CESSNA T182T
Albany, WY — May 14, 2023
Event Information
| Date | May 14, 2023 |
| Event Type | ACC |
| NTSB Number | WPR23FA188 |
| Event ID | 20230514171570 |
| Location | Albany, WY |
| Country | USA |
| Coordinates | 41.43867, -106.06018 |
| Highest Injury | FATL |
Aircraft
| Make | CESSNA |
| Model | T182T |
| Category | AIR |
| FAR Part | 091 |
| Aircraft Damage | DEST |
Conditions
| Light Condition | DAYL |
| Weather | IMC |
Injuries
| Fatal | 2 |
| Serious | 0 |
| Minor | 0 |
| None | 0 |
| Total Injured | 2 |
Probable Cause
The pilot’s decision to conduct flight into an area of icing in an airplane that was prohibited from such conditions, which resulted in exceedance of the airplane’s critical angle of attack, an aerodynamic stall/spin, and the pilot’s spatial disorientation while attempting to recover from the loss of control.
Full Narrative
HISTORY OF FLIGHTOn May 14, 2023, about 1135 (all times mountain daylight time, or mdt), a Cessna T182T airplane, N665B, was destroyed when it was involved in an accident near Albany, Wyoming. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to the pilot’s son, his father and his father’s wife were on a cross-country trip that originated in Bend, Oregon, and included a stop in Toronto, Canada, to attend a funeral. A review of commercially available ADS-B and ForeFlight preflight data showed that from April 25th to April 28th, the pilot conducted multiple visual flight rules (VFR) flights and one IFR flight while enroute to the Buttonville, Municipal Airport (CYKZ) Toronto, Canada. There were no indications of flight abnormalities during these flights.
While in Toronto, the airplane was loaded with personal items, and on May 11, 2023, the pilot and passenger began their return trip. The couple departed CYKZ and travelled to Buffalo Niagara International Airport (BUF) Buffalo, New York. The flight then continued to the Chicago Executive Airport (PWK) Chicago, Illinois, where the couple visited family. According to the pilot’s son, the pilot adjusted his flight itinerary to avoid adverse weather to the west.
On May 13, 2023, the pilot and passenger departed PWK and conducted an IFR flight to the Lincoln Airport (LNK), Lincoln, Nebraska. While at LNK the pilot mentioned to the front desk team that they were waiting on weather so they will be in Lincoln a little longer than expected. While at LNK, during the fueling operation, a “fueler” did not secure the left-wing tank cap, and it separated from the wing, later to be recovered by a fixed base operator (FBO) employee. The pilot and passenger, unaware of the missing cap, departed and conducted an IFR flight to Northern Colorado Regional Airport (FNL) Fort Collins, Colorado. While at Fort Collins, the pilot was made aware of the missing cap, and replaced it with an automotive cap.
While in Fort Collins, the wife of the pilot texted a family member and wrote, “The visibility is very low at the moment. We may be stuck here for a bit.” The pilot also communicated with his son and notified him that they had safely arrived at Fort Collins and that he was hopeful to return home the following day.
According to ForeFlight records, the pilot filed an IFR flight plan from FNL to the Southwest Wyoming Regional Airport (RKS) Rock Springs, Wyoming, that would occur on May 14, 2023. A weather briefing was provided to the pilot that included Airmen’s Meteorological Reports (AIRMETS) for IFR conditions, mountain obscurations, moderate turbulence, and moderate icing conditions along portions of the route.
ADS-B data and air route controller communication records showed the airplane departed runway 33 at FNL about 10:46. ADS-B data showed the airplane maintained about 95 knots ground speed during the initial climb out. After departure the pilot was in radio contact with departure control and was directed to climb to 12,000 ft msl and later cleared to fly direct to the YAMMI intersection to join the Laramie transition. About 1059, the pilot was directed to contact the air route controller. Immediately afterwards, the pilot contacted the air route controller and reported climbing to 12,000 ft. The air route controller advised the pilot of the Laramie altimeter setting.
About 1107, the air route controller directed the pilot to climb to 13,000 ft. Two minutes later the pilot was directed to cross the Laramie very high frequency omnidirectional range station (LAR VOR) at 13,000 ft, which the pilot acknowledged. ADS-B data showed that after reaching 13,000 ft, the airplane accelerated to a maximum ground speed of about 146 knots for a moment, then reduced and maintained a groundspeed of about 115 knots. About 1115, before arriving over the LAR VOR, the pilot reported mild rime ice at 13,000 ft, and an outside air temperature of -2°C. The air route controller asked the pilot if he wanted to climb higher and the pilot replied that they were okay for now. ADS-B data showed the airplane crossed over LAR VOR about 13,175 ft while maintaining about 115 knots. The airplane then turned left to a heading of about 288° magnetic and proceeded northwest, consistent with tracking along the V4 low altitude enroute airway towards the Cherokee VOR (CKW VOR).
At 1131:34, while about 15 miles northwest of the LAR VOR, the airplane’s speed reduced to about 95 knots and the airplane turned off course to the right and began a descent. About the same time, the engine data monitor (EDM) recorded an increase of power. The airplane’s speed increased momentarily to about 126 knots but continued to vary from about 126 to 72 knots for the remainder of the flight. The air route controller issued a low-altitude alert and advised the pilot that the minimum IFR altitude (MIA) was 13,000 feet and advised him to climb immediately. The air route controller received no response. The air route controller advised the pilot with a second low altitude alert and again received no response. The air route controller then made a broadcast for N665B which the pilot responded with “we got a problem, hold on.” About that time, ADS-B showed that the airplane was right of course about ½ mile, maintaining a heading of about 348° magnetic, and was descending through about 11,950 ft. About one minute later the air route controller asked the pilot if he needed a heading for lower altitude or to an airport. The pilot responded with, “will get back to you in a minute.” About that time, ADS-B showed that the airplane was about 1 mile right of course in a continuous, tightening right turn and descending through about 10,900 ft about 1,825 ft per minute, while the EDM recorded that the power remained high. The air route controller attempted to contact the pilot on multiple occasions but received no further response. The last ADS-B data point recorded the airplane at an altitude of 9,075 ft msl (about 965 ft agl) with a groundspeed of 87 knots about 890 ft north of the accident site. Figure 1 is a Google Earth image illustrating the airplane’s ADS-B track during the final moments of the flight. About 1150, the air route controller issued an alert notification (ALNOT) for N665B, and the wreckage was located about 1425.
Figure 1. Google Earth view of the ADS-B defined route of flight and the accident location. The arrows indicate the direction of flight. The dashed line is an estimate of airway V4 and the LYMPS waypoint between the LAR VOR and the CKW VOR. PERSONNEL INFORMATIONA review of an excerpt of the pilot’s personal logbook showed that he underwent instrument proficiency flights on June 30, 2018, September 4, 2020, and January 28, 2022.
According to a certificated instrument flight instructor (CFII), he flew 11 flights with the accident pilot between September 4, 2020, to February 8, 2023. The flights included two instrument proficiency flights that occurred on September 4, 2020, and January 28, 2022. He recorded 16 approaches and logged 15.5 hours of dual flight time including 10.0 hours of hood time. He reported the accident pilot’s instrument flying skills showed remarkable improvement from previous instrument flights. The flight instructor recalled that on the last instrument training flight with the accident pilot, about October 6, 2023, he noticed that the attitude indicator would develop an error and give false indications. He advised the pilot to get the attitude indicator fixed before taking the airplane into instrument conditions. While on the flight, the CFII took a photograph of the instrument panel (see Figure 2) that showed the attitude indicator and the turn coordinator were not in agreement; the attitude indicator showed the airplane in a left turn while the turn coordinator indicated a right turn
Figure 2. Photograph of the accident airplane's instrument panel. Photo courtesy of the CFII. AIRCRAFT INFORMATIONFuel records revealed that the pilot purchased 74.3 gallons of 100 low lead aviation fuel while at FNL. According to the Fixed Base Operation (FBO) at FNL, the pilot topped off the airplane with fuel before departing, which resulted in about 92 gallons or 552 pounds. The contents of the airplane were weighed and determined to be 310 pounds. The pilot and passenger’s weights were estimated to total 350 pounds. A Pilot’s Operating Handbook for an exemplar Cessna T182T airplane listed the standard empty weight as 2,023 pounds, the maximum useful load of 1,089 pounds, and a maximum takeoff weight of 3,100 pounds. Calculations revealed that the load (baggage, crew, and fuel weights) of the accident airplane was about 1,212 pounds, or about 123 pounds over the maximum useful load. If the accident airplane’s empty weight was the same as the exemplar airplane, the maximum calculated takeoff weight for the accident airplane would have been about 3,235 pounds, or about 135 pounds above the maximum takeoff weight.
Maintenance records for the airplane were not recovered. A photocopy of some maintenance records revealed that an annual inspection occurred on October 5, 2022, at a tachometer time of 2,537.4 hours. Damage to the cockpit area precluded identification of the autopilot manufacturer; however, the Pilot’s Operating Handbook for a similar airplane listed the Bendix/King KAP 140 2-Axis autopilot as standard equipment. According to the CFII, the airplane was equipped with an autopilot that was coupled to a Garmin 400.
The attitude indicator was destroyed and provided no useful data. Determination of the preaccident status of the attitude indicator was inconclusive. Attempts to contact the maintenance company where previous maintenance on the airplane was conducted were unsuccessful. According to the CFII, who worked for the same company, the maintenance shop was no longer in business, and he was unaware if the pilot had the attitude indicator repaired. According to the son of the pilot, he did not talk to his father much about the airplane and could provide no details on the airplane’s maintenance.
The Pilot’s Operating Handbook (POH) stated in part, “The Cessna T182T Nav III airplane is approved for day and night, VFR and IFR operations. Flight into known icing conditions is prohibited.” METEOROLOGICAL INFORMATIONA weather study revealed that a low-pressure trough stretched from north to south from central Wyoming into central and western Colorado. The trough was located above the accident site. Troughs can act as lifting mechanisms to help produce clouds and precipitation if sufficient moisture is present.
Laramie Regional Airport (LAR) had the closest official weather station to the accident site. KLAR had an Automated Surface Observing System (ASOS). The LAR ASOS was located 19 miles southeast of the accident site, at an elevation of 7,284 ft, and issued the following observations surrounding the period of the accident:
LAR weather at 1153, automated, wind from 070° at 12 knots, visibility 10 miles or greater, overcast ceiling at 1,900 ft agl, temperature of 10°C, dew point temperature of 6°C, and an altimeter setting of 30.49 inHg. Remarks: automated station with a precipitation discriminator, sea level pressure 1027.1 hPa, 6-hourly precipitation of a trace, temperature 10.0°C, dew point temperature 5.6°C, 6-hourly maximum temperature of 10.6°C, 6-hourly minimum temperature of 5.6°C, 3-hourly pressure increase of 0.1 hPa.
The 1200 High-Resolution Rapid Refresh (HRR) model sounding indicated a conditionally unstable to stable environment from the surface through 18,000 ft. RAOB indicated a cloud layer from 8,300 ft through 18,000 ft. Light to moderate rime icing was indicated by RAOB in a layer between 11,000 ft and 14,000 ft.
Geostationary Operational Environmental Satellite number 16 (GOES-16) visible and infrared data were obtained. Figure 3 presented the GOES-16 visible image at 1136 at 2X magnification, with the accident site highlighted with a red square. The visible imagery indicated cloud cover above the accident site at the accident time with the cloud cover moving from southeast to northwest.
Figure 3. GOES-16 visible image at 11:36
Figure 4 presented the Cheyenne Regional Airport (CYS) Cheyenne, Wyoming, WSR-88D base reflectivity images for the 0.48° elevation scans initiated at 1128:07 and 1132:39, with resolutions of 0.5° X 250 m. These images depicted scattered areas of reflectivity values between -5 and 15 dBZ moving from east to west over the last 12 minutes of the accident flight track.
Figure 4. CYS WSR-88D reflectivity for the 0.48° elevation scan initiated at 11:28 with the accident site marked with the red circle, the location of the accident airplane in the black circle, and the accident flight track in magenta.
The National Weather Service (NWS) Aviation Weather Center (AWC) had text Airmen’s Meteorological Information (AIRMET) advisory Sierra valid for the accident site at the accident time. The text AIRMET Sierra was issued at 0845 and forecast (1) IFR conditions due to precipitation, mist, and fog and (2) mountain obscuration due to clouds, precipitation, and mist. AIRMET Zulu for moderate icing was valid for the accident flight through a point 20 miles east of KLAR but was not valid for the accident site. The ForeFlight weather briefing that the pilot received contained the above mentioned AIRMETS.
The Current Icing Product (CIP) and Forecast Icing Product (FIP) imagery provided information on expected icing severity as five categories: none, trace, light, moderate, and heavy. The FIP icing probabilities and icing severity products for the 1-hour forecast, valid at 1100 and 1200 at 11,000 through 15,000 ft, indicated a 30 to 80% probability of trace to moderate icing above the accident site. The highest probabilities and intensity rates were from 12,000 to 15,000 ft. The CIP products indicated a 30 to 85% probability of light to heavy icing from 10,000 ft through 15,000 ft at 1100 and 1200 above the accident site. AIRPORT INFORMATIONFuel records revealed that the pilot purchased 74.3 gallons of 100 low lead aviation fuel while at FNL. According to the Fixed Base Operation (FBO) at FNL, the pilot topped off the airplane with fuel before departing, which resulted in about 92 gallons or 552 pounds. The contents of the airplane were weighed and determined to be 310 pounds. The pilot and passenger’s weights were estimated to total 350 pounds. A Pilot’s Operating Handbook for an exemplar Cessna T182T airplane listed the standard empty weight as 2,023 pounds, the maximum useful load of 1,089 pounds, and a maximum takeoff weight of 3,100 pounds. Calculations revealed that the load (baggage, crew, and fuel weights) of the accident airplane was about 1,212 pounds, or about 123 pounds over the maximum useful load. If the accident airplane’s empty weight was the same as the exemplar airplane, the maximum calculated takeoff weight for the accident airplane would have been about 3,235 pounds, or about 135 pounds above the maximum takeoff weight.
Maintenance records for the airplane were not recovered. A photocopy of some maintenance records revealed that an annual inspection occurred on October 5, 2022, at a tachometer time of 2,537.4 hours. Damage to the cockpit area precluded identification of the autopilot manufacturer; however, the Pilot’s Operating Handbook for a similar airplane listed the Bendix/King KAP 140 2-Axis autopilot as standard equipment. According to the CFII, the airplane was equipped with an autopilot that was coupled to a Garmin 400.
The attitude indicator was destroyed and provided no useful data. Determination of the preaccident status of the attitude indicator was inconclusive. Attempts to contact the maintenance company where previous maintenance on the airplane was conducted were unsuccessful. According to the CFII, who worked for the same company, the maintenance shop was no longer in business, and he was unaware if the pilot had the attitude indicator repaired. According to the son of the pilot, he did not talk to his father much about the airplane and could provide no details on the airplane’s maintenance.
The Pilot’s Operating Handbook (POH) stated in part, “The Cessna T182T Nav III airplane is approved for day and night, VFR and IFR operations. Flight into known icing conditions is prohibited.” WRECKAGE AND IMPACT INFORMATIONThe airplane impacted open, sparsely vegetated terrain and came to rest upright on a magnetic heading of 360° at an elevation of 8,082 ft msl. The first point of probable impact was a gouge of about 12 inches deep directly underneath the engine. The airplane appeared to have not moved beyond the initial impact spot. All major components of the airplane remained attached, except for one propeller blade. A debris field of about 50 ft extended forward of the wreckage. The fuselage was fragmented and extensively crush damaged. Both wings exhibited accordion-type aft buckling throughout their respective spans, with hydraulic deformation visible on the leading edges of both wings. The empennage displaced over the fuselage in a scorpion-like profile. An automotive fuel cap was secured to the left-wing fuel port. The engine was displaced aft beyond the firewall, and the cabin roof was displaced forward over the engine. A large amount of cargo filled the aft seating area.
Postaccident examination of the airframe and engine revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation.
The engine data monitor (EDM) recorded data that included cylinder head temperature (CHT), exhaust gas temperature (EGT), and fuel flow (FF). The EDM recorded the entire accident flight and revealed EGT, CHT and FF consistent with normal operations throughout most of the flight, except for the last 2.5 minutes, when the fuel flow momentarily spiked downward from about 18.5 gallons per minute to about 10 gallons per minute then increased to about 22 gallons per minute, and the exhaust gas temperatures fluctuated around 1,270°F then increased to about 1,360°F, consistent with an increase of power. The increase in power remained applied until the end of the recorded data.
An Appareo Stratus device was recovered from the airplane. The Stratus contained an internal attitude, heading and reference system, in addition to GPS/wide area augmentation system (WASS) data, and ADS-B data. A review of the Stratus accident flight data showed a flight path consistent with the FAA-provided ADS-B data, and also showed normal pitch, roll, and yaw attitudes; however, the Stratus data ended about 1126:21 while the airplane was in level flight at 13,241 ft msl at 122 knots ground speed, about 7 miles northwest of the LAR VOR, or about 11.5 miles from the accident site. ADDITIONAL INFORMATIONThe Airplane Flying Handbook provides a generic stall recovery procedure for a light general aviation airplane.
1. Disconnect the wings leveler or autopilot.
2. Pitch nose-down control.
3. Roll wings level.
4. Add thrust/power.
5. Retract speed brakes/spoilers.
6. Return to the desired flight path.
The FAA Instrument Flying Handbook FAA-H-8083-15B, states in part, “Structural icing is a condition that can only get worse. Therefore, during an inadvertent icing encounter, it is important the pilot act to prevent additional ice accumulation. Regardless of the level of anti-ice or deice protection offered by the aircraft, the first course of action should be to leave the area of visible moisture. “The effects of ice on aircraft are cumulative—thrust is reduced, drag increases, lift lessens, and weight increases. The results are an increase in stall speed and a deterioration of aircraft performance.
The FAA defines plan continuation bias as the continuation of an original plan even when information suggests the plan should be abandoned. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by the Weld County Coroner’s Office, Greely, Colorado, which listed the cause of death as “multiple blunt force injuries.”
Postmortem toxicological testing by the FAA Forensic Sciences Laboratory detected ethanol at 0.013 g/dL in blood; ethanol was not detected in liver or muscle tissue.
Ethanol is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including a prohibition on piloting a civil aircraft while having a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol may sometimes be produced by microbes in a person’s body after death, potentially elevating ethanol levels in some postmortem specimens but not others.
About This NTSB Record
This aviation event was investigated by the National Transportation Safety Board (NTSB). NTSB investigates all U.S. civil aviation accidents to determine probable cause and issue safety recommendations to prevent future accidents.