1 fatality

2021-07-13: Cessna 421C Golden Eagle III (N678SW) — M. E. Mullaly — Monterey, United States of America

Monterey, United States of AmericaTakeoff (climb)

On July 13, 2021, a Cessna 421C Golden Eagle III (registration N678SW) operated by M. E. Mullaly was involved in an aviation accident near Monterey, United States of America during takeoff. One person was killed. Investigators recorded the probable cause as: The pilot’s failure to maintain airplane control due to spatial disorientation during an instrument departure procedure in instrument meteorological conditions, which resulted in a collision with terrain. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781189993Data APIEditorial standards

A pilot experienced spatial disorientation during an instrument departure in instrument meteorological conditions, leading to a loss of control and collision with terrain. The pilot lacked recent instrument currency and was distracted by radio tasks.

Flight Details

The pilot initially filed an instrument flight rules (IFR) flight plan but canceled it before takeoff, requesting a visual flight rules (VFR) on-top clearance. The controller issued this clearance via the Monterey Five departure procedure, which included a left turn after takeoff. The pilot took off, climbed to about 818 feet, and then entered a right turn. The air traffic controller observed the incorrect turn and issued a heading correction, instructing a right-hand turn to 030°, which the pilot acknowledged. The airplane continued climbing through another 925 feet before entering a descent. The controller issued two low altitude alerts, but the pilot did not respond. No further radio communication was received. The airplane continued its descent until it struck trees, terrain, and a residence approximately 1 mile from the departure airport.

Weather and Conditions

Weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 feet above ground level and tops near 2,000 feet mean sea level. The airplane entered IMC shortly after takeoff, during the climbing right turn.

Aircraft Examination

Examination of the airframe and engines revealed no anomalies that would have precluded normal operation.

Pilot Experience

Review of the pilot's logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC, combined with a momentary diversion of attention to manage the radio, may have contributed to the development of spatial disorientation.

Probable Cause

The official probable cause is the pilot’s failure to maintain airplane control due to spatial disorientation during an instrument departure procedure in instrument meteorological conditions, which resulted in a collision with terrain. Contributing to the accident was the pilot’s lack of recent instrument flying experience.