NTSB Factual Report

HISTORY OF FLIGHT

On February 24, 2000, approximately 1845 mountain standard time, a Cessna 182E, N2988Y, owned and operated by the pilot, was destroyed when it collided with terrain while descending 1.5 miles east of the Taos Municipal Airport at El Prado, New Mexico. The private instrument rated pilot, the sole occupant aboard, was fatally injured. Instrument meteorological conditions prevailed, and a VFR flight plan was filed for the personal flight being conducted under Title 14 CFR (Code of Federal Regulations) Part 91. The flight originated at Albuquerque, New Mexico, approximately 1758.

According to a friend of the pilot's, he was contacted at home by the pilot who inquired as to the weather conditions at Taos. The friend said he told him that it was snowing, and that he "should not even think of flying." The pilot then received an in-person abbreviated weather briefing from the Albuquerque Flight Service Station (FSS). He was advised that VFR (visual flight rules) flight was not recommended (VNR) due to mountain tops being obscured, turbulence, and icing conditions. This information was based on Doppler radar and the Taos AWOS (Automated Weather Observation System). The pilot's friend said that about 45 minutes later, the pilot telephoned a second time and told him that it would be possible to make the flight VFR because the Taos AWOS was reporting 10 miles visibility and ceiling of at least 10,000 feet. His friend told him that it was still snowing where he lived (about 25 miles west of the airport and 8,200 feet above sea level). The pilot said he was going to attempt the flight anyway, citing his friend living "right at the edge of the snow level."

The pilot took off and established radio contact with the Albuquerque Air Route Traffic Control Center (ARTCC) at 1806. At 1818, the pilot requested and was given permission to leave the frequency momentarily. He contacted a friend at his home on (Unicom) frequency 122.75 MHz, and told him he had just passed Santa Fe and wanted to know what the weather was like at Taos. His friend, using a hand-held radio, looked outside and told him that the weather was clear in Taos, but snow was falling over the mountains.

The pilot reestablished radio contact with Albuquerque ARTCC at 1823. Shortly thereafter, the controller told the pilot that his filed flight plan went only as far as the Taos VORTAC (Very High Frequency Omnidirectional Radio Range Tactical Air Navigation), and asked if he planned to land at Taos. The pilot said he did, but was considering turning back and landing at Santa Fe. At 1831, radar contact was lost and at 1832, the pilot's request for a frequency change was approved.

The pilot again contacted his friend and told him he had passed Espinola, and that the snow had moved in behind him. His friend said it was now snowing at Taos, too. The next contact with the pilot was when he reported being 5 miles southwest of the airport. Then the pilot said he had the airport in sight, but was having difficulty maintaining visual contact with the runway lights because he was "in and out of snow showers." His friend asked him what his altitude was, and the pilot replied he was at 7,600 feet (airport elevation is 7,091 feet). The pilot then said he was "picking up ice" and "[thought he was] in trouble." This was the last contact with the pilot. The pilot's friend telephoned the airport manager, who went outside his home and noted that it was "snowing chicken feathers" (wet snow, large flakes, heavy downfall).

At 1859, the pilot of a Beech 200, N444MT, advised Albuquerque ARTCC that he was receiving an ELT (emergency locator transmitter) signal. At 2027, the pilot of an Air Force C-130 agreed to fly to Taos in an attempt to locate the source of the ELT signal using a DF (directional finder) steer. At 2108, C-130 pilot reported picking up a strong ELT signal southwest of Taos and provided the controller with latitude and longitude coordinates. At 2151, the C-130 pilot executed an NDB (nondirectional beacon) runway 4 instrument approach to Taos in an attempt to get below the overcast. At 2202, he reported no success in acquiring visual contact. The wreckage was located by ground search teams approximately 2230.

The accident occurred during the hours of darkness at a location of 36 degrees, 44.532 (36/26.779) minutes north latitude, and 105 degrees, 6448 minutes (105/38.688) west longitude.

PERSONNEL INFORMATION

The pilot, a psychiatrist, maintained a practice and residence in both Taos and Los Angeles, California. He was also on the faculty at UCLA Medical Center, serving as associate clinical professor in the psychiatry and biobehavioral science departments.

According to FAA documents and two logbooks found in the wreckage, the pilot started taking flying lessons on January 7, 1991. Nine months later, he purchased N2988Y and continued his training in that airplane, earning his private pilot's license on November 24, 1991. On October 13, 1995, he received an instrument rating His most recent biennial flight review was dated October 9, 1999. The last entry in his logbook was dated February 17, 2000. (For a summary of the pilot's flight time, see docket exhibits).

As a result of a flight that occurred on August 5, 1997 (logbook entry attached, see docket exhibits), FAA initiated a certificate enforcement action against the pilot, alleging that he "entered into IFR conditions without prior clearance, failed to maintain assigned altitude, and departed airway contrary to ATC clearance." Specifically, the pilot was charged with violating FAR (Federal Aviation Regulation) 91.13(a), 91.123(a), and 91.173.

According to the enforcement action, the pilot reportedly inadvertently entered a thunderstorm somewhere in the vicinity of Santa Fe, New Mexico, became disoriented, and was given a flight assist by Albuquerque ARTCC. FAA documents indicate the pilot was offered and accepted "remedial training." The training consisted of additional instrument flight instruction given by a certified flight instructor and monitored by FAA's accident prevention specialist.

AIRCRAFT INFORMATION

N2988Y (s/n 18253988), a model 182E, was manufactured by the Cessna Aircraft Company in February 1962. It was equipped with a Continental O-470-R engine (s/n 83474-2-R), rated at 230 horsepower, and a McCauley 2-blade, all-metal, constant speed propeller (m/n 2A36C).

The airplane's maintenance records were never located. According to a mechanic for Taos Aviation, however, he performed an annual inspection on the airplane on June 13, 1999. At that time, the tachometer registered 76.4 hours, and he computed the airframe total time to be 4,050.58 hours. At the accident site, the tachometer registered 1,800 rpm and recorded 0134.1 hours.

METEOROLOGICAL INFORMATION

Weather observations at the Taos Municipal Airport are made by AWOS (automated weather observation system) without precipitation discriminator (A01). The following weather observation was recorded at 1840, or about 5 minutes before the accident, to wit:

WIND 300 DEGREES AT 12 KNOTS; VISIBILITY 9 STATUTE MILES; FEW CLOUDS AT 1,200 FEET, 1,900 FEET SCATTERED, CEILING 3,400 FEET BROKEN, TEMPERATURE 2 DEGREES CELCIUS, DEW POINT -6 DEGREES CELCIUS; ALTIMETER 29.70 INCHES OF MERCURY.

Twenty minutes later, at 1900, the following weather observation was recorded:

WIND 290 DEGREES AT 3 KNOTS; VISIBILITY 1 STATUTE MILE; CEILING 100 FEET OVERCAST; TEMPERATURE 1 DEGREE CELCIUS, DEW POINT -5 DEGREES CELCIUS; ALTIMETER 29.70 INCHES OF MERCURY.

The Flight Service Station specialist told the pilot that VFR flight was not recommended due to mountains being obscured, turbulence, and icing conditions. These advisories were contained in AIRMETs (Airmen's Meteorological Information) Tango, Zulu, and Sierra (attached, see docket exhibits).

In addition to describing accident weather conditions as "snowing chicken feathers" (wet snow, large flakes, heavy downfall), the airport manager estimated there was a 100 foot obscured ceiling and a 1/4-mile visibility at the time of the accident.

WRECKAGE AND IMPACT INFORMATION

The on-scene investigation commenced and terminated on February 25, 2000.

The wreckage was strewn along a path on a magnetic heading of 171 degrees. The elevation at the site was approximately 7,091 feet msl (mean sea level). Although snow had fallen during and after the accident, no snow was noted beneath major portions of the wreckage. The main body of wreckage was inverted about 115 feet from the initial ground interruptions. All major structural components remained attached to the airframe with the exception of the right wing, containing residual fuel, located 59 feet beyond the main wreckage. The nose and right main landing gears remained attached to the fuselage. The left main landing gear, along with the left elevator, pieces of both ailerons, and the left wing fuel tank cap, were found near the initial impact point. The left horizontal stabilizer was bent down. The remainder of the empennage was relatively undamaged. The flap actuator indicated the flaps were retracted, and this was confirmed by no exposed threads on the jackscrew. Ice was noted on the lower leading edge of an aileron. Control continuity was established between the ailerons and wing root, and between the elevators and rudder to the cockpit.

The cabin was crushed. Both front seats were torn from the seat rails. The rear bench seat was torn away from the floor mounts. The safety belt attach brackets were torn from the floor. A post-production shoulder harness was installed and remained attached to the airframe. The slot in the attachment buckle was elongated.

The engine lay rightside up. Drive train continuity was established. One propeller blade was found at the initial ground contact. The second blade was found attached to the hub. Its cambered surface bore chordwise scratches and was bent in torsion.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsy and toxicology protocols were (#1747-200-8T) conducted by the New Mexico State Medical Examiner's Office. According to its report, 12.51 MG/KG, 0.38 MG/L, and 3.97 MG/L fluoxetine were detected in the liver, right chest cavity blood, and bile, respectively.

A toxicological screen was also conducted by FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to CAMI's report (#200000047001), the following levels were detected: 0.405 (ug/mL, ug/g) and 12.84 (ug/mL, ug/g) Fluoxetine was detected in blood and liver, respectively, and 0.299 (ug/mL, ug/g) and 17.75 (ug/mL. Ug/g) Norfluoxetine was detected in blood and liver, respectively.

TESTS AND RESEARCH

NTAP (National Track Analysis Program) data was received from the Albuquerque ARTCC and plotted by a private concern in Great Falls, Virginia. According to this data, N2988Y departed runway 30, turned right, and followed Interstate Highway 25 and the Rio Grande northeastward. At 1825:06, in the vicinity of the communities of Lyden and Velarde, radar contact was lost when the airplane was at an encoded altitude of 9,200 feet msl (mean sea level). At that point, N2988Y was 23.5 miles southwest of the Taos Airport.

ADDITIONAL DATA/INFORMATION

The wreckage was verbally released to the pilot's friend on February 25, 2000. A written wreckage release, that included the return of the vacuum pump and several gyroscopic instruments, was executed on April 25, 2000.

In addition to the Federal Aviation Administration, parties to the investigation included the Cessna Aircraft Company and Teledyne Continental Motors.

**This case was modified on February 27, 2008.**

NTSB Probable Cause

The pilot's improper preflight planning/preparation in that he initiated flight into known adverse weather, and continued VFR flight into IMC to the point where remedial action was not possible. Factors were the weather conditions that included snow, low ceiling, and obscuration, a dark night, and his overconfidence in his abilities.

**This case was modified on February 27, 2008.**