Controlled Flight Into Terrain: Cessna 182D Skylane, N8889X; accident occurred April 02, 2017 near Blue Earth Municipal Airport (KSBU), Faribault County, Minnesota

Aviation Accident Final Report - National Transportation Safety Board

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Minneapolis, Minnesota

Investigation Docket - National Transportation Safety Board:

https://data.ntsb.gov/Docket

https://registry.faa.gov/N8889X

Location: Blue Earth, Minnesota 

Accident Number: GAA17CA215

Date & Time: April 1, 2017, 22:00 Local 

Registration: N8889X

Aircraft: Cessna 182

Aircraft Damage: Substantial

Defining Event: Controlled flight into terr/obj (CFIT) 

Injuries: 2 Minor, 1 None

Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The pilot reported that, while approaching the destination airport in night, marginal visual meteorological conditions, he turned on the pilot-controlled runway lights. He added that he began a descent to the runway without observing the runway lights or airport and encountered "ground fog" about 200 to 300 ft above ground level (agl). He further added that he continued the descent to the runway while referencing the navigational moving map and GPS altitude on his electronic flight bag (EFB) application ForeFlight. Subsequently, while in a left turn, the airplane impacted terrain about 1 nautical mile south of the runway.

The left wing, firewall, and fuselage sustained substantial damage.

The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. He added that, while en route, he reset his airplane installed barometric pressure altimeter to the GPS altitude indicated on his EFB, which resulted in a "300 ft. error."

An automated weather observing station, about 14 nautical miles west of the accident airport, recorded visibility at 2 1/2 statute miles, light rain, mist, and an overcast cloud ceiling at 300 ft agl.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's decision to continue the night, visual flight into instrument meteorological conditions, which resulted in controlled flight into terrain while on final approach. Contributing to the accident was the pilot's improper use of an electronic flight bag.

Findings

Personnel issues Decision making/judgment - Pilot

Aircraft Altitude - Not attained/maintained

Aircraft (general) - Incorrect use/operation

Environmental issues Fog - Decision related to condition

Environmental issues Below VFR minima - Decision related to condition

Factual Information

History of Flight

Approach-VFR pattern final VFR encounter with IMC

Approach-VFR pattern final Loss of visual reference

Approach-VFR pattern final Controlled flight into terr/obj (CFIT) (Defining event)

Pilot Information

Certificate: Private

Age: 67, Male

Airplane Rating(s): Single-engine land 

Seat Occupied: Right

Other Aircraft Rating(s): None 

Restraint Used: Unknown

Instrument Rating(s): Airplane

Second Pilot Present: Yes

Instructor Rating(s): None

Toxicology Performed: No

Medical Certification: Class 3 With waivers/limitations

Last FAA Medical Exam: December 22, 2015

Occupational Pilot: No

Last Flight Review or Equivalent: September 9, 2016

Flight Time: (Estimated) 1069.8 hours (Total, all aircraft), 32.8 hours (Total, this make and model), 1069.8 hours (Pilot In Command, all aircraft), 12.1 hours (Last 90 days, all aircraft), 7 hours (Last 30 days, all aircraft), 7 hours (Last 24 hours, all aircraft)

Student pilot Information

Certificate: Student 

Age: 56, Male

Airplane Rating(s): None

Seat Occupied: Left

Other Aircraft Rating(s): None 

Restraint Used: Unknown

Instrument Rating(s): None

Second Pilot Present: Yes

Instructor Rating(s): None

Toxicology Performed: No

Medical Certification: Class 3 Without waivers/limitations

Last FAA Medical Exam: September 29, 2016

Occupational Pilot: No 

Last Flight Review or Equivalent:

Flight Time: (Estimated) 35 hours (Total, all aircraft), 35 hours (Total, this make and model)

Passenger Information

Certificate: Age: Male

Airplane Rating(s): 

Seat Occupied: Left

Other Aircraft Rating(s): 

Restraint Used: Unknown

Instrument Rating(s): 

Second Pilot Present: Yes

Instructor Rating(s): 

Toxicology Performed: No

Medical Certification:

Last FAA Medical Exam:

Occupational Pilot: No 

Last Flight Review or Equivalent:

Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 

Registration: N8889X

Model/Series: 182 D 

Aircraft Category: Airplane

Year of Manufacture: 1961

Amateur Built: No

Airworthiness Certificate: Normal

Serial Number: 18253289

Landing Gear Type: Tricycle

Seats: 4

Date/Type of Last Inspection: Unknown

Certified Max Gross Wt.: 2650 lbs

Time Since Last Inspection: 

Engines: 1 Reciprocating

Airframe Total Time: 3143.15 Hrs at time of accident

Engine Manufacturer: Continental

ELT: C91A installed, not activated

Engine Model/Series: O-470-L

Registered Owner:

Rated Power: 230 Horsepower

Operator: On file 

Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC)

Condition of Light: Night

Observation Facility, Elevation: KFRM, 1162 ft msl 

Distance from Accident Site: 14 Nautical Miles

Observation Time: 03:06 Local

Direction from Accident Site: 270°

Lowest Cloud Condition: 

Visibility 2.5 miles

Lowest Ceiling: Overcast / 300 ft AGL

Visibility (RVR):

Wind Speed/Gusts: 7 knots / 

Turbulence Type Forecast/Actual:  / None

Wind Direction: 170° 

Turbulence Severity Forecast/Actual:  / N/A

Altimeter Setting: 29.8 inches Hg 

Temperature/Dew Point: 9°C / 8°C

Precipitation and Obscuration: Moderate - None - Mist

Departure Point: ST PAUL, MN (21D) 

Type of Flight Plan Filed: None

Destination: BLUE EARTH, MN (SBU) 

Type of Clearance: None

Departure Time: 20:30 Local

Type of Airspace: Class G

Airport Information

Airport: BLUE EARTH MUNI SBU

Runway Surface Type: Asphalt

Airport Elevation: 1107 ft msl 

Runway Surface Condition: Dry

Runway Used: 34 

IFR Approach: None

Runway Length/Width: 3400 ft / 75 ft

VFR Approach/Landing: Straight-in

Wreckage and Impact Information

Crew Injuries: 2 Minor 

Aircraft Damage: Substantial

Passenger Injuries: 1 None

Aircraft Fire: None

Ground Injuries: N/A Aircraft

Explosion: None

Total Injuries: 2 Minor, 1 None 

Latitude, Longitude: 43.595275,-94.092781(est)

Preventing Similar Accidents

Reduced Visual References Require Vigilance

About two-thirds of general aviation accidents that occur in reduced visibility weather conditions are fatal. The accidents can involve pilot spatial disorientation or controlled flight into terrain. Even in visual weather conditions, flights at night over areas with limited ground lighting (which provides few visual ground references) can be challenging.

Preflight weather briefings are critical to safe flight. In-flight, weather information can also help pilots make decisions, as can in-cockpit weather equipment that can supplement official information. Incockpit equipment requires an understanding of the features and limitations.

We often see pilots who decide to turn back after they have already encountered weather; that is too late.

Pilot's shouldn't allow a situation to become dangerous before deciding to act. Additionally, air traffic controllers are there to help; be honest with them about your situation and ask for help.

Even when flying at night, visual weather conditions can also be challenging. Remote areas with limited ground lighting provide limited visual reference cues for pilots, which can be disorienting or render rising terrain visually imperceptible. Topographic references can help pilots become more familiar with the terrain. The use of instruments, if pilots are proficient, can also help pilots navigate these challenging areas.

See http://www.ntsb.gov/safety/safety-alerts/documents/SA_020.pdf for additional resources.

The NTSB presents this information to prevent recurrence of similar accidents. Note that this should not be considered guidance from the regulator, nor does this supersede existing FAA Regulations (FARs).