Gainesville, GA, USA
N3652C
CESSNA R182
The instrument-rated pilot departed on an instrument flight rules (IFR) flight plan into instrument meteorological conditions (IMC) that included a cloud ceiling 400 ft above ground level (agl), mist, and low-level wind shear. The pilot was instructed to fly a heading that would have required a 30° right turn from the departure runway heading after takeoff and to climb to 3,000 ft mean sea level (msl). After departure, the airplane entered a right turn to more than 180° from the departure runway heading and performed a series of climbs and descents with corresponding deviations in groundspeed, reaching a maximum altitude of 2,500 ft msl before descending rapidly into trees and terrain. Postaccident examination of the airplane and engine did not reveal any preimpact failures or malfunctions that would have precluded normal operation. The accident site and distribution of the wreckage were consistent with impact at high speed and with the engine producing power. A friend of the pilot reported that the pilot was proficient in the operation of modern digital flight instruments, but not proficient in the use of analog flight instruments like those installed in the accident airplane. The friend reported that he advised the pilot not to fly the accident airplane in IMC until he upgraded the instrumentation and avionics. The friend also reported that the pilot had likely not previously flown by himself in low IMC, like those present at the time of the accident. The pilot had received preflight weather briefings that advised of the low cloud ceilings, visibility, and wind shear; however, the conversations indicated that the pilot was focused on the potential for icing at cruise altitude. The airplane’s pitch attitude deviations after takeoff, as evidenced by its climbs, descents, and groundspeed changes, are consistent with the pilot experiencing a type of spatial disorientation known as a somatogravic illusion, which resulted in spatial disorientation, loss of control, and impact with trees and terrain. It is likely that the pilot’s decision to depart into low instrument flight rules conditions, which resulted in his entry into low-visibility conditions during a high-workload phase of flight such as the takeoff and initial climb, increased his susceptibility to the effects of spatial disorientation.
HISTORY OF FLIGHTOn February 26, 2021, about 1811 eastern standard time, a Cessna R182 airplane, N3652C, was substantially damaged when it was involved in an accident near Gainesville, Georgia. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Lee Gilmore Memorial Airport (GVL), Gainesville Georgia, destined for Daytona Beach International Airport (DAB), Daytona Beach, Florida. According to Federal Aviation Administration (FAA) air traffic control (ATC) information, the pilot established communication with the clearance delivery controller and requested an IFR clearance to DAB. The pilot also requested an enroute altitude of 3,000 feet msl. The controller subsequently issued a release for departure with instructions to fly heading 140°, maintain 3,000 feet, and issued a clearance void time of 10 minutes. The airplane departed about 1808:24, and the pilot established communication with the controller while climbing through 1,800 feet for 3,000 feet. The airplane then began turning southwest as it climbed through 2,200 ft msl. The controller informed the pilot that they appeared to be on a westbound heading and asked them if they were on the assigned heading of 140°; however, the pilot did not respond. The airplane began a rapid descent and then the Low Altitude Alert System activated at the controller’s station. The controller issued a safety alert to the pilot as the airplane was descending through 1,400 ft, but the pilot did not respond. The airplane was next observed climbing to 2,500 ft before entering another rapid descent, followed by a loss of radar contact. Track data indicated that, after departure, the airplane began a right turn and continued climbing, and ground speed continued to increase until about 1809:25, when ground speed started to decrease. Several seconds later, after reaching a maximum altitude of about 2,200 ft msl, the airplane began to descend while remaining in the right turn. About 1809:34, the ground speed began to increase from about 75 knots (kts) to a high of about 165 kts, then altitude and ground speed varied between 1,700 and 2,000 ft msl and 100 to 110 kts, respectively. About 1810:19, the airplane started to lose ground speed rapidly from about 100 kts to below 30 kts while climbing from about 2,000 to 2,500 ft msl, before ground speed increased and the airplane descended rapidly until track data were lost. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued on April 8, 2019. He had accrued approximately 384 total flight hours, of which about 44 hours were in the airplane make and model. He had also accrued about 33 hours of actual instrument time and about 38 hours of simulated instrument time. AIRCRAFT INFORMATIONThe accident airplane was a four seat, high wing, airplane of conventional metal construction. It was equipped with a variable pitch propeller and retractable landing gear. Review of FAA airworthiness records indicated that the airplane was equipped with a rate-based autopilot, an electric turn-and-bank indicator, a standby vacuum pump, radar altimeter, and horizontal situation indicator (HSI). A Garmin GNS 430W, which was capable of providing Wide Area Augmentation System navigation capabilities and position relative to ground features, chart data, navaids, flight plan routings and approach procedures, was installed, as well as a 3M WX-10A Stormscope, which offered thunderstorm avoidance information. METEOROLOGICAL INFORMATIONAt the time of the accident, a northeast wind and cold air damming east of the Appalachian Mountains along with a frontal boundary located across central Georgia, helped to induce low cloud cover across northern Georgia and the accident site. At the time of the accident, visibility restrictions due to fog and mist with ceilings at 400 feet agl were indicated at GVL. Light rain was also noted between 1809 and 1837; however, the weather radar imagery did not support the light rain. It is therefore likely that mist near the ASOS sensor triggered the report of rainfall. Wind gusting to 18 knots with low level wind shear (LLWS) and turbulence was indicated by a high-resolution rapid refresh (HRRR) sounding valid at the time of the accident. An AIRMET advisory for instrument flight rules conditions and LLWS and a Center Weather Advisory (CWA), which warned of ceilings below 500 feet agl and visibilities less than 1 mile, were valid for the area of the accident site at the time of the accident. The pilot had received weather briefings from Leidos Flight Service at both 1715 and 1759 and during both of the weather briefings, the forecast and warnings for low cloud ceilings and LLWS were provided to the pilot. During both discussions with Leidos, the pilot seemed most concerned with the freezing level and the potential for icing conditions below 5,000 ft msl (his intended enroute cruise altitude). Based on the 1800 sounding, the freezing level was above 10,000 ft msl at the accident time. AIRPORT INFORMATIONThe accident airplane was a four seat, high wing, airplane of conventional metal construction. It was equipped with a variable pitch propeller and retractable landing gear. Review of FAA airworthiness records indicated that the airplane was equipped with a rate-based autopilot, an electric turn-and-bank indicator, a standby vacuum pump, radar altimeter, and horizontal situation indicator (HSI). A Garmin GNS 430W, which was capable of providing Wide Area Augmentation System navigation capabilities and position relative to ground features, chart data, navaids, flight plan routings and approach procedures, was installed, as well as a 3M WX-10A Stormscope, which offered thunderstorm avoidance information. WRECKAGE AND IMPACT INFORMATIONThe airplane contacted the top of an approximately 50-ft-tall tree about 0.66 nautical miles (nm) southwest of the approach end of runway 5 at GVL. The airplane continued on a northerly magnetic heading, impacting another tree about 30 ft above ground level with the left wing and fuselage. The left wing separated from the fuselage, with the outboard half of the wing remaining in the tree while the inboard half fell through the roof of a mobile home. Parts continued to separate from the airplane, including the outboard portion of the right wing and the empennage. The cabin area, engine, and the remainder of the right wing were found about 550 ft from the initial impact point with the tree. Examination of the airplane revealed that the flaps remained attached to their respective wings, and the inboard half of each aileron remained attached to the wing. The outboard aileron hinges also remained attached to each wing. The right aileron separated from its wing and was found in multiple pieces along the wreckage path. The right fiberglass wingtip and the remains of its navigation light were found near the start of the wreckage path. Both aileron direct cables had separated near the firewall, and the aileron interconnect cable had separated in the cabin overhead. Both elevator torque tubes separated from the aft bellcrank. The left horizontal stabilizer was found in two pieces; the inboard piece remained attached to the empennage, the outboard portion was found near the start of the wreckage path. The left elevator was found in two pieces along the first half of the wreckage path. The right elevator remained attached to the right horizontal stabilizer apart from the counterweight, which was found embedded in the ground near the end of the wreckage path. All the flight control cables exhibited signatures of tension overload, with their associated cable ends attached to the cockpit flight controls and flight control surfaces. The rudder cables, upper elevator cable, and both elevator trim cables had separated in tension overload at the bottom of the firewall. The lower elevator cable separated near the aft bellcrank. Fuel came out of the fuel strainer when it was removed from the firewall. The electric boost pump screen was clear of debris and fuel was found inside. The fuel selector valve was found near the right wing at the end of the wreckage path. The shaft was bent and exhibited impact damage. The valve was in an intermediate position, though ports were observed at all holes. A strong fuel smell was present in the mobile home that contained the inboard section of the left wing. The attitude indicator was disassembled, and rotational scoring was present on the gyro rotor and the rotor housing. The vacuum pump was opened, and the composite drive assembly, carbon rotor, and carbon vanes were intact. The radar altimeter indicated an altitude of 200 feet. The standby vacuum pump switch was in the “OFF” position. The throttle control, mixture control, and carburetor heat control were all fully forward, and a needle slap mark was observed at the 25 inHg line on the manifold pressure gauge. The propeller remained attached to the engine crankshaft flange. The propeller spinner was partially crushed. One propeller hub socket was fractured, and the corresponding propeller blade was displaced aft about 50° and was free to rotate in the hub. The outboard 8 inches of that blade were bent aft about 90°. The blade tip was broken off, and the trailing edge of the bent portion exhibited “S” bending. Another blade was also free to rotate in the hub. The tip of that blade was bent forward slightly. The remaining blade tip was twisted slightly toward the blade face. The governor control arm separated from the governor. The governor drive spline was rotated freely by hand. The governor oil screen was absent of debris. The engine remained attached to the airplane firewall through the tubular engine mount. The intake and exhaust tubing were partially crushed. The exhaust mufflers were partially crushed and separated from the engine. The engine crankshaft was rotated by turning the propeller and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Compression and suction were observed from all cylinders except from the No. 4 cylinder, which was impact damaged. The carburetor was fractured across the throttle bore and separated from the engine. The throttle and mixture control cables remained attached to the carburetor throttle and mixture control arms and the arms remained attached to the carburetor. The carburetor was partially disassembled and no damage to the internal components was noted. Fuel was observed in the carburetor float bowl. The carburetor fuel inlet screen was absent of debris. The engine-driven fuel pump remained attached to the engine and no damage was noted. Fuel drained from the pump as it was removed. No damage was noted to the internal rubber diaphragms or check valves. The magneto housing remained attached to the engine and was fractured over the left condenser. Spark was produced from all 12 ignition towers. The ignition harness was impact damaged. The spark plug electrodes exhibited dark gray coloration and worn normal condition. The No. 1 cylinder top and the No. 4 cylinder bottom sparkplugs were impact damaged. Oil was observed in the engine. The oil suction screen was unobstructed. The oil filter media exhibited a few silver-colored flakes consistent in appearance with aluminum flakes. ADDITIONAL INFORMATIONAccording to a friend, the pilot and the other occupants of the airplane were flying to DAB to meet up with him for the weekend. He considered the pilot very proficient with state-of-the-art electronics/instruments, such as G1000 avionics, but he was not proficient with a traditional "six pack", vacuum instruments, and HSI. The friend said that the pilot was planning on upgrading the airplane with state-of-the-art electronics/avionics in the near future, along with upgrades to the interior and painting the airplane. Because he felt that the pilot was not a proficient pilot with the older style instruments, he told the pilot that he should consider the airplane visual flight rules only until he upgraded the instruments and avionics. His friend labeled the pilot as a "magenta line pilot" and stated that he liked to use the autopilot regularly. His friend also stated that he was very upset at the pilot for flying in the weather conditions that existed at the time of the accident flight. He further stated that he did not believe the pilot had ever taken off in such low visibility and ceilings by himself, that the lowest ceilings he had flown in by himself were usually around 3,000 ft agl. He said the pilot may have taken off in and flown in lower ceilings and visibilities like those at the time of the accident, but it would have been with somebody else. The friend also estimated that he had flown with the pilot “between 50 to 100 hours,” and that the pilot had flown about 40 hours in the last few weeks. Spatial Disorientation According to the FAA's General Aviation Safety Enhancement Fact Sheet on Spatial Disorientation, pilots flying under both instrument and visual flight rules are subject to spatial disorientation and optical illusions that may cause a loss of aircraft control. 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. Contributing to these phenomena are the various types of sensory stimuli: visual, vestibular (organs of equilibrium located in the inner ear), and proprioceptive (receptors located in the skin, muscles, tendons, and joints). Changes in linear acceleration, angular acceleration, and gravity are detected by the vestibular system and the proprioceptive receptors, and then compared in the brain with visual information. In a flight environment, these stimuli can vary in magnitude, direction, and frequency, resulting in a sensory mismatch that can produce illusions and lead to spatial disorientation. According to FAA's Aeromedical Safety Brochure, "Spatial Disorientation: Why You Shouldn't Fly By the Seat of Your Pants", somatogravic illusions involving the utricle and the saccule of the vestibular system are most likely under conditions with unreliable, or unavailable external visual references. These illusions include: "The Head-Up Illusion", which involves a sudden forward linear acceleration during level flight where the pilot perceives the illusion that the nose of the aircraft is pitching up. The pilot's response to this illusion would be to push the yolk (control wheel) or the stick forward to pitch the nose of the aircraft down. A night take-off from a well-lit airport into a totally dark sky (black hole) or a catapult take-off from an aircraft carrier can also lead to this illusion and could result in a crash. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy performed on the pilot by the Georgia Bureau of Investigation, Division of Forensic Sciences in Decatur, Georgia, reported the cause of death as multiple blunt impact injuries. Toxicological testing performed at the FAA Forensic Sciences Laboratory was negative for carboxyhemoglobin, alcohol, or other drugs. FIRENone
The pilot’s loss of control due to spatial disorientation. Contributing to the accident was the pilot’s decision to depart into low instrument meteorological conditions.
Source: NTSB Aviation Accident Database
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