Cessna R182 accident near Altadena, California, May 15, 2016
On May 15, 2016 at about 3:29 pm local time, a 1978 Cessna R182, registered N133BW, was destroyed in an accident during approach (IFR initial approach) near Altadena, California (Santa Monica Muni airport). It was a personal flight under general aviation rules (Part 91). 1 person was killed. The weather was instrument conditions (cloud, fog or low visibility).
The NTSB's probable cause their words, unchanged
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.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- May 15, 2016 · about 3:29 pm local time
- Place
- Altadena, California · Santa Monica Muni · map
- Type
- Accident
- Injuries
- 1 person was killed.
- Weather
- instrument conditions (cloud, fog or low visibility)
- Aircraft
- Cessna R182 NO SERIES, built 1978 · all R182s on the register
- Registration
- N133BW · no longer on the register · serial R18200450
- Damage
- Destroyed
- Flight
- Personal flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
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.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Controlled flight into terrain or object (CFIT) during approach (IFR initial approach) defining event
The NTSB's findings
- cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › Altitude › Not attained/maintained
- cause Personnel issues › Action/decision › Action › Lack of action › Pilot
- cause Personnel issues › Psychological › Perception/orientation/illusion › Situational awareness › Pilot
- cause Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Low visibility › Effect on operation
- factor Personnel issues › Task performance › Use of equip/info › Use of equip/system › Pilot
- factor Aircraft › Aircraft systems › Communications system › (general) › Not used/operated
- factor Not determined › Not determined › (general) › (general) › Unknown/Not determined
- Environmental issues › Physical environment › Terrain › Mountainous/hilly terrain › Contributed to outcome
- Personnel issues › Physical › Health/Fitness › Use of medication/drugs › Pilot
Pilot
- Certificate: private
- Ratings: single-engine land; instrument: airplane
- Flight time: 625 hours in all
- Medical certificate: Class 3 (with waivers/limitations)
- Seat: unk
- Injury: fatal
The aircraft
- Airframe total time: 8,912.3 hours
- Last inspection: annual inspection, November 12, 2015
- Maximum gross weight: 3,100 lb
- Seats: 4
- Landing gear: retractable
- Engine: Lycoming O-540-J3C5D (piston); 0 hours total
The flight
- Departed from: San Diego CA at 2:37 pm
- Destination: Santa Monica CA
- Flight plan: IFR
Weather at the time
- Light: daylight
- Visibility: 10 statute miles
- Sky: overcast at 1,600 ft
- Temperature: 61°F (16°C), dew point 54°F (12°C)
- Altimeter: 29.92 inHg
- Observation at 3:53 pm from KBUR, 11 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.
