FLIGHT FINDINGSAVIATION OCCURRENCE MAP
Back to map

WPR16FA111 · Cessna R182

15 May 2016 · Altadena, CA, United States

Cessna R182 · Accident: controlled flight into terrain/object (CFIT) on approach

From San Diego, CA to Santa Monica, CA

Report a problem

Event

NTSB case
WPR16FA111
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
1 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Instrument Meteorological Cond

Cessna R182

Aircraft type
Cessna 182
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N133BW
Operator
Unknown
Onboard fatalities
Unknown
Route
From San Diego, CATo Santa Monica, CA
Aircraft age
About 38 years (built 1978)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach · IFR initial approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Controlled flight into terrain/object (CFIT)
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed

Cause areas

  • Aircraft › Aircraft oper/perf/capability
  • Environmental issues › Conditions/weather/phenomena
  • Personnel issues › Action/decision
  • Personnel issues › Psychological

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The instrument-rated private pilot departed in the airplane on a cross-country flight under daytime instrument meteorological conditions (IMC). Throughout the first portion of the flight, the pilot was in contact with air traffic control (ATC) controllers. As the flight neared its destination, the pilot was instructed to turn the airplane to a heading of 030° and maintain an altitude of 4,000 ft mean sea level (msl). The pilot complied with the instructions and was told to change frequencies to another ATC sector. The new controller provided the pilot with an altimeter setting and approach information, which the pilot acknowledged receiving. A short time later, the controller issued the pilot directions to turn left to a heading of 290° and descend to 3,000 ft msl for a radar vector to the final approach course. Despite 10 attempts by the controller to reach the pilot, no response was received. About 3 minutes after the controller issued the initial heading and altitude change, the pilot transmitted that he was still on the 030° heading. The controller immediately responded to the pilot and provided him instructions to turn left and climb to 6,000 ft msl. The pilot did not respond, and the airplane continued on the 030° heading toward mountainous terrain with elevations above the airplane's 4,000-ft altitude. The controller made 17 additional attempts to communicate with the pilot over a period of about 5 minutes. There was no response before radar contact with the airplane was lost. The airplane impacted mountainous terrain near the last recorded radar target at an elevation of about 4,000 ft.

Weather data indicated that the flight would likely have been in IMC between 2,800 and 5,000 ft msl; therefore, the terrain would not have been visible to the pilot. However, avionics equipment installed in the airplane could have displayed a moving map showing the airplane's current position in relation to airports, and navigational aids.

The wreckage was severely fragmented and mostly consumed by a postimpact fire. The damage to the airplane was consistent with controlled flight into terrain. Although no evidence of preimpact mechanical malfunctions was found, the severity of the damage to the airplane precluded testing of the airplane's avionics equipment. It could not be determined why the pilot was unable to communicate with ATC or why he failed to maintain situational awareness and clearance from rising mountainous terrain.

The pilot's autopsy results revealed severe coronary artery disease, which placed the pilot at significantly increased risk of acute impairment or incapacitation by a cardiac event such as ischemia, a heart attack, or an arrhythmia, which could include symptoms ranging from chest pain, shortness of breath, or palpitations all the way to loss of consciousness. However, during the pilot's last transmission, he did not mention any such symptoms, and he did not seem to be in distress. Therefore, it is unlikely that an acute cardiac event caused or contributed to this accident. Toxicology testing identified the pilot's use of a potentially impairing drug, hydrocodone. However, there was no blood available for testing, and there is no method for calculating blood levels from liver or urine results. While the impairing effects of hydrocodone and its metabolite dihydrocodeine could have decreased the pilot's attentiveness or increased his susceptibility to a distraction, whether this occurred could not be determined.

Probable cause

The pilot's failure to maintain clearance from rising mountainous terrain while flying in instrument meteorological conditions. Contributing to the accident was the loss of radio communications for a reason that could not be determined because of the extensive impact and thermal damage to the airplane.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR16FA111
Event ID
20160516X04030
Case number
WPR16FA111
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: 69f93f1266ddacf98b220432652b14fb7e001f62af470588636e84613684f90b; retrieved 2026-09-14T21:45:59.016Z.