National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Ephraim, WI

Accident Number:

CEN16FA373

Date & Time:

09/18/2016, 2031 CDT

Registration:

N2012F

Aircraft:

CESSNA 182

Aircraft Damage:

Destroyed

Defining Event:

Controlled flight into terr/obj (CFIT)

Injuries:

2 Fatal

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

 

The private pilot was flying a passenger, who was a student pilot, home after her completion of a lesson with a flight instructor. During the night arrival to a nontowered airport, the pilot descended to about 150 ft above the ground on an extended right base to the runway. He subsequently flew across the runway's final approach course and began a left turn away from the runway, which continued for about 300° until impact with 50-ft-tall trees.

Although adequate visibility and moon illumination existed for a night visual approach, the runway's final approach was over an unpopulated state park surrounded by water on three sides with little cultural lighting. The lack of visual cues over this dark area likely contributed to the pilot perceiving his altitude to be higher than it was. Additionally, when the pilot turned left toward the dark area, he turned the airplane away from the runway's visual glideslope indicator, which could have provided the pilot with information about his height above the terrain. Further, the low altitude at which the pilot approached the airport and subsequently initiated his maneuvering to align with the runway did not allow for any imprecision in altitude control.

It is unlikely that the pilot's diabetes, high blood pressure, or medications used to treat these conditions impaired the pilot or contributed to the accident. Additionally, there is no evidence the pilot's coronary artery disease or bilateral cataracts impaired the pilot or contributed to the accident.

 

Probable Cause and Findings

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

The pilot's improper decision to execute a maneuvering approach at low altitude during night conditions, which resulted in controlled flight into terrain.

 

Findings

Aircraft

Altitude - Not attained/maintained (Cause)

Personnel issues

Incorrect action selection - Pilot (Cause)

Aircraft control - Pilot (Cause)

Decision making/judgment - Pilot (Cause)

Environmental issues

Dark - Decision related to condition (Cause)

Dark - Effect on operation (Cause)

Factual Information

 

HISTORY OF FLIGHT

On September 18, 2016, about 2031 central daylight time, a Cessna 182T airplane, N2012F, impacted terrain during a visual approach to the Ephraim-Gibraltar Airport (3D2), Ephraim, Wisconsin. The private pilot and the passenger were fatally injured, and the airplane was destroyed. The airplane was registered to Keller Aviation LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the flight, which departed from the Green Bay-Austin Straubel International Airport (GRB), Green Bay, Wisconsin, at 2003 on an instrument flight rules (IFR) flight plan.

According to the pilot's friends, he flew the passenger, who was a student pilot, from 3D2 to GRB earlier that day for a lesson with a flight instructor. According to Federal Aviation Administration (FAA) air traffic control information, on the return flight from GRB, at 2023, the pilot cancelled his IFR flight plan during the descent to 3D2. Air traffic control radar showed the airplane descend to about 150 ft above ground level (agl) while on an extended right base to runway 14. The airplane continued straight ahead and crossed the final approach course to runway 14 about 1,500 ft from the approach end. After crossing the final approach course, the airplane made a left turn away from the runway. The left turn continued at low altitude for 19 seconds until radar contact was lost. The last radar return was recorded at 2030 and showed the airplane about 3,800 ft northwest of the runway 14 threshold, heading away from the runway, at an altitude about 150 ft agl.

Two witnesses located northeast of 3D2 noticed the airplane approach from the southwest. One of the witnesses stated that the airplane began a left turn that "seemed a bit sharp, more like a U-turn." As the turn continued, the airplane "made a wiggle or some kind of an odd movement." The airplane "straightened out" and descended below the tree line, and the witnesses heard the sounds of a crash. The witnesses did not report hearing any unusual engine noises before the accident.

PERSONNEL INFORMATION

The pilot, age 69, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. On his most recent FAA airman medical certificate application, dated August 31, 2016, the pilot reported 920 total hours of flight experience with 17.6 flight hours in the last 6 months. On December 14, 2014, he completed a flight review in the accident airplane. Pilot logbooks were not available during the investigation. According to other pilots at 3D2, the pilot told them he would be flying practice night patterns and landings on the evening before the accident, since his night currency to carry passengers had expired. The investigation was not able to determine if this currency flight occurred.

AIRCRAFT INFORMATION

The airplane, serial number 18281769, was issued a standard airworthiness certificate on October 6, 2008. The airplane was equipped with a Lycoming IO-540-1ABA5 engine, serial number L-31073-48E, a McCauley 3-bladed aluminum-hub propeller, and a Garmin G1000 integrated flight information system. The airplane's last annual inspection was completed on March 2, 2016, at a total airframe time of 3,122 flight hours. The airplane's last 100-hour inspection was completed on September 8, 2016, at a total airframe time of 3,426 flight hours.

METEOROLOGICAL INFORMATION

At 2035, the weather observation station at 3D2 reported the following conditions: wind 190° at 8 knots, visibility 10 miles, clear skies, temperature 17°C, dew point 15°C, and altimeter setting 29.91 inches of mercury. Sunset occurred at 1853 with the end of civil twilight at 1922 and moonrise at 2015. At the time of the accident, the moon was about 2° above the horizon and at an azimuth of 83° with 93% of the moon's visible disk illuminated.

AIRPORT INFORMATION

3D2, located 1 mile south of Ephraim, is a nontowered airport that is open to the public. The airport is at an elevation of 763 ft mean sea level and has a 2,697-ft-long by 60-ft-wide asphalt runway designated as runway 14/32. The runway is lit with medium-intensity lighting and has no runway end identifier lights. A precision approach path indicator (PAPI) configured for a 3.5° glideslope is located on the left side of the runway.

Following the accident, a remotely-piloted aircraft was flown at various altitudes along the final approach of runway 14. No anomalies were noted with the PAPI or runway lighting.

WRECKAGE AND IMPACT INFORMATION

The airplane collided with 50-ft-tall trees about 3,500 ft northwest of the runway 14 threshold. The impact heading was about 112°, and the airplane came to rest inverted about 210 ft beyond the initial tree strike. A postcrash fire ensued, which consumed the inboard sections of both wings, the fuselage, and the empennage.

Flight control continuity was established for the ailerons, rudder, and elevators. The fuel system was compromised by the fire, and the fuel selector was not located. One of the propeller blades was bent slightly forward and broken free from the hub. The other two blades were straight with minimal rotational signatures. Several tree branches were found with diagonal cuts consistent with a rotating propeller.

The engine was examined at a recovery facility. The accessory case was significantly fire-damaged, and the gear train was rusted. The crankshaft was rotated by hand, and drive train continuity was established throughout the engine. Thumb compression was established on all cylinders. Cylinder Nos. 4 and 6 had low compression due to heat damage to their valve springs and push rods. The cylinders were borescope-inspected with no anomalies noted. All six fuel injector nozzles were found to be clear of debris. The propeller governor control was nearly full forward. The propeller piston was forward, and the propeller spring was extended, consistent with a low propeller pitch. The two magnetos could not be rotated due to fire damage. The top and bottom sparkplugs, Champion REM37BY, appeared normal when compared to the Champion Aviation Service Manual (AV6-R). Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

An Appareo Stratus PRX V2, a portable unit that includes a GPS receiver, an automatic dependent surveillance-broadcast receiver, and a heading/attitude system, was recovered from the accident site. The unit had minimal damage, but it's logging feature was turned off, and there was no recorded historical data.

The two Garmin G1000 displays installed in the airplane record data on memory cards; however, due to fire damage, no data could be recovered from the memory cards.

MEDICAL AND PATHOLOGICAL INFORMATION

According to FAA documents, at the time he applied for his most recent medical certificate in August 2016, the pilot reported having high blood pressure controlled with lisinopril and diabetes controlled with the oral medication metformin. These medications are generally considered not to be impairing. The aviation medical examiner documented that the pilot did not have any other significant medical issues. The pilot was issued a special issuance third class medical certificate with the limitation: valid for 12 months following the examination.

Review of the pilot's annual diabetic ophthalmology examination records from August 2014 through August 2016 indicated that the pilot had bilateral cataracts with mild to moderate nuclear sclerosis. The ophthalmologist's records indicated that the pilot had non-insulin dependent diabetes with no diabetic retinopathy and no pathology that affected the pilot's vision.

The Dane County Medical Examiner, Madison, Wisconsin, performed an autopsy of the pilot and determined that the pilot's cause of death was thermal injuries and inhalation of superheated gases. The pilot's heart was enlarged with 40% to 50% narrowing of the right coronary and 60% to 80% narrowing of the left anterior descending and left circumflex coronary arteries. The autopsy did not find evidence of ischemic heart muscle damage. The autopsy was limited due to the extent of injury, and the brain was not examined.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The toxicology testing was negative for tested-for-drugs, alcohol, and carbon monoxide.

The 16-year-old passenger did not have nor was she required to have a medical certification. The Dane County Medical Examiner's autopsy report for the passenger documented the cause of death was thermal injuries and inhalation of superheated gases. No natural disease was identified. FAA Bioaeronautical Sciences Research Laboratory toxicology testing on the passenger was negative for tested-for-drugs, alcohol, and carbon monoxide.

ADDITIONAL INFORMATION

The final approach to runway 14 at 3D2 was over an unpopulated state park bordered on three sides by water with little cultural lighting. After flying through final approach, the pilot turned left toward this dark area.

Regarding night operations, the FAA Airplane Flying Handbook, FAA-H-8083-B, states, in part:

"To fly a traffic pattern of proper size and direction, the runway threshold and runway-edge lights must be positively identified. Once the airport lights are seen, these lights should be kept in sight throughout the approach. Distance may be deceptive at night due to limited lighting conditions. A lack of intervening references on the ground and the inability to compare the size and location of different ground objects cause this. This also applies to the estimation of altitude and speed. Consequently, more dependence must be placed on flight instruments, particularly the altimeter and the airspeed indicator. Maintain the recommended airspeeds and execute the approach and landing in the same manner as during the day. A low, shallow approach is definitely inappropriate during a night operation. The altimeter and VSI should be constantly cross-checked against the airplane's position along the base leg and final approach."

 

 

History of Flight

Approach-VFR pattern base

Navigation error

Approach

Controlled flight into terr/obj (CFIT) (Defining event)

 

 

Pilot Information

Certificate:

Private

Age:

69, Male

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

3-point

Instrument Rating(s):

Airplane

Second Pilot Present:

Yes

Instructor Rating(s):

None

Toxicology Performed:

Yes

Medical Certification:

Class 3 Waiver Time Limited Special

Last FAA Medical Exam:

08/31/2016

Occupational Pilot:

No

Last Flight Review or Equivalent:

12/14/2014

Flight Time:

(Estimated) 920 hours (Total, all aircraft), 300 hours (Total, this make and model)

 

 

Student Pilot Information

Certificate:

Student

Age:

16, Female

Airplane Rating(s):

None

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:

None

Last FAA Medical Exam:

 

Occupational Pilot:

No

Last Flight Review or Equivalent:

 

Flight Time:

 

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

CESSNA

Registration:

N2012F

Model/Series:

182 T

Aircraft Category:

Airplane

Year of Manufacture:

2006

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

18281769

Landing Gear Type:

Tricycle

Seats:

4

Date/Type of Last Inspection:

09/08/2016, 100 Hour

Certified Max Gross Wt.:

2348 lbs

Time Since Last Inspection:

 

Engines:

1 Reciprocating

Airframe Total Time:

3426 Hours as of last inspection

Engine Manufacturer:

LYCOMING

ELT:

C91A installed, not activated

Engine Model/Series:

IO-540-AB1A5

Registered Owner:

KELLER AVIATION LLC

Rated Power:

290 hp

Operator:

KELLER AVIATION LLC

Operating Certificate(s) Held:

Commercial Air Tour (136)

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Night

Observation Facility, Elevation:

3D2, 763 ft msl

Distance from Accident Site:

1 Nautical Miles

Observation Time:

2035 CDT

Direction from Accident Site:

320°

Lowest Cloud Condition:

Clear

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

8 knots /

Turbulence Type Forecast/Actual:

/ None

Wind Direction:

190°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

29.91 inches Hg

Temperature/Dew Point:

17°C / 15°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Green Bay, WI (GRB)

Type of Flight Plan Filed:

IFR

Destination:

Ephraim, WI (3D2)

Type of Clearance:

IFR

Departure Time:

2003 CDT

Type of Airspace:

Class G

 

Airport Information

Airport:

EPHRAIM-GIBRALTAR (3D2)

Runway Surface Type:

Asphalt

Airport Elevation:

763 ft

Runway Surface Condition:

Dry

Runway Used:

14

IFR Approach:

None

Runway Length/Width:

2697 ft / 60 ft

VFR Approach/Landing:

Unknown

 

Wreckage and Impact Information

Crew Injuries:

1 Fatal

Aircraft Damage:

Destroyed

Passenger Injuries:

1 Fatal

Aircraft Fire:

On-Ground

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

2 Fatal

Latitude, Longitude:

45.145833, -87.197222 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Michael J Folkerts

Report Date:

07/16/2018

Additional Participating Persons:

Jon H Weston; Flight Standards District Office; Milwaukee, WI

Andrew L Hall; Textron Aviation; Wichita, KS

Troy Helgeson; Lycoming Engines; Williamsport, PA

Publish Date:

07/16/2018

Note:

The NTSB traveled to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=94027