# NTSB CEN19FA155: Cessna R172, N2583V, Mertzon, TX, May 28, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 28, 2019, 05:50 local (10:50 UTC) - Place: Mertzon, TX - Coordinates: 31.259727, -100.82004 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=31.2597&lon=-100.8200&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Continental Aerospace Technologies, Textron Aviation, FAA - NTSB case key (mKey): 99487 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA155 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99487/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99487 - Page: https://openairdocs.org/ntsb/CEN19FA155 ## Probable cause The pilot's loss of control due to spatial disorientation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2072431), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna R172K, 19 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072431), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna R172K, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2072431), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Cessna R172K, 2 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2072431), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna R172K, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072431), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot departed on a visual flight rules cross-country flight in night conditions. He had attempted the flight the previous night but turned around because it was “too dark.” The pilot did not arrive at his destination as expected, and the accident site was subsequently located in a remote area, which would have been devoid of cultural lighting at the time of the accident. Examination of the wreckage revealed no evidence of mechanical failure or malfunction that would have precluded normal operation of the airframe or engine. The pilot did not hold an instrument rating and his recent flight experience could not be determined. The pilot’s family indicated that he had not flown in “a couple of months” before the accident. The night conditions present at the time of the accident, the remote area in which the airplane was operating, and the pilot’s lack of an instrument rating were all conducive to the development of spatial disorientation. It is likely that the pilot became spatially disoriented during the flight, which resulted in a loss of control and impact with terrain. ## Factual narrative Spatial Disorientation The FAA Civil Aerospace Medical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a "loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth." Factors contributing to spatial disorientation, include changes in angular acceleration, flight in IFR conditions, frequent transfer from VFR to IFR conditions, and unperceived changes in aircraft attitude. The document concluded, "anytime there is low or no visual cue coming from outside of the aircraft, you are a candidate for spatial disorientation." The FAA's Airplane Flying Handbook, FAA-H-8083-3B, describes hazards associated with flying when the ground or horizon is obscured. The handbook states in part the following: The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. The airplane’s maintenance records were not located. The pilot’s family stated that they were not aware of any recent maintenance completed on the airplane. On May 28, 2019, about 0550 central daylight time, a Cessna R172K airplane, N2583V, was destroyed when it was involved in an accident near Mertzon, Texas. The pilot was fatally injured. The airplane was operated as Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated at Gaines County Airport (GNC), Seminole, Texas, about 0453 with a destination of Sealy, Texas. The pilot’s family stated the pilot, who owned two irrigation businesses, was transporting a piece of irrigation pipe to a job site. They stated that the pilot had not previously flown the accident route of flight, and that he occasionally flew at night, but most of his flights were during daylight hours. The pilot attempted to complete the flight the night before the accident but reported to his family that he turned around because it was “too dark,” and the pilot told his wife that he would complete the flight early the next morning. His wife suggested that they drive and meet someone halfway, but the pilot stated that he would rather fly. The pilot left his house about 0400 on the morning of the accident. The South Plains Forensic Pathology, Lubbock, Texas, performed an autopsy of the pilot. The report stated that the probable cause of death was "visceral injuries with evisceration due to blunt impact trauma due to airplane crash" and the manner of death was “accident.” The FAA Forensic Sciences Laboratory conducted toxicological testing of specimens of the pilot. The pilot’s muscleand brain tissue were positive for ethanol at 0.032 grams per hectogram (gm/hg) and 0.010 gm/hg, respectively. No tested for drugs were detected in liver tissue. Tissue samples were reported as exhibiting putrefaction. Toxicology testing performed by the medical examiners’ office was positive for ethanol at 0.085 gm/hg in spleen tissue. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. Ethanol can be produced after death by microbial activity. The moon was about 28° above the horizon and about 32% illuminated at the time of the accident. Sunrise for May 29th, the day after the accident, was 0641. The pilot's most recent Federal Aviation Administration (FAA) third class medical certificate was dated May 10, 2016. On the application for that certificate, he reported 780 total hours of flight experience. The medical certificate expired for all classes on May 31, 2018. A pilot logbook recovered from the wreckage contained flights from March 1993 until August 15, 2015, and the pilot’s recent flight experience could not be determined. His family stated that the pilot did not fly consistently, and that, not including the flight the night before the accident, it had “been a couple months” since he last flew the airplane. The airplane came to rest on hilly, rocky terrain at an elevation of 2,330 ft above mean sea level on a magnetic heading of about 070º. The airplane impacted the ground in a near-vertical, nose-down attitude. The main wreckage included one propeller blade, the engine, wings, fuselage, and tail sections. The second propeller blade was located about 25 ft southeast of the main wreckage. The accident location and the surrounding area was located in a remote landscape with no ground lighting, such as streetlights or other cultural lighting. All structural components of the airframe were accounted for at the accident site. Flight control continuity was established from the rudder, elevator, and elevator trim to the forward cabin floor assembly. Aileron continuity was established from the wings to the aft door post, where the cables were cut by first responders; the aileron chains remained engaged on the control wheel. The flap actuator was in the retracted (flaps up) position. Internal engine continuity was observed through the bottom of the crankcase. No signs of failure of the crankshaft, camshaft, or connecting rods were noted. The magnetos and ignition harness were impact damaged and neither magneto produced spark when rotated; both magnetos were disassembled with no preimpact anomalies noted. Examination of the airframe and engine revealed no mechanical anomalies that would have precluded normaloperation. Additional information is available in the public docket for this accident. ## Aircraft - Registration: [N2583V](https://openairdocs.org/deregistered/N2583V-2019-09-03), registration cancelled 2019-09-03, S/N R1722224, built 1976 (OpenAirDocs) - Reported make and model: Cessna R172 (K) - Registry model: [Cessna R172K](https://openairdocs.org/model/cessna-r172k) (registry code 2072431) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: R1722224 - Year built: 1976 - Engines: Continental IO-360-K1A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Banman Henry K - Registered owner: Banman Henry K - Airworthiness certificate: Standard, Normal; Standard, Utility - Departed: GNC, Seminole, TX - Destination: Sealy, TX - Equipment: Satellite tracking device, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 780 total ## Weather - Conditions: Visual (VMC), Night - Wind: 200° at 9 knots, gusting 16 - Visibility: 8 statute miles - Lowest ceiling: 2,000 ft overcast - Temperature: 75 °F, dew point 66 °F - Altimeter: 29.73 inHg - Observed at: KSJT, 18 nm away - METAR: KSJT 281051Z AUTO 20009G16KT 8SM OVC020 24/19 A2973 RMK AO2 SLP040 T02390194 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190528005349A](https://openairdocs.org/incident/20190528005349A), May 28, 2019: Cessna R172K, Mertzon, TX, Destroyed, 1 fatal. On may 28, 2019, at approximately 1400, N2583V, a Cessna R172K registered to a private owner, impacted terrain near Mertzon, Texas. The aircraft was being… ## Docket (6 files) The files NTSB released with the investigation on June 30, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99487. 12.3 MB in all. - Interview summary with pilot's family (item 1, PDF, 2 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339207&FileExtension=pdf&FileName=Family%20Interview-Rel.pdf - Memorandum of record for wreckage exam (item 2, PDF, 3 pages, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339083&FileExtension=pdf&FileName=CEN19FA155%20Memorandum%20of%20Record%20for%20Wreckage%20Exam-Rel.pdf - Moon rise data may 28, 2019 (item 3, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339688&FileExtension=pdf&FileName=Moon%20rise%20data%20May%2028%202019-Rel.pdf - Accident site photographs (item 4, PDF, 3 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339872&FileExtension=pdf&FileName=photos%20for%20docket-Rel.pdf - Pilot toxicology report (item 5, PDF, 1 page, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339789&FileExtension=pdf&FileName=Banman%20Tox%20Results%20for%20docket_Redacted-Rel.pdf - Signed NTSB party forms (item 6, PDF, 2 pages, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12339799&FileExtension=pdf&FileName=Signed%20Party%20Forms%20for%20Docket_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.