# NTSB CEN23FA187: Cessna 172, N2946U, Chambers, NE, May 15, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 14, 2023, 21:25 local (May 15, 2023, 02:25 UTC) - Place: Chambers, NE · Rural Farm Field - Coordinates: 42.241217, -98.623517 - Nearby events: https://openairdocs.org/map.md?lat=42.2412&lon=-98.6235&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Cessna, FAA FSDO - NTSB case key (mKey): 174543 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23FA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174543/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=174543 - Page: https://openairdocs.org/ntsb/CEN23FA187 ## Probable cause The pilot’s continued VFR flight into instrument meteorological conditions at night and his failure to maintain adequate altitude, which resulted in controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172D, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072410), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=2072410), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=2072410), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2072410), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Cessna 172D, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2072410), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot departed on the cross-country flight with instrument meteorological conditions (IMC) reported over the entire region along the route of flight. The NWS had multiple forecasts calling for instrument flight rule conditions as well as an AIRMET for the threat of low ceilings and low visibility over the area. There was no record of the pilot having received a weather briefing and no flight plan was filed. In addition, there were no known communications with the pilot during the flight. Witnesses reported hearing the airplane flying at a low altitude beneath the clouds just before the accident. They reported that the weather at the time was foggy, misty, and raining. The airplane was substantially damaged when it impacted the terrain in a slight nose-down, wings-level attitude. Postaccident examination of the airframe and engine did not reveal any anomalies that would have prevented normal operation of the airplane. The airplane was operating in conditions conducive to serious carburetor icing; however, the witnesses reported the airplane was loud when they heard it flying overhead just before impact. The pilot’s autopsy revealed coronary artery disease; however, there was no clear evidence that the disease contributed to the accident. Weather forecasts for the area called for precipitation and overcast ceilings at 300 ft. The forecasts were consistent with witness accounts of the weather at the time of the accident. The nighttime IMC conditions would have made visual navigation next to impossible without a discernable horizon. Based on the accident site, wreckage examinations, and the witness accounts, the pilot was likely attempting to fly beneath the low clouds when the airplane impacted the ground. ## Factual narrative On May 14, 2023, about 2125 central daylight time, a Cessna 172D airplane, N2946U, was substantially damaged when it was involved in an accident near Chambers, Nebraska. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Federal Code of Regulations Part 91 personal flight. According to the airplane owner, the flight departed from Newton City/County Airport (EWK), Newton, Kansas. Its intended destination was Glen Ullin Regional Airport (D57), Glen Ullin, North Dakota. There were no records of the pilot filing a flight plan or obtaining a weather brief. There were no recorded communications from the pilot during the flight. Several witnesses reported that they heard an airplane flying low over their residence, about 1.6 miles south of the accident site. Another witness observed the airplane flying low, slightly above tree top height. The witness stated that he saw that the airplane’s landing light was on and saw the flashing lights of the airplane. The witnesses stated that there were low clouds, fog, and mist in the area at the time they saw the airplane. A home video surveillance camera showed what appeared to be the landing light of the airplane descending toward the ground. The video also showed precipitation and fog. The airplane was not equipped with ADS-B. No radar data was available for the flight and no distress calls were heard from the pilot. The wreckage was located by a local rancher about 1300 on May 16th. An autopsy on the pilot was conducted at the Douglas County Morgue, Omaha, Nebraska. The cause of death was blunt force injuries. Coronary artery disease was present, including 75-90% narrowing of the left anterior descending coronary artery by calcified plaque, 10-25% narrowing of the right coronary artery by plaque, and less than 10% narrowing of the left main and left circumflex coronary arteries by plaque. No coronary artery clot or heart muscle scarring was seen. Toxicology tests conducted by the Federal Aviation Administration’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, were negative for drugs and alcohol. The National Weather Service (NWS) Surface Analysis Chart and Prognostic Charts depicted a low-pressure system over eastern Kansas with an extensive area of overrunning clouds and precipitation extending over Kansas and Nebraska. Weather observations over the area reported northeasterly winds and visibility restricted in light rain, with low overcast ceilings at 300 ft in the immediate vicinity of the accident site. Witness accounts also reported misty and foggy conditions at the time of the accident. The NWS had multiple forecasts current calling for instrument flight rule conditions and had an AIRMET for the threat of low ceilings and low visibility over the area. No records were found of the pilot obtaining a weather briefing before his departure. A review of the astronomical conditions indicated the end of civil twilight occurred about 5 minutes before the accident, so darknighttime conditions existed at the time of the accident with no illumination from the moon. Witness accounts of the local weather were consistent with the official weather forecast and reports. Weather conditions were conducive for carburetor ice at cruise power. However, witnesses reported hearing the airplane just before the impact and described it as loud. The wreckage debris path was oriented about 049° magnetic. The path extended about 152 ft from the initial impact area. Examination of the airframe and the engine did not reveal any preimpact anomalies. Flight control continuity was confirmed from the cockpit to all flight surfaces. The propeller blades showed polishing and bending consistent with rotation at impact. The carburetor heat knob was found in the off position. Fuel samples taken from the wing tanks tested negative for water and contaminants. Ground scars at the accident site were consistent with the airplane impacting the ground in a shallow, wings-level attitude. ## Aircraft - Registration: [N2946U](https://openairdocs.org/aircraft/N2946U), registered now, S/N 17250546 (OpenAirDocs) - Reported make and model: CESSNA 172 (D) - Registry model: [Cessna 172D](https://openairdocs.org/model/cessna-172d) (registry code 2072410) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17250546 - Year built: 1963 - Airframe hours: 3700 - Engines: Continental O-300-D 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Pearson Eugene L - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 15, 2022 - Departed: EWK, Newton, KS - Destination: D57, Glen Ullin, ND - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; commercial, flight instructor, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; restraint: lap only; toxicology performed; flight hours: 1,300 total, 30 in this make and model, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: 40° at 12 knots, gusting 19 - Visibility: 5 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 54 °F, dew point 52 °F - Altimeter: 30.42 inHg - Icing: Mixed - Observed at: KONL, 14 nm away - METAR: KONL 150235Z AUTO 04012G19KT 5SM -RA OVC003 12/11 A3042 RMK AO2 P0007 T01150107 ## 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 20230515006129A](https://openairdocs.org/incident/20230515006129A), May 15, 2023: Cessna 172D, Chambers, NE, Destroyed, 1 fatal. Evidence at the accident site was consistent with the airplane impacting terrain in a slight nose down, wings level attitude. The initial impact point was… ## Docket (12 files) The files NTSB released with the investigation on February 26, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=174543. 133 MB in all. - Memorandum for the record accident site examination CEN23FA187 (item 1, PDF, 2 pages, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292029&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Accident%20Site%20Examination%20CEN23FA187_Redacted-Rel.pdf - Meteorology factual report (item 2, PDF, 25 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16187215&FileExtension=pdf&FileName=CEN23FA187%20-%20Chambers,%20NE%20WX%20Factual-Rel.pdf - Memorandum for the record witness statement summaries CEN23FA187 (item 3, PDF, 1 page, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18294355&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Witness%20Statement%20Summaries%20CEN23FA187_Redacted-Rel.pdf - Memorandum for the record owner interview summary CEN23FA187 (item 4, PDF, 1 page, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292998&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Owner%20Interview%20Summary%20CEN23FA187_Redacted-Rel.pdf - Memorandum for the record engine examination findings CEN23FA187 (item 5, PDF, 2 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292923&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Engine%20Examination%20Findings%20CEN23FA187_Redacted-Rel.pdf - Memorandum for the record security camera footage CEN23FA187 (item 6, PDF, 1 page, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292718&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Security%20Camera%20Footage%20CEN23FA187_Redacted-Rel.pdf - Security camera video CEN23FA187 (item 7, MOV, 128 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292039&FileExtension=MOV&FileName=Security%20Camera%20Video%20CEN23FA187-Rel.MOV - Carburetor icing probability graph CEN23FA187 (item 8, PDF, 1 page, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292276&FileExtension=pdf&FileName=Carburetor%20Icing%20Probability%20Graph%20CEN23FA187-Rel.pdf - Medical factual memorandum for record (item 9, PDF, 2 pages, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17970203&FileExtension=pdf&FileName=CEN23FA187_MedicalFactualMemo-Rel.pdf - Toxicology report CEN23FA187 (item 10, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18140905&FileExtension=pdf&FileName=Toxicology%20Report%20CEN23FA187_Redacted-Rel.pdf - Certificate of party representative Textron CEN23FA187 (item 11, PDF, 1 page, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18292708&FileExtension=pdf&FileName=Certificate%20of%20Party%20Representative%20Textron%20CEN23FA187_Redacted-Rel.pdf - NTSB wreckage release CEN23FA187 (item 12, PDF, 2 pages, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18295163&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release%20CEN23FA187_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.