# NTSB ERA09FA092: Cessna 172S, N967SP, Goodland, FL, December 18, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 17, 2008, 19:45 local (Dec 18, 2008, 00:45 UTC) - Place: Goodland, FL - Coordinates: 25.908611, -81.648887 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.9086&lon=-81.6489&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 23, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Cessna Aircraft Company, Lycoming Engines - NTSB case key (mKey): 69587 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09FA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69587/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69587 - Page: https://openairdocs.org/ntsb/ERA09FA092 ## Probable cause The pilot's failure to maintain aircraft control due to spatial disorientation. Contributing to the accident was the night light conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2072439), [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 · Contributed to outcome (probable cause); cases with it: [Cessna 172S, 19 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2072439), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 172S, 8 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2072439), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172S, 49 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072439), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172S, 118 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed at night in visual meteorological conditions to work on night recurrence training and was flying in an area over water with limited visual references. Witnesses near the accident site reported hearing the sound of an airplane engine that increased in rpm. Some witnesses observed the airplane in a "nose-dive" toward the water. The airplane crashed into about 5 feet of water on a tidal mud-flat, about 16 miles south-southeast of the departure airport. Examination of the wreckage did not reveal any preimpact malfunctions or anomalies. The pilot had accumulated about 820 hours of total flight experience and had flown about 20 hours during the 2 years preceding the accident. He did not possess an instrument rating. A law enforcement helicopter pilot who responded to the accident site reported that it was very dark and believed that lack of visual cues with the naked eye would have required navigation via aircraft instrumentation. ## Factual narrative HISTORY OF FLIGHT On December 17, 2008, about 1945 eastern standard time, a Cessna 172S, N967SP, was destroyed when it impacted water while maneuvering near Goodland, Florida. The certificated private pilot was killed. Night visual meteorological conditions prevailed and no flight plan had been filed for the local flight that departed Naples Municipal Airport (APF), Naples, Florida, about 1930. The personal flight was conducted under Title 14 Code of Federal Regulations Part 91. The airplane was operated by Naples Air Center, a flight school, based at APF. A witness at the airport stated that the pilot told her he was going flying to work on night recurrency training. Several witnesses near the accident site reported hearing the sound of an airplane engine, which increased in rpm, and was then followed by a loud "bang" or "explosion." Two witnesses reported hearing the engine noise increase and observing the airplane in a "nose-dive" toward the ground. The airplane crashed into about 5 feet of water, on a tidal mud-flat, about 16 miles south-southeast of APF. PERSONNEL INFORMATION The pilot, age 74, held a private pilot certificate with a rating for airplane single-engine land. He did not possess an instrument rating. The pilot's logbook was not recovered. He reported 812 hours of total flight experience, which included 6.2 hours during the preceding 6 months, on his most recent application for a Federal Aviation Administration (FAA) third-class medical certificate, which was issued on April 16, 2008. According to flight school records, the pilot had accumulated 16.5 flight hours at the flight school during the 2 years preceding the accident. The pilot's most recent biennial flight review was completed on April 3, 2007. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number 172S8169, was manufactured in 1999. It was powered by a Lycoming IO-360-L2A, 180-horsepower engine, equipped with a McCauley propeller. Review of maintenance records revealed that the airplane had been operated for about 20 hours since its most recent 100-hour inspection, which was performed on December 12, 2008. The airplane had been operated for about 515 hours since its most recent annual inspection, which was performed on July 29, 2008, at a total airframe time of 5,313 hours. According to fueling records, the airplane was topped-off with 20.4 gallons of 100-low-lead aviation gasoline earlier in the day. The flight school reported that the airplane was flown on two flights, for 2.9 total hours, after the refueling and prior to the accident flight. METEOROLOGICAL INFORMATION A weather observation taken at APF at 1953, reported wind from 060 degrees at 5 knots; visibility 10 statute miles, sky clear; temperature 21 degrees Celsius (C), dew point 16 degrees C; altimeter 30.22 inches of mercury. A Collier County Sheriff's Office helicopter pilot, who responded to the accident site shortly after the accident, reported that the lighting conditionswere "very dark and on a heading of 170 degrees provided no visual reference to a horizon looking out towards the Gulf of Mexico." He further reported that the lack of visual cues with the naked eye would have required navigation via aircraft instrumentation. According to data obtained from the U.S. Naval Observatory, sunset occurred at 1739, and the end of civil twilight was at 1804. WRECKAGE AND IMPACT INFORMATION The accident site was also located about 5 miles from the end of runway 17, at the Marco Island Airport (MKY), Marco Island, Florida, left of the extended runway centerline. The airplane was recovered to a hanger at APF for examination. All major portions of the airplane were accounted for. The airframe forward of the aft bulkhead was completely fragmented. Both wings were separated and the main cabin structure was compromised. The cabin seats, along with portions of the roof, sidewall, and floor structure were scattered around the accident site. The cockpit and instrument panel were destroyed. Both wings were impact damaged and in two primary pieces, separated at the flap-aileron junction. The right wing contained leading edge aft compression damage to the forward spar. The right aileron was in three pieces. A 52-inch portion remained attached to the right wing at its middle and inboard hinge. The left wing leading edge contained some leading edge distortion; however, it contained no compression type damage. The left aileron was intact, but separated from the wing. The empennage remained intact and was canted to the left, just forward of the horizontal stabilizer. The right horizontal stabilizer was crushed aft and upward. The left horizontal stabilizer was crushed aft, consistent with impact to the left side of the empennage. The rudder and elevator control surfaces remained attached. Flight control cable continuity was confirmed from the rudder to the rudder pedals, and from the elevator to the elevator quadrant in the forward cockpit area. Aileron control cables were intact from the aileron quadrant to the wing root, and from the forward cockpit area to the wing root, for each respective wing. The aileron carry-through cable was separated about mid-span. Measurement of the flap actuator jackscrew corresponded to a retracted flap position. The propeller was separated from the crankshaft, which contained an approximate 45-degree shear lip at the point of separation. Both propeller blades exhibited "s" bending. One blade displayed additional twisting and the outboard 5-inches of the blade was separated. Both magnetos and the fuel servo were separated from the engine and not recovered, except for a fragmented lower portion of the left magneto. All spark plugs were removed. Their electrodes were intact and they displayed varying degrees of wear and corrosion. The engine was rotated via an adapter inserted into an accessory drive. Valve train continuity was confirmed and thumb compression was attained on all cylinders. The oil suctionscreen and oil filter did not contain any contamination. One of the airplane's dual vacuum pumps was separated from the engine. The attached vacuum pump was removed from the engine and disassembled. The drive coupling was intact and the pump rotor and vanes were not damaged. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the District Twenty Medical Examiner, Collier County, Naples, Florida, on December 18, 2008. According to the autopsy report, the cause of death was listed as “multiple blunt force injuries." Toxicological testing was performed on the pilot by the FAA Forensic Toxicology Research Laboratory, Oklahoma City, Oklahoma. The tests were negative for carbon monoxide, and drugs. The tests were positive for ethanol which was attributed to post mortem putrefaction. ADDITIONAL INFORMATION FAA Advisory Circular 60-4A Federal Aviation Administration Advisory Circular 60-4A "Pilot's Spatial Disorientation" stated in part: "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation….Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common on overwater flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions…." ## Aircraft - Registration: [N967SP](https://openairdocs.org/deregistered/N967SP-2009-04-22), registration cancelled 2009-04-22, S/N 172S8169, built 1999 (OpenAirDocs) - Reported make and model: CESSNA 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming I0-360-B1E](https://openairdocs.org/engine/lycoming-i0-360-b1e) (registry code 41559, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S8169 - Airframe hours: 5830 - Engines: LYCOMING I0-360-L2A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Naples Air Center - Registered owner: Cessna 172s LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 12, 2008, 20 hours before - Departed: APF, Naples, FL - Destination: APF, Naples, FL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review April 3, 2007; seat: left; toxicology performed; flight hours: 820 total, 1 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 60° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 61 °F - Altimeter: 30.21 inHg - Observed at: APF, 16 nm away ## 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 20081217856729A](https://openairdocs.org/incident/20081217856729A), Dec 17, 2008: Cessna 172S, Naples, FL, Destroyed, 1 fatal. N967SP departed from the Naples (apf) airport approximately at 1920 local time. He flew towards marco island airport. He crossed marco island airport at… ## Other investigations on N967SP (1) 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. - [NTSB CHI07CA103](https://openairdocs.org/ntsb/CHI07CA103), Apr 14, 2007: Cessna 172S (N967SP), Naples, FL, substantial damage. Probable cause: The pilot's failure to maintain directional control of the airplane during landing. A contributing factor to the accident was the runway marker sign. ## Docket (16 files) The files NTSB released with the investigation on December 15, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69587. 4.5 MB in all. - Witness Statements (item 1, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322326&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Collier County Sheriff's Office Report (excerpt) (item 2, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322327&FileExtension=.PDF&FileName=Collier%20County%20Sheriff%27s%20Office%20Report%20(excerpt)-Redacted.PDF - Pilot Records (item 3, .PDF, 676 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322328&FileExtension=.PDF&FileName=Pilot%20Records-Redacted.PDF - Maintenance Records (excerpts) (item 4, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322329&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Redacted.PDF - Airplane Fueling Records (item 5, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322330&FileExtension=.PDF&FileName=Airplane%20Fueling%20Records-Redacted.PDF - Airplane Dispatch Forms (item 6, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322331&FileExtension=.PDF&FileName=Airplane%20Dispatch%20Forms-Redacted.PDF - Naples Airport Weather Observations (item 7, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322335&FileExtension=.PDF&FileName=Naples%20Airport%20Weather%20Observations-Master.PDF - U.S. Naval Observatory Data (item 8, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322336&FileExtension=.PDF&FileName=U.S.%20Naval%20Observatory%20Data-Master.PDF - FAA Advisory Circular – AC 60-4A – Pilot's Spatial Disorientation (item 9, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322343&FileExtension=.PDF&FileName=FAA%20Advisory%20Circular%20%E2%80%93%20AC%2060-4A%20%E2%80%93%20Pilot%27s%20Spatial%20Disorientation%20-Master.PDF - FAA Forensic Toxicology Report (item 10, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322337&FileExtension=.PDF&FileName=FAA%20Forensic%20Toxicology%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322341&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322344&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photograph # 1 – Ariel view of accident site (item 13, .PDF, 520 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322346&FileExtension=.PDF&FileName=Photograph%20%23%201%20%E2%80%93%20Ariel%20view%20of%20accident%20site%20-Master.PDF - Photograph # 2 – View of accident site from water surface (item 14, .PDF, 745 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322348&FileExtension=.PDF&FileName=Photograph%20%23%202%20%E2%80%93%20View%20of%20accident%20site%20from%20water%20surface%20%20-Master.PDF - Photograph # 3 – Close-up view of main wreckage (item 15, .PDF, 629 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322350&FileExtension=.PDF&FileName=Photograph%20%23%203%20%E2%80%93%20Close-up%20view%20of%20main%20wreckage%20%20-Master.PDF - Photograph # 4 – View of propeller as it came to rest (item 16, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40322352&FileExtension=.PDF&FileName=Photograph%20%23%204%20%E2%80%93%20View%20of%20propeller%20as%20it%20came%20to%20rest%20%20-Master.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.