Mobile, AL, USA
N784CP
CESSNA 182
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.
HISTORY OF FLIGHTOn 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. PERSONNEL INFORMATIONComposition 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 INFORMATIONThe 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 INFORMATIONSynoptic 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 pilotthrough 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. Astronom
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.
Source: NTSB Aviation Accident Database
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