Cessna 421C accident near Monterey, California, July 13, 2021
On July 13, 2021 at about 5:42 pm local time, a Cessna 421C, registered N678SW, was destroyed in an accident during initial climb near Monterey, California (Monterey Rgnl airport). It was a personal flight under general aviation rules (Part 91). 2 people were 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 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.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- July 13, 2021 · about 5:42 pm local time
- Place
- Monterey, California · Monterey Rgnl · map
- Type
- Accident
- Injuries
- 2 people were killed.
- Weather
- instrument conditions (cloud, fog or low visibility)
- Aircraft
- Cessna 421C · all 421Cs on the register
- Registration
- N678SW · no longer on the register · serial 421C1023
- Damage
- Destroyed
- Flight
- Personal flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o, which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. 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, resulting in a loss of airplane control.
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
- Collision with terrain or object (not controlled flight into terrain) during initial climb defining event
The NTSB's findings
- Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
- Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima › Effect on operation
- Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation › Pilot
- Personnel issues › Experience/knowledge › Experience/qualifications › Recent instrument experience › Pilot
Pilot
- Certificate: airline transport pilot, commercial pilot
- Ratings: multi-engine land; single-engine land; single-engine sea; instructor: airplane multi-engine; instructor: airplane single-engine; instructor: instrument airplane; instrument: airplane
- Flight time: 9,337 hours in all
- Last flight review: July 17, 2020
- Medical certificate: Class 3 (with waivers/limitations)
- Seat: left
- Injury: fatal
Passenger
- Seat: rgt
- Injury: fatal
The aircraft
- Airframe total time: 5,818.7 hours
- Last inspection: annual inspection, October 1, 2020
- Seats: 8
- Landing gear: retractable
- Engine 1: Continental Motors GTSIO-520-N ( (piston); 0 hours total
- Engine 2: Continental Motors GTSIO-520-N ( (piston); 0 hours total
- Fire on the ground
The flight
- Destination: KMHR Sacramento CA
- Flight plan: IFR
Weather at the time
- Light: daylight
- Wind: from 280° at 7 knots
- Visibility: 9 statute miles
- Sky: overcast at 800 ft
- Temperature: 59°F (15°C), dew point 52°F (11°C)
- Altimeter: 29.99 inHg
- Observation at 10:54 am from KMRY, 1 miles away
Weather report (METAR): KMRY 131754Z 28007KT 9SM OVC008 15/11 A2999 RMK AO2 SLP166 T01500111 10150 20133 51013
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 1 | |||
| Passengers | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
15 documents, released by the NTSB on March 29, 2023. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.
| # | Document | What it is | |
|---|---|---|---|
| 1 | Witness Interviews and Statements | PDF, 6 pages | View Download |
| 2 | Pilot Logbook Excerpt | PDF, 5 pages | View Download |
| 3 | Meteorology Specialist's Factual Report | PDF, 10 pages | View Download |
| 4 | ATC Specialist's Factual Report | PDF, 12 pages | View Download |
| 5 | ATC Specialist's Factual Report - Attachment 1 - ADS-B Data | data file | Download |
| 6 | ATC Specialist's Factual Report - Attachment 2 - Opsvue Track Data | data file | Download |
| 7 | ATC Specialist's Factual Report - Attachment 3 - ATC Audio Transcript-partial | PDF, 4 pages | View Download |
| 8 | Accident Site Examination | PDF, 14 pages | View Download |
| 9 | Airframe and Engine Examination | PDF, 20 pages | View Download |
| 10 | Photo Array | PDF, 4 pages | View Download |
| 11 | Memo for Record Autopsy | PDF, 1 page | View Download |
| 12 | Toxicological Report | PDF, 1 page | View Download |
| 13 | Textron Party Form | PDF, 1 page | View Download |
| 14 | Smithsonian Institutiona��s Feather Lab Report | PDF, 1 page | View Download |
| 15 | Wreckage Release Form | PDF, 1 page | View Download |
The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.
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.
