Sunday, September 29, 2019

Loss of Control in Flight: Cessna T182T Turbo Skylane, N1880B; fatal accident occurred June 10, 2018 near Monroe Municipal Airport (KEFT), Green County, Wisconsin

Colleen Deininger, a successful broker and family matriarch, was killed when the Cessna T182T Turbo Skylane she was piloting went down June 10th, 2018. She was headed to a family celebration with her daughter and two grandchildren.



Colleen Deininger's daughter, Lisa Deininger-Dickman and her children, 17-year-old Emmarose Dickman and 13-year-old Alex Dickman were also killed in the crash.  

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Milwaukee, Wisconsin
Textron Aviation; Wichita, Kansas
Lycoming Engines; Williamsport, Pennsylvania

Aviation Accident Factual 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/N1880B


Location: Monroe, WI
Accident Number: CEN18FA216
Date & Time: 06/10/2018, 1201 CDT
Registration: N1880B
Aircraft: CESSNA T182T
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 10, 2018, at 1201 central daylight time, a Cessna T182T airplane, N1880B, was destroyed during a collision with trees and terrain about 3/4 mile north-northwest of the Monroe Municipal Airport (EFT), Monroe, Wisconsin. The pilot and three passengers were fatally injured. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day instrument meteorological conditions prevailed. The flight was operated on an instrument flight rules flight plan. The flight originated from the Kenosha Regional Airport (ENW) about 1126 and was destined for EFT.

Federal Aviation Administration (FAA) air traffic control (ATC) radar position and communications data revealed that, after departing from ENW, the airplane proceeded westbound en route to EFT at a cruising altitude of 4,000 ft mean sea level (msl). The pilot requested the RNAV (GPS) Rwy 30 approach at EFT. She initially inquired about being cleared to the Davis initial approach fix (IAF). However, the controller suggested proceeding to GENZU due to weather southeast of Janesville. At 1139, the pilot was cleared to the GENZU initial approach fix on the RNAV (GPS) Rwy 30 approach into EFT. At 1150, the pilot was instructed to cross GENZU at 3,000 ft and was cleared for the approach. The airplane began a descent from 4,000 ft and subsequently leveled at 3,000 ft about 2 minutes later. At 1154, the airplane passed the GENZU initial approach fix and turned to the south-southeast along the published GPS Rwy 30 approach transition.

The pilot informed the controller that she would like to proceed to the Rockford International Airport (RFD) in the event of a missed approach. However, she later advised the controller that she wanted to go back to ENW. The controller provided alternate missed approach instructions: fly heading 090° and climb and maintain 4,000 ft. At 1155, the controller authorized the pilot to change to the airport common traffic advisory frequency and the pilot acknowledged. No further communications were received from the pilot. At 1156, the airplane passed the XOTIY intermediate approach fix and turned to the west-northwest inbound to runway 30. At 1159, the airplane passed the ZEBRU final approach fix at 2,700 ft. The final radar data point was recorded at 1201:06. The airplane was 1.90 nautical miles southeast of the runway 30 approach threshold at 1,700 ft. Radar contact was lost consistent with coverage limitations and was not regained.

A witness reported that she was at home when she heard the airplane. It sounded similar to an airplane performing aerobatic maneuvers, with a loud, high-pitched sound. She subsequently looked out of her kitchen window and observed a "fireball" through an opening in the tree line behind her home. She then heard a loud "boom" and saw thick black smoke rising above the trees.

The accident site was located in a wooded ravine about 1/2 mile north of the runway 30 departure threshold.




Pilot Information

Certificate: Commercial
Age: 81, Female
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 06/21/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  4600 hours (Total, all aircraft), 90 hours (Total, this make and model) 

Three pilot logbooks provided to the National Transportation Safety Board by a family representative for review were current to September 21, 2014. The family representative reported that the pilot had moved to a computer-based logbook after that point and he did not know where that data was stored. The pilot's total flight time after the final entry in the third logbook was 4,348.5 hours. The pilot had logged about 110 hours in Cessna 152 airplanes, about 385 hours in Cessna 172 airplanes, about 919 hours in Cessna 182 airplanes, about 1,625 hours in Cessna 206 airplanes, and about 1,300 hours in Cessna T206 airplanes. The logged actual and simulated instrument flight times totaled 491 and 85 hours, respectively.

On the most recent medical certificate application, dated June 2017, the pilot reported a total flight time of 4,480 hours with no flight time in the preceding 6 months. However, on the previous medical certificate application, dated April 2015, the pilot noted a total flight time of 4,600 hours with 90 hours in the preceding 6 months.

A review of the available pilot's logbooks, in conjunction with FAA records, revealed that the pilot had owned several airplanes before the accident airplane. These included a 2010 Cessna T206H, a 2004 Cessna 206H, a 1998 Cessna T206H and a 1997 Cessna 182S. Available information indicated that the accident airplane, the 2010 Cessna T206H and the 2004 Cessna 206H were equipped with Garmin G1000 avionics systems.

Federal Aviation Administration records revealed that the pilot had two pilot deviations. One event involved an altitude deviation while operating on an instrument flight rules clearance. The pilot had stated that the airplane was not on the desired flight track due to an error in loading the flight plan into the Garmin 1000 system. She disconnected the autopilot and corrected the flight track; however, she allowed her instrument scan to deteriorate and inadvertently climbed 500 ft above the assigned altitude. The second event involved a failure to change frequencies as required by air traffic control. 

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N1880B
Model/Series: T182T T
Aircraft Category: Airplane
Year of Manufacture: 2012
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: T18209078
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 05/04/2018, Annual
Certified Max Gross Wt.: 3100 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 844.3 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: TIO-540-AK1A
Registered Owner: On file
Rated Power: 235 hp
Operator: On file
Operating Certificate(s) Held: None 

Federal Aviation Administration records revealed that the pilot purchased the accident airplane in January 2017. An airframe maintenance logbook entry, dated April 2017, noted the recording tachometer time as 755.3. This was the initial logbook entry after the pilot had purchased the airplane. According to the maintenance records, the most recent annual inspection was completed on May 4, 2018, at a tachometer time of 844.3 hours.

Personnel at ENW stated that the pilot brought the airplane in for maintenance a few days before the accident noting that the engine did not shut down using the mixture control after a previous flight. Maintenance personnel reported that a visual examination did not reveal any anomalies. An engine run-up was conducted and the engine operated normally and shut-down without any difficulties at that time. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: EFT, 1086 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1215 CDT
Direction from Accident Site: 150°
Lowest Cloud Condition:
Visibility:  2.5 Miles
Lowest Ceiling: Overcast / 200 ft agl
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: Terrain-Induced / None
Wind Direction: 10°
Turbulence Severity Forecast/Actual: Moderate / N/A
Altimeter Setting: 29.9 inches Hg
Temperature/Dew Point: 16°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Kenosha, WI (ENW)
Type of Flight Plan Filed: IFR
Destination: Monroe, WI (EFT)
Type of Clearance: IFR
Departure Time: 1126 CDT
Type of Airspace: Class G 

Departure airport conditions, recorded at 1122, included overcast clouds at 300 ft agl, with 3 miles visibility in light rain and mist. The National Weather Service weather radar composite, valid at 1200, did not depict any defined thunderstorms along the immediate route of flight or any significant weather echoes over the accident site. A forecast for moderate turbulence below 10,000 ft msl over northern Illinois and Wisconsin was valid at the time of the accident flight. However, the available pilot reports either reported negative turbulence (smooth flight) conditions or did not mention turbulence at all.

A witness recalled that it had been misting all morning and the ground was wet. The cloud ceiling was low and "no blue sky" was visible "at all" through the overcast. A review of surface observations for EFT indicated that low instrument weather conditions prevailed from 0500 through 1555. At the time of the accident, the recorded cloud ceiling at EFT was 200 ft agl.

Airport Information

Airport: Monroe Municipal (EFT)
Runway Surface Type: Asphalt
Airport Elevation: 1086 ft
Runway Surface Condition: Vegetation
Runway Used: 30
IFR Approach: None
Runway Length/Width: 5000 ft / 75 ft
VFR Approach/Landing: None 

The RNAV (GPS) 30 approach LNAV minimum descent altitude (MDA) was 1,480 ft msl, which was 410 ft above the runway touchdown zone elevation. The circling MDA was 1,540 ft msl, which was 454 ft above the airport elevation. The published missed approach specified a climbing left turn to 3,000 ft, direct to the DAVIS initial approach fix and hold. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 4 Fatal
Latitude, Longitude: 42.627778, -89.597500 

The accident site was located in a wooded ravine. The debris path was oriented on an east-southeasterly heading. The main wreckage came to rest near the top of the ravine about 114 ft from the initial tree impact. The terrain rose about 20 ft from the initial tree impact to where it came to rest at the top of the ravine. The airplane was fragmented consistent with impact forces and portions of the fuselage were partially consumed by a postimpact fire.

Postaccident airframe and engine examinations did not reveal any anomalies consistent with a preimpact failure or malfunction. A detailed summary of the examinations is included in the docket associated with the accident investigation. 

Medical And Pathological Information

An autopsy of the pilot was performed by the Anatomic Pathology Laboratory in Madison, Wisconsin. The pilot's death was attributed to injuries sustained in the accident. Toxicology testing performed by the FAA Forensic Sciences laboratory identified metoprolol in kidney and muscle tissues. It was negative for all other substances in the testing profile. Metoprolol is commonly prescribed to control high blood pressure and is considered not to be impairing. 

Additional Information

Spatial Disorientation

The Federal Aviation Administration Civil Aeromedical Institute publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude.


The Federal Aviation Administration Airplane Flying Handbook describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: "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."

4 comments:

Anonymous said...

"Topographical disorientation (TD) refers to navigational impairment as an effect of aging or brain damage. Decreases in navigational performance with aging are more due to deficits in the ability to mentally represent space in an object-centered (allocentric) than in a self-centered (egocentric) format." https://www.ncbi.nlm.nih.gov

Anonymous said...

Probably should have driven that day. It was LIFR all over SE WI that day. They had a graduation party to attend that afternoon. The ceiling was lower than the MDA, she knew this that’s why she requested heading to Rockford if she couldn’t get in.

Anonymous said...

This was a hard one to read.....very sad.

Unknown said...

Very sad, but we can all (hopefully) learn from it. good for her for still flying at 81 (I hope I am) but by then I hope to transition to CAVU days mostly.

RIP All