissue and ibuprofen in liver tissue. Doxylamine is a sedating antihistamine available in many over-the-counter products intended to treat allergies, colds, and as a sleep aid. Ibuprofen is an over-the-counter medication used to treat pain and fevers and is not considered impairing.

Mission Scanner

The Alabama Department of Forensic Sciences, Mobile, Alabama, performed an autopsy the mission scanner the cause of death was multiple blunt force injuries and the manner of death was accident.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma Performed toxicology testing that was negative for carbon monoxide, cyanide, and tested-for drugs, with the exception of amlodipine, a calcium blocker heart medication used in the treatment of hypertension, detected in muscle and liver; diphenhydramine, an over-the-counter (OTC) antihistamine used in the treatment of colds and hay fever, detected in muscle and liver; losartan, used in the treatment of hypertension, detected in liver; and trazodone, a tranquilizer used in the treatment of anxiety disorders, detected in muscle and liver. 

Tests And Research

Mission Information

According to the CAP, the mission pilot and mission scanner had completed the flight on behalf of Mercy Flight Southeast, a non-profit volunteer pilot organization that provided free air transportation to medical facilities for individuals who were financially distressed or unable to travel on public transportation.

At the time of the accident, the use of CAP aircraft in support of flying for organizations like Mercy Flight Southeast was approved on a case-by-case basis. Pilots interested in conducting these flights would coordinate with their wing operations and command staff to accept a specific mission.

The pilots involved in these compassion flights funded all costs (fuel, oil, maintenance, overnight stays if required, etc.) themselves; the pilots could not be reimbursed. CAP allowed any CAP pilot to potentially support these missions, although the organizations for whom the pilot completed these flights may have imposed more restrictive pilot requirements, such as minimum flight experience or possession of an instrument rating. Additionally, at the time of the accident, CAP was in the process of establishing agreements with several organizations to show their support for these flights.

Operational Risk Management

Before each flight, pilots were required to complete a risk assessment form to determine the risk value of a flight based on various factors, such as crew experience, currency, and health; aircraft maintenance and performance factors; mission complexity; and environmental factors, including weather, terrain, and whether the flight was conducted in day or night conditions. Flights determined to be "low risk" could be approved by the flight release officer (FRO); any flights with values above the "low risk" category were required to obtain approval from leadership at either the squadron or wing level, depending on the risk value.

Flight Release Process

At the time of the accident, CAP required that an FAA flight plan be filed and activated for every flight of a CAP aircraft beyond 50 nm from the point of origin. Those flights that were part of a supervised mission could be exempted from this requirement by the mission incident commander (IC) contingent upon alternate flight following procedures.

Flight to destinations outside a wing's boundaries required the authorization of an IC (during supervised missions) or a wing or higher commander, unless permitted under an approved memorandum of understanding.

CAP had two exemptions granted by the FAA for flying non-CAP passengers. This exemption to 14 CFR Parts 61.113 and 91.501 allowed their pilots to obtain reimbursement as a private pilot and provided a tool for CAP to comply with specific FAA requirements regarding transportation flights. Non-CAP passengers, were required to fill out a hold harmless agreement, and the form was required to be left in a secure location on the ground for the Flight Release Officer (FRO) or mission IC.

A flight release was required for all CAP flight activities. The release was made directly between the FRO and the pilot-in-command (PIC) via a personal or telephone conversation before the flight. The FRO was expected to verify appropriate information before giving a flight release, was not required to flight follow a flight unless they desired to and was not responsible for the actual conduct of the flight. The FRO was responsible for confirming that the aircraft safely arrived at its destination. Following the conversation with the PIC, the FRO was required to input the flight into an electronic database (WMIRS).

At the time of the accident, FROs were not required to have flight experience as either a pilot or aircrew member. To become qualified as an FRO, a CAP member was required to complete a one-time online FRO course. Once the training was complete, an automated message would be sent out for a supervisor to approve of the member as an FRO. The FRO was responsible for authorizing a CAP pilot to fly as PIC in CAP aircraft. The release was made directly between the FRO and the PIC. The PIC and the FRO would have a personal or telephone conversation prior to flight release. The FRO was expected to verify appropriate information prior to giving a flight release, was not required to flight follow a flight unless they desired to and was not responsible for the actual conduct of the flight. They were responsible for confirming the aircraft safely arrived at its destination.

Prior to flight, the flight release was required for all CAP flight activities. All flights would be released prior to takeoff using the eFlight Release function in the web mission information reporting system (WMIRS). The only exception was if access to WMIRS was not possible, at which time a CAP Flight Release Log, could be used to temporarily track flight releases and would be accomplished prior to take-off. Flight release log released flights were required to be recorded as eFlight releases in WMIRS within 24 hours unless extenuating circumstances existed.

The FRO of the accident flight (who was not a certificated pilot), stated that he conducted a phone conversation with the pilot before the first leg of the trip to release all three legs of the planned flight. He discussed with the pilot his health and readiness to fly, that the operational risk management was low, and that there was no forecast low weather; although clouds at altitude would require the pilot to file an IFR flight plan on each leg. The FRO entered the flight release into WMIRS at 0643 and had a follow-up phone discussion with the pilot before the first leg, at 0810. He received another phone call from the pilot later that morning; the pilot, who was at ECP, advised that all his subsequent departures and arrivals would be delayed 2 1/2 hours, as the airplane that was delivering the passenger to ECP had arrived late. There was no further communication with the FRO.

Fueling Information

According to fueling records from L38, the pilots added a total of about 52 gallons of fuel to the airplane before departure. According to the mission pilot's filed flight plan information, the airplane had 5 hours of fuel onboard at departure. The estimated flight time from L38 to BFM was 1 hour.

Instrument Landing System

An Instrument Landing System (ILS) is a precision runway approach aid based on two radio beams that together provide both vertical and horizontal guidance during an approach to landing.

An approach may not normally be continued unless the visibility is above a specified minimum. When an approach is flown, the pilot follows the ILS guidance until the decision height (DH) is reached (which in this instance, would have been a Category I standard of 200 ft above the runway threshold elevation). At the DH, the approach may only be continued if the specified visual reference (in this case, a 1/2 statute mile) is available; otherwise, a missed approach must be executed.

Review of the airport information for BFM and MOB indicated that both airports were equipped with ILS approaches. Due to the wind conditions, the ILS at BFM was unusable for a straight-in approach. The other approaches at BFM had a decision altitudes or minimum descent altitudes higher than that of the DH for the ILS.

Alternate Airport Requirements

Lockheed Martin Flight Service records indicated that the mission pilot had filed his IFR flight plan through a Direct User Access Terminal Service (DUATS) vendor. Review of the DUATS data indicated that the mission pilot had filed an alternate for all three of the mission's legs. For the first and second legs, from BFM to ECP, and from ECP to L38, respectively, the mission pilot had filed BFM as the alternate. For the third leg from L38 to BFM, the mission pilot had filed MOB as his alternate.

Title 14 CFR section 91.169 specifies the conditions under which a pilot must include an alternate airport in an IFR flight plan, and the conditions which must be satisfied at an airport for it to be used as an alternate. In summary, the regulation states that an alternate must be selected if, from 1 hour before to 1 hour after the estimated time of arrival, the ceiling is forecast to be less than 2,000 ft agl or the visibility is less than 3 sm.

If the airport selected as an alternate does not have any instrument approaches, the regulation states that at the estimated time of arrival at the alternate you must be able to descend all the way from the minimum enroute altitude (MEA) to the airport under VFR conditions.

If the alternate airport has a precision approach (such as an ILS), then the ceilings must be at least 600 ft agl, and visibility must be at least 2 sm at the estimated time of arrival at the alternate.

If the alternate airport has a non-precision approach (such as a VOR) then ceilings must be at least 800 feet agl, and visibility must be at least 2 sm at the estimated time of arrival at the alternate.

CAP standard operating procedures did not require that pilots adhere to any IFR operational minimums beyond those outlined in 14 CFR Part 91. 

Organizational And Management Information

The Civil Air Patrol (CAP) was founded on December 1, 1941, to protect the nation's shorelines from invading German submarines. Since that time, CAP has evolved into a congressionally chartered, federally supported, non-profit corporation, that conducts emergency service and operational missions in the air and on the ground and serves as the civilian auxiliary of the United States Air Force (USAF).

At the time of the accident, CAP had about 56,000 members, and was flying about 100,000 hours per year in a fleet of 550 aircraft. The organization was headed by CAP National Headquarters, under which there were eight regional commands and 52 wings (one in each of the 50 states plus Washington, D.C. and Puerto Rico). Each wing supervised the individual groups and squadrons that comprised the basic operational units of the organization.

Oversight of Operations

Oversight of CAP was conducted by the Air Force through HQ CAP-USAF, and its subordinate liaison region staff. CAP-USAF monitored CAP operations including CAP's use of aircraft and gliders nationwide. CAP-USAF was also responsible for program management responsibilities established in the Cooperative Agreement between CAP and the USAF, and the associated Statement of Work. These documents established Air Force requirements for CAP's programs and activities, including CAP's flight operations. 

Additional Information

Spatial Disorientation

According to the FAA's General Aviation Joint Steering Committee, a pilot's sight, supported by other senses, allows a pilot to maintain orientation while flying. However, when visibility is restricted (i.e., no visual reference to the horizon or surface detected), the body's supporting senses can conflict with what is seen. When this spatial disorientation occurs, sensory conflicts and optical illusions often make it difficult for a pilot to tell which way is up.
The FAA Airplane Flying Handbook (FAA-H-8083-3) described some hazards associated with flying when visual references, such as the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, 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."

The FAA publication Medical Facts for Pilots (AM-400-03/1), described several vestibular illusions associated with the operation of aircraft in low visibility conditions. Somatogravic illusions, those involving the utricle and saccule of the vestibular system, were generally placed into one of three categories, one of which was "the head-up illusion." According to the text, the head-up illusion involves a forward linear acceleration, such as takeoff, where the pilot perceives that the nose of the aircraft is pitching up. The pilot's response to this illusion would be to push the control yoke forward to pitch the nose of the aircraft down. "A night takeoff from a well-light airport into a totally dark sky (black hole) or a catapult takeoff from an aircraft carrier can also lead to this illusion and could result in a crash."

FAA Advisory Circular AC 60-22, Aeronautical Decision Making, stated, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'" One of the common behavioral traps identified was "Get-There-Itis." The text stated, "Common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action."


At left is 2nd Lt. Phil J. Dryden of Gulf Shores, and at right is Maj. David R. Mauritson of Fairhope.

NTSB Identification: ERA16FA100 
14 CFR Part 91: General Aviation
Accident occurred Monday, February 01, 2016 in Mobile, AL
Aircraft: CESSNA 182T, registration: N784CP
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On February 1, 2016, about 1945 central standard time, a Cessna 182T, N784CP, was destroyed by a collision with trees, terrain and a post-crash fire following a missed approach to the Mobile Regional Airport (MOB), Mobile, Alabama. The airline transport pilot and pilot-rated passenger were fatally injured. The airplane was registered to and operated by the Civil Air Patrol as a personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions existed at the airport at the time of the accident, and the flight was operated on an instrument flight rules flight plan. The flight originated from Louisiana Regional Airport (L38), Gonzales, Louisiana, about 1830.

The flight was returning to its home base at Mobile Downtown Airport (BFM), Mobile, Alabama. While in flight, the pilot contacted air traffic control and requested to divert to MOB. At 1935, approach control cleared the flight to MOB via radar vectors. The automated terminal information service-provided weather information for MOB was verified with the pilot and the airplane was vectored to a base leg 7 miles outside of the final approach fix, and cleared for the instrument landing system (ILS) approach to runway 15. At 1936, approach control issued alternate missed approach instructions, which included a climb to 2,000 feet and to maintain runway heading. Once acknowledged by the pilot, he was advised to contact the control tower.

The pilot checked in with the control tower and was cleared to land on runway 15. At 1944, the pilot declared a missed approach and the control tower responded by restating the climb to 2,000 feet and verified that he was issued the runway heading; the pilot responded "affirmative." Shortly thereafter, the tower controller noticed that the airplane was not climbing and reissued the instruction to climb to 2,000 feet; the pilot responded "roger." This was the last transmission made by the pilot. At 1945, the tower controller informed approach control that the airplane had been lost from radar.

Local authorities were notified and a ground search was initiated near the area of the airplane's last radar-derived position. The wreckage was located in a swampy, wooded area at approximately 0151 the following day.

Examination of the accident site revealed that the airplane initially impacted the top of a 90-foot-tall pine tree. About 50 feet from the base of the pine tree, the right wing and outboard section of the left wing came to rest. The debris path was orientated on a magnetic heading of about 150 degrees and extended about 360 ft. The main wreckage consisted of the fuselage, the rudder and vertical stabilizer, the left and right horizontal stabilizer and both elevators, and the inboard section of the left wing. A post-impact fire consumed the cockpit, cabin, and baggage area. The instrument panel and avionics were destroyed by fire. The airframe and engine were retained for further examination.

At 1956, surface weather observation for MOB, about 2 miles northeast of the accident site, included wind from 140 degrees at 7 knots, visibility 1/2 statute-mile in fog, and vertical visibility 200 ft.. The temperature was 18 degrees Celsius (C), the dew point was 18 degrees C, and the altimeter setting was 29.93 inches of mercury.

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