CEN12FA143

NTSB accident investigation · Cessna 177A · North Vernon, IN · January 22, 2012

Accident · FatalField investigationFinal report
Date
January 21, 2012, 20:41 local (Jan 22, 2012, 01:41 UTC)
Place
North Vernon, IN
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N3435TCessna 177A
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed · report March 13, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Cessna Aircraft Company, Lycoming, Federal Aviation Administration
FAA report
20120122001129A
Case key
82730

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The non-instrument-rated pilot's decision to fly into known instrument meteorological conditions, which resulted in the pilot's spatial disorientation and loss of airplane control.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 177: 20 casesAll aircraft: 9,295 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Effect on operationCessna 177: 1 caseAll aircraft: 65 cases
Experience/qualifications: qualification/certificationPersonnel issues › Experience/knowledge · PilotCessna 177: 1 caseAll aircraft: 280 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The non-instrument-rated pilot was conducting the accident flight under visual flight rules (VFR) without a flight plan in dark night conditions. Before the flight, the pilot obtained several weather briefings indicating that instrument meteorological conditions prevailed along his route of flight. Postaccident review of weather and radar data indicated that the airplane descended into instrument meteorological conditions near the destination airport. Based on the wreckage distribution, which was consistent with a high-speed impact, and the adverse weather conditions present at the time of the accident, it is likely that the pilot experienced spatial disorientation and lost control of the airplane. Federal Aviation Administration guidance indicated that spatial disorientation can occur when there is no natural horizon or surface reference, such as night flight in sparsely populated areas similar to that of the accident area and in instrument conditions. A postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Factual narrative

FAA's Advisory Circular (AC) 60-4A, entitled "Pilot's Spatial Disorientation," states that disorientation is caused by a lack of visual reference to the natural horizon, and can be brought about by low visibility, night conditions, and reflected light from the anti-collision rotating beacon. Disorientation can cause the pilot to inadvertently place the airplane in a dangerous attitude. To avoid becoming disoriented, the Advisory recommends that pilots obtain training and maintain proficiency in aircraft control by reference to instruments, to rely solely on those instrument indications, and to avoid flying in poor or deteriorating weather conditions. The airplane was a 1969-model Cessna 177A, which is a single-engine, high-wing airplane, with fixed-tricycle landing gear, and was configured for 4 seats. The airplane was powered by a Lycoming O-360 series reciprocating engine, rated at 180 horsepower. The engine drove a Hartzell 2-blade constant speed propeller. The airplane's maintenance records were not located during the investigation. A Federal Aviation Administration (FAA) Form 337, Major Repair and Alteration, dated June 19, 2008, indicated a total airframe time of 4,269 hours. On January 21, 2012, at 2041 eastern standard time, a Cessna 177A single-engine airplane, N3435T, sustained substantial damage when it impacted wooded terrain near North Vernon, Indiana. The private pilot and passenger sustained fatal injuries. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed, and visual flight rules (VFR) flight following services were provided for the 14 Code of Federal Regulations Part 91 personal flight. The flight departed Lake in the Hills Airport (3CK), Lake in the Hills, Illinois, approximately 1830 central standard time, and was destined for the Madison Municipal Airport (IMS), Madison, Indiana. Air traffic control information revealed the pilot requested VFR flight following near the Boiler VHF Omnidirectional Range/Tactical Aircraft Control (VORTAC), Lafayette, Indiana, at an altitude of 7,800 feet mean sea level (msl). At 2036, the pilot was instructed to contact the Louisville air route traffic control center, which the pilot acknowledged. No further communications were received from the pilot. Radar data showed the airplane in a gradual descent from 7,800 feet msl to 2,800 feet msl, before radar contact was lost approximately 14 miles northwest of IMS. The airplane impacted wooded terrain adjacent to a residence. The homeowner reported he heard a low flying airplane, looked out the back window of his house, and noticed a small fire in the woods behind his residence. The homeowner called 911 and rescue efforts commenced. The Jennings County Coroner's Office performed the autopsy on the pilot on January 25, 2012. The autopsy concluded that the cause of death was extensive blunt force trauma, and the report listed the specific injuries. The FAA's Civil Aerospace Medical Institute (CAMI),Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Tests were negative for all screened substances. At 2056, the Columbus Airport, Columbus, Indiana, automated weather observing system (AWOS), located 27 miles northwest of the accident site, reported the wind from 080 degrees at 6 knots, 10 statute miles visibility, overcast clouds at 1,500 feet above ground level (agl), temperature minus 3 degrees Celsius, and an altimeter setting of 30.22 inches of mercury. The National Weather Service (NWS) Surface Analysis Chart for 1900 indicated a high pressure ridge extending over Indiana with the station models surrounding the accident site indicated winds from the east at approximately 5 to 10 knots, overcast clouds, temperatures in the mid 20's degrees Fahrenheit (F), with temperature-dew point spreads of 4 degrees or less. Several stations in Kentucky to the southeast through south of the accident site reported fog and mist. A review of the NWS weather radars surrounding the period indicated no weather echoes over southern Indiana or the route of flight surrounding the period. The NWS Weather Depiction Chart for 1900 depicted an area of instrument flight rules (IFR) conditions extending over southern Indiana and Ohio, and most of all of Kentucky. Pilot reports across the accident area confirmed a low layer of overcast clouds with bases from 1,700 and 1,900 feet and tops from 2,500 to 5,000 feet. Multiple reports of icing conditions were reported in the clouds. At 2110, a pilot operating a CRJ regional jet over Evansville, IN (EVV) west of the accident site reported encountering moderate rime icing during descent into an overcast layer of clouds, with tops at 5,000 feet. The closest Terminal Forecast (TAF) to the destination airport was from Louisville, Kentucky, and Covington/Cincinnati, Kentucky. Marginal VFR (MVFR) to IFR conditions with mist (fog) and low ceilings were forecast for the period. An Airman's Meteorological Information (AIRMET) advisory for IFR conditions was active for the accident location at the time of the accident. No advisories were current over Indiana for icing or turbulence. The pilot obtained several Direct User Access Terminal System (DUATS) weather briefings on selected stations during the day. A route weather briefing to IMS was requested at 0800. All the subsequent updates were for weather conditions near the departure airport at 1046 and 1914. At the time of the accident, both the Sun and the Moon were more than 25 degrees below the horizon and provided no illumination. The pilot held a private pilot certificate with an airplane single-engine land rating. He was issued a third-class medical certificate on August 25, 2010, with the limitation for corrective lenses. According to the pilot's logbook, he accumulated 458 total flight hours, 12 hours of simulated instrument flight, and 36 flight hours at night. The pilot's most recent flight review was conducted onDecember 1, 2011. An examination of the accident site and airplane revealed the airplane's right wing contacted a tree approximately 50 feet agl. The airplane impacted several trees prior to coming to rest on the ground. The wreckage debris path was approximately 150 feet in length along a measured magnetic heading of 235 degrees. A postimpact fire partially consumed the fuselage and fragmented wings. All major components of the airplane were located at the accident site. The left and right wings were fragmented and sections were located within the debris path. The ailerons and flaps were fragmented and separated. The flap jackscrew was found in the retracted position. The empennage remained attached to the fuselage. The vertical stabilizer and horizontal stabilizer were separated. The rudder remained attached to the vertical stabilizer. Several semi-circular indentations were noted on the fragmented sections of the wings, vertical stabilizer, and horizontal stabilizers, consistent with tree impacts. Several flight control cables displayed broomstraw fractures consistent with overload failures. No abnormal disconnects or failures were noted with the flight control system. The cabin area, from the firewall extending aft to the baggage compartment, was consumed by fire. The forward seat assemblies were separated from the cabin floor. The instrument panel was destroyed and several instruments were separated from the panel. The cockpit throttle lever was pulled aft approximately 3 inches and bent in that position. The mixture lever was pulled aft, and the propeller lever was in the full forward position. The engine was separated from the airframe and came to rest forward of the main wreckage. The engine crankcase was fragmented and the accessories were separated. The propeller assembly was separated from the crankshaft. Both propeller blade tips were separated from their respective propeller blades. The propeller blades remained attached to the propeller hub. Postaccident examinations did not reveal any anomalies consistent with a preimpact failure or malfunction.

Aircraft

Registration
N3435T
Reported as
Cessna 177A
Category
Airplane
Serial number
17700735
Engine
reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
On File
Registered owner
On File
Airworthiness certificate
Standard, Normal
Departed
3CK · Lake of the Hil, IL
Destination
IMS · Madison, IN
Flight plan
VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
55
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
December 1, 2011
Seat
Left
Toxicology
Performed
Flight hours
458 total · 421 as pilot in command

Weather

Conditions
Visual (VMC) · Night/dark
Wind
80° at 6 knots
Visibility
10 statute miles
Lowest ceiling
1,500 ft overcast
Temperature
27 °F
Altimeter
30.21 inHg
Observed at
BAK, 27 nm away

Docket · 15

The files NTSB released with the investigation on January 30, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.