MONTEREY – The National Transportation Safety Board has determined the probable cause of the Monterey plane crash that killed two people and a dog in July 2021 was “spatial disorientation” of the pilot, causing her to lose control of the airplane.

The Ntsb released its final report on the accident earlier this year, more than 20 months after an initial investigation into the crash began.

On the morning of July 13, 2021, a Cessna 421C crashed into a home in Monterey’s Monterra Ranch community, less than five minutes after taking off from the Monterey Regional Airport. The home was reportedly unoccupied at the time of the crash but suffered severe damage.

The plane was piloted by Pacific Grove resident Mary Ellen Carlin, family members confirmed following the accident. Carlin, 74, was accompanied by Rancho Cordova resident Alice Diane Emig, as well as Emig’s dachshund, Toby. All three died in the crash.

Carlin and Emig were longtime friends, family members previously told the Herald. Carlin was reportedly flying Emig back home to Rancho Cordova in Sacramento County when they fatally crashed.

According to the NTSB’s final report, it was “the pilot’s failure to maintain airplane control due to spatial disorientation” while flying in overcast conditions that led to the accident. The pilot’s lack of experience navigating through low cloud ceilings, the NTSB said, also played a part.

The NTSB’s report laid out a full picture of what happened before, during and after the 2021 crash.

Carlin left Monterey Regional Airport on July 13 at 10:54 a.m. During her ascent, Carlin established radio communication with the Oakland Air Route Traffic Control Center. She climbed to about 818 feet then entered a right turn. Departure procedure, however, required a left turn after takeoff.

An Oakland controller noticed that the airplane was turning the wrong direction and issued instructions for a heading correction, which Carlin acknowledged. She continued to climb right for another 925 feet, then she began to descend.

The air traffic controller issued two low-altitude alerts with no response. There was no further audio communication from Carlin.

The plane continued to fall until it hit trees, terrain and ultimately, a residence about one mile south of the Monterey Regional Airport. The NTSB said that the Cessna’s debris path was about 995 feet long (just under 0.19 miles) from its first identifiable point of contact.

The morning of Carlin’s flight, the NTSB determined that there were “prevailing instrument meteorological conditions” in the area due to it being cloudy with a low ceiling, with ceilings near 800 feet above ground level.

Instrument meteorological conditions (IMC) is a flight category that, as a consequence of weather, requires pilots to fly primarily by reference to instruments rather than by outside visual references. In instrument meteorological conditions, pilots follow a different set of regulations known as “instrument flight rules.”

Carlin began climbing right shortly after entering instrument meteorological conditions, according to the NTSB, while she also managed radio communications with air traffic control.

In reviewing Carlin’s logbook, the NTSB found that Carlin had logged a total 9,337 hours in the air through her flying career. Though for the conditions she faced in July 2021, the NTSB reported that Carlin had only accumulated about 0.3 hours of simulated instrument flight, 0.7 hours of actual instrument flight and no instrument approaches in the 12 months preceding her fatal accident. As a result, the NTSB concluded that she had “not met the instrument currency requirements” and was likely not proficient at controlling her airplane on instruments.

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“The pilot’s lack of 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 NTSB report read.

According to the Federal Aviation Administration, spatial disorientation is a “loss of proper bearings; state of mental confusion as to position, or movement relative to the position of the earth.”

Factors that contribute to spatial disorientation include changes in acceleration, instrument meteorological conditions and unexpected changes in aircraft altitude.

The NTSB did not find any issues or malfunctions with Carlin’s Cessna that would have contributed to the crash.

An autopsy from the Monterey County Sheriff’s Office determined Carlin’s cause of death was “multiple blunt force injuries.” An FAA toxicology test found no evidence of drug use.