According to maintenance records and interviews with individuals who had spoken with the pilot before the accident flight, the Cessna 182Q had a persistent autopilot problem.
The autopilot, when engaged and selected to altitude hold mode (ALT HOLD), would begin an altitude oscillation that would eventually reach 1,500 feet per minute in climbs and descents. Disengaging the autopilot had not been an issue.
Maintenance records showed autopilot discrepancies and corrective actions from October 2020 to Jan. 21, 2022. The maintenance shop that worked on the autopilot thought that the issue had been corrected, and, on Jan. 31, 2022, the pilot departed with his airplane. The oscillations still persisted, so he brought his airplane back to the maintenance shop on Feb. 14, 2022.
In addition to the original autopilot altitude porpoise issue, the pilot reported that he had performed autopilot/trim system troubleshooting, but he did not describe the specific actions he took to the maintenance shop manager. The pilot indicated that the programmer/computer for the autopilot displayed a fault but that the manual elevator trim wheel operation was normal.
The pilot did not have an appointment for service, and the shop could not evaluate the airplane at that time so the pilot decided to return to the shop at a later time.
No record indicated any maintenance performed after January 2022.
The airport manager at Jack Barstow Airport (KIKW) in Midland, Michigan, spoke with the pilot three days before the accident. She stated that, according to the pilot, he was “chasing an autopilot issue” that was still not fixed. She also stated that the pilot had indicated that he would be completing his planned trip to Northwest Florida Beaches International Airport (KECP) in Florida without the autopilot operating.
According to a friend of the pilot who spoke with him three days before the accident, the pilot stated that he was going to fly to Florida as soon as his airplane was fixed.
The friend asked the pilot, “are you comfortable flying without autopilot and single pilot that far?” The pilot responded, “yeah I’ll be fine.”
According to a family member, the pilot and his wife planned a cross-country flight departing from their home airport, KIKW, with a final destination of Panama City, Florida.
Review of Automatic Dependent Surveillance–Broadcast (ADS-B) data revealed that the pilot completed a 10-minute local flight at KIKW that concluded about 1118 (10:18 eastern standard time).
He then initiated an instrument flight rules (IFR) cross-country flight from KIKW about 1212 (11:12 eastern standard time) and arrived at Warren County Memorial Airport (KRNC), in McMinnville, Tennessee, about 1503 central standard time, resulting in a total flight time of 3 hours 51 minutes.
A fuel receipt showed that, about 1520, the pilot purchased 74 gallons of 100 low-lead fuel. The airplane departed KRNC about 1554 and arrived in the KECP area after about 2 hours 45 minutes of flight time.
Review of air traffic control (ATC) communications provided by the US Air Force and the FAA revealed that the flight was in contact with Tyndall Air Force Base.
The approach controller informed the pilot that automatic traffic information service information Quebec was current, cleared him to the initial approach fix, and instructed the pilot to cross the initial approach fix at or above 3,000 feet mean sea level (msl).
Subsequently, the controller issued an approach clearance for the straight-in instrument landing system (ILS) Runway 16 approach. A few minutes later, the pilot confirmed that the airplane was established on the approach, and the controller then instructed the pilot to contact the KECP tower.
The pilot informed the KECP tower that the airplane was inbound on the ILS Runway 16 approach. The controller acknowledged the transmission and provided the current weather observation at the airport, which indicated that the wind was from 150° at 6 knots, visibility was 2 statute miles, an overcast ceiling was present at 200 feet above ground level (agl) and the barometric pressure was 29.92 inches of mercury.
The pilot stated, “200 overcast we’ll give it a try and see if we can get her down.”
The controller then issued a landing clearance and offered to turn up the approach lights to the highest setting available. The pilot stated, “affirmative that would be good.”
The controller subsequently told the pilot that, if the airplane were able to descend beneath the overcast clouds, the approach lights might be “pretty bright,” and the pilot acknowledged this information.
About 40 seconds later, the controller stated, “I’m receiving a low altitude alert. Check your altitude,” to which the pilot stated “affirmative.”
The controller then informed the pilot that the Tyndall approach controller noticed that the airplane’s flight track was deviating to the right of the final approach course and advised the pilot to use caution.
The controller again provided the wind and ceiling information, which had not changed from the previous report; the pilot stated “affirmative.” The controller then stated, “there are other airports nearby with better weather conditions.” The pilot replied, “alright we’ll try this down to minimums and go around if need be.”
About 12 seconds later, the controller stated that the airplane appeared to be “drifting a little to the right” and then “well to the right.”
No further communications were received from the pilot despite several attempts by the controller to reach him. The controller subsequently alerted airport operations of a possible downed airplane.
Review of the ADS-B flight track in the final approach phase found that the airplane’s course continuously deviated left and right from the initial approach fix to the accident site, which was 1.55 nautical miles from the runway threshold.
The airplane’s altitude showed momentary descents and climbs while on final approach. At both instrument approach fixes, OTTOE (initial) and LIVVY (final), the airplane crossed the waypoints below the minimum altitudes prescribed in the instrument approach chart by about 500 and 700 feet, respectively.
The final ADS-B data point recorded the airplane at 75 feet MSL at a groundspeed of 144 knots and a ground track heading of 130°.
The wreckage came to rest in an area of heavily wooded terrain and was fragmented. The initial impact area coincided with 100-foot-tall trees, and the debris path was oriented on a magnetic heading of 130° to 140°. The airplane’s angle of descent through the trees was about 18° to 20°.
The pilot and his wife died in the crash.
All major components of the airplane were located in the debris path. Flight control and trim cable continuities were confirmed from the cockpit to each flight control surface except for the aileron balance cable, which exhibited tension overload and splayed ends. The flap actuator was found in a position that corresponded to flaps up.
The cockpit and instrument panel sustained significant impact damage. Most of the instrumentation displayed unreliable indications. The altimeter was found set to a barometric pressure of 29.88 inches of mercury (which would have resulted in the altimeter displaying altitudes that were about 40 feet lower compared with the setting of 29.92 that was current at KECP during the accident approach).
An S-TEC 55 X autopilot mode control unit was found loose in the cockpit and displayed significant impact damage. An S-TEC altitude alerter was found separated in the cockpit with impact damage.
A second autopilot mode control panel had fragmented and sustained significant impact damage.
The autopilot ON/OFF toggle switch was found on. The altitude alert ON/OFF toggle switch was found in a middle position that did not correspond to any setting. The ON/OFF trim switch was found on, and the NAV 1/2 mode was found in the NAV2 position.
According to a customer service employee at KRNC, the pilot discussed that he was on his way to Florida and was trying to beat bad weather arriving at the KECP area. He explained that he was trying to arrive between two lines of thunderstorms. The pilot appeared to be checking the weather and filing a flight plan on his personal iPad.
According to ForeFlight archived records, the pilot filed an IFR flight plan from KRNC to KECP with an alternate of Dothan Regional Airport (KDHN), in Dothan, Alabama. The flight plan was filed at 1028 eastern standard time (before the first flight leg of the day). The pilot received a standard preflight weather briefing as part of filing the flight plan. No records showed that the pilot received additional weather briefings later that day.
A National Transportation Safety Board weather study reviewed National Weather Service forecast and observation data for KECP and surrounding airports. The weather at KECP at 1453 (while the pilot was on the ground at KRNC) indicated the following: Wind from 140° at 11 knots gusting to 19 knots, 7-statute mile visibility, and a broken ceiling at 1,800 feet AGL. An AIRMET for IFR conditions was valid for the accident site at the accident time.
The terminal aerodrome forecast issued for KECP at 1140 called for, between 1500 and 2000, visibility greater than 6 statute miles, scattered clouds at 2,500 feet, and broken clouds at 25,000 feet. At 2000, the forecast called for a visibility of 6 statute miles, mist, and overcast ceilings at 400 feet AGL.
At 1721, while the airplane was en route from KRNC to KECP, another terminal aerodrome forecast was issued for KECP. The forecast called for, at 2000, a visibility of 1 statute mile, mist, and overcast ceilings at 500 feet AGL.
The KECP hourly weather observations showed that about 1700, IFR conditions were reported that continued to deteriorate throughout the evening.
At 1756, about 45 minutes before the pilot’s approach into KECP, the weather conditions were visibility 4 statute miles, mist, ceiling broken at 400 feet AGL, overcast at 800 feet AGL; the remarks section indicated that the ceiling was variable from 300 to 700 feet AGL.
A special hourly weather observation, which was issued at 1827, indicated a visibility of 2 statute miles, mist, and an overcast ceiling at 300 feet AGL; the remarks section indicated the ceiling was variable from 200 feet to 700 feet AGL.
The pilot’s alternate airport KDHN was about 60 nautical miles north of KECP, about a 25- to 30-minute diversion. The pilot’s route of flight from KRNC to KECP resulted in the airplane passing about 28 miles west of KDHN about 1815 (31 minutes before the accident occurred). The weather observations at KDHN starting at 1753 included visual meteorological conditions with calm wind.
Review of the pilot’s logbook revealed that he had accumulated 691 hours of total flight time, of which 569 hours were in the accident airplane. He had logged a total of 35 hours of night flight experience and a total of 2.5 hours of night actual instrument flight experience.
During the 12 months that preceded the accident, he had logged 13 hours of actual instrument experience; 1.5 hours of night flight experience, 0.5 hours of which was in actual instrument experience; and four night landings. During the six months before the accident, the pilot logged 11 instrument approaches. During the 90 days preceding the accident, he logged 51.3 hours of actual instrument flight experience and no night flights. His most recent flight review was competed on June 14, 2021. There was no record indicating that the pilot had landed at KECP within the 3 years before the accident.
The pilot received his instrument airplane rating on June 27, 2019, on the third practical examination attempt. The pilot received a notice of disapproval during two separate practical examination flights (in May and early June 2019). The comments on the first notice of disapproval indicated that the pilot became distracted, lost situational awareness, and improperly managed tasks during partial panel operations. The comments on the second notice of disapproval indicated that the pilot had flown an ILS approach to a full-scale deflection on the glideslope.
According to an individual who had flown with the pilot as a safety pilot during instrument training, the pilot would typically disengage the autopilot and hand fly approaches.
Probable Cause: The pilot’s deviation from the final approach course during a night instrument approach with low instrument meteorological conditions, which resulted in an impact with heavily wooded terrain. Contributing to the accident was the pilot’s decision to continue the approach after being warned of his flightpath deviations and his lack of experience in instrument conditions at night.
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This March 2022 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
I’m seeing additional items besides the pilot’s inability to track the ILS. I have roughly 1000 hours in 182s, maybe a little more, and I’ve never seen any that burned 19 gph. Yet if he refueled with 74 gallons after a 3 hour 52 minute flight, that was his fuel burn. I note that the engine had a P-Ponk modification, but that still doesn’t explain a fuel burn which is so excessive—unless the pilot didn’t lean at all. A normal O-470 burns about 12-13 gph; a P-Ponk conversion will burn maybe 3 gph more.
The usable fuel with long range tanks in a 182Q is 75 gallons. Putting 74 gallons into the tanks indicates really poor fuel planning. The NTSB report does not indicate that the airplane was equipped with auxiliary tanks, so when they landed at the intermediate stop, the airplane was almost out of fuel.
The approach speed of 140 knots is way more than is typical, even for a very experienced instrument pilot, in a 182. 90 knots is typical, with the first notch of flaps extended, not fully retracted. An experience instrument pilot might make the approach at 100 knots, but not 140 knots.
In other words, this was a pilot who was an accident waiting happen, with substandard capabilities that finally all came together.
what a shame. retired, looking for a winter home. blew chunks on his instrument check ride twice. i often wonder if a guy like that reads reports like these.
if it may be of some use … back in the day when i flew an ifr rated plane and actually stayed current i stumbled across a technique that i thought was very challenging and just as fun.
for practice approaches in VFR, descending at the IAP i would leave the landing gear up. i didn’t touch the power after that and left the flaps up. as i got closer to the minimum altitude i would really be moving, usually i was indicating 140 kts. by then. no autopilot. i never trusted it, original 1986 state of the art. it was great at altitude hold and following a bug.
when i did real approaches with the standard method in IFC it was a little boring actually and much easier than practice approaches. i never got close to doing a night approach in real IFC. too chicken, i admit.
I feel terrible about this crash and the loss of life. But hopefully there are a few lessons to be learned from this.
I noticed the flight track of this pilot on the approach and he was not holding the course. Could this be because the A/P was not following NAV or heading bug?
Observation based on experience:
One needs to be proficient hand flying an approach before allowing an A/P to fly an approach. That way, when you see the needles not staying in the donut, or it can’t hold a heading using the heading bug, you know that George is not having a good day and it just might put you into an unusual attitude and drop out.
Given that this pilot had issues with partial panel on a check ride for the Instrument rating and most of us will never be as good on partial panel as we were coming up to our Instrument checkride…..
Now to this A/P and its issues. If it could be demonstrated to be able to follow the heading bug with the other functions not being used, so that you could have it follow a course… I would consider the rest of the unit to be INOP and would ONLY use the heading bug to lessen my workload as a single pilot doing IFR.
I speak from experience. I’ve been in planes that had an A/P that could not hold the heading bug. In one case the A/P had to be “overhauled”, in the other case a sense cable had been damaged and had to be replaced.
I was the test pilot when trying to diagnose these things.
In the case of a multi-function A/P we had to treat it as INOP (actually, put an INOP sticker on it). It not only could not hold a heading, it was chasing altitude as well.
I also learned that A/Ps may have restrictions in their POH such that a single axis A/P may not be engaged below 2000 AGL when departing. Or altitude functions may not be used prior to 2000 AGL (just giving some examples).
Sounds like his cockpit management challenge exceeded his ability to perform, plus placing reliance on his known defective autopilot took two lives. RIP.
How were autopilot problems a contribution? Did you read the NTSB’s Probable Cause statement?
It’s a resource that if functioning correctly would have kept the airplane on a safe course.
Exactly, Mr. Warren Webb Jr.