ERA09LA064

NTSB accident investigation · Cessna 172S · Groton, CT · November 19, 2008

Accident · Minor injuriesLimited investigationFinal report
Date
November 19, 2008, 18:33 local (23:33 UTC)
Place
Groton, CT
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N2337FCessna 172S
Defining event
Approach-VFR pattern final: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Cessna Aircraft Company, AmSafe Aviation
FAA report
20081119853159A
Case key
69474

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

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Probable cause

The student pilot’s failure to maintain a proper descent profile to avoid trees during the night visual approach and the flight instructor’s inadequate oversight.

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.

Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on operationCessna 172S: 19 casesAll aircraft: 448 cases
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeCessna 172S: 11 casesAll aircraft: 933 cases
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172S: 18 casesAll aircraft: 809 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotCessna 172S: 206 casesAll aircraft: 9,295 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotCessna 172S: 8 casesAll aircraft: 200 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 student pilot, sitting in the left seat, was flying the final approach segment for his third full-stop night visual landing when he lost sight of the runway and the airplane impacted trees. The flight instructor stated that he was looking at the airspeed indicator, and when he looked back up he saw only trees. The trees were “generally aligned” with the runway, which was 4,000 feet long and 100 feet wide, with the threshold displaced 205 feet due to the trees. A 3.5-degree Precision Approach Path Indicator (PAPI) normally provided visual glideslope information; however, a Notice to Airmen (NOTAM) was in effect that indicated it was out of service due to tree growth. Neither pilot indicated that he was relying upon the PAPI for correct glideslope information and neither pilot reported any preaccident mechanical anomalies with the airplane.

Factual narrative

On November 19, 2008, at 1833 eastern standard time, a Cessna 172S, N2337F, was substantially damaged when it impacted trees during a night traffic pattern approach to Groton-New London Airport (GON), Groton, Connecticut. The certificated flight instructor and the certificated student pilot incurred minor injuries. Visual meteorological conditions prevailed, and no flight plan had been filed for the flight, which originated at Westchester County Airport (HPN), White Plains, New York. The instructional flight was conducted under 14 Code of Federal Regulations (CFR) Part 91. The student pilot, sitting in the left seat, reported that he was practicing full stop landings at Groton. About 1825, he took off from runway 33 for his third circuit, and on final approach, he "suddenly lost sight of the runway and went into the trees." The flight instructor stated that while on the final approach to runway 33, he looked at the airspeed indicator, and when he looked back up, all he saw were trees. The flight instructor further noted that it appeared that the airplane was "lined up properly and centered on the runway." Runway 33 was 4,000 feet long and 100 feet wide. Runway elevation was 6 feet above mean sea level (msl). The runway threshold was displaced 205 feet due to trees. A 3.5-degree Precision Approach Path Indicator (PAPI) normally provided visual glideslope information. According to a Federal Aviation Administration (FAA) inspector, a Notice to Airmen (NOTAM) was in effect at the time of the accident, indicating that the PAPI was out of service. A previous flight check revealed that tree heights obscured the PAPI on final approach, and although the trees had subsequently been cut to alleviate the problem, they had not been cut sufficiently to eliminate the need for the NOTAM. An examination of the wreckage site by the inspector revealed that the airplane impacted 30- to 40-foot trees, about 1/4 mile from, and “generally aligned with the runway.” The trees were located in a hilly, heavily wooded area at an elevation of about 200 feet msl. Tree damage extended for about 100 feet and was aligned toward runway 33. The inspector also noted that the airplane’s engine was separated from the fuselage, which was “severely crushed and twisted.” The tail section was also damaged, with the rudder and elevator twisted. The left door was missing from the fuselage and the cabin compartment was “somewhat intact.” A Survival Factors Group documented the three-point inflatable (airbag) restraint system. According to the Group Factual Report, the student pilot, seated in the left seat, was 6 feet, 9 inches tall and weighed 290 pounds. The flight instructor, seated in the right, was 6 feet, 4 inches tall and weighed 185 pounds. An examination of the cockpit revealed that the trim control switch plate on the left side control column was fractured, exposing trim electrical wires. The throttle lever was bent inboard towards the mixture control and the adjacent mixturelever was bent inboard towards the throttle lever. The flap lever on the right side of the cockpit was bent downward and the parking brake bracket was fractured and bent rearward. The fuse panel on the right lower side of the instrument panel was compressed forward and fractured at the outboard and center console. The outboard side of the instrument panel was compressed 4 inches forward toward the firewall and the inboard side next to the center console was compressed 3 inches forward. The left pilot seat was locked into the 11th pin hole back from full forward while the right seat was locked into the 9th pin back from full forward. The seats were removed and no deformation was noted. The three-point AmSafe restraints were intact and the webbing showed no evidence of trauma. The webbing on each shoulder restraint exhibited a thin area of stress, consistent with the seatbelts having been worn at the time of the crash. Both airbags were deployed. The airbag stitching and seams were intact, and no damage was observed. The latch sensors (buckle switches) for both airbags were intact and the vent holes for both airbags were round and intact. On the left airbag, there were small black scuff marks on the pilot’s side approximately 14 inches from the top of the bag to 19 inches from the top of the bag and 3 inches from the inboard edge of the bag. On the right airbag, there were black scuff marks on the instrument panel side of the bag at the base extending approximately 5.5 inches from the bottom. Both pilots had been soaked with fuel during the accident, but neither pilot incurred any broken bones or other serious injuries. Neither pilot reported any preaccident mechanical anomalies with the airplane. Weather, reported at the airport at 1856, included winds from 330 degrees true at 8 knots, a few clouds at 12,000 feet, and visibility 10 statute miles. According to U.S. Naval Observatory data, sunset occurred at 1625, and the end of civil twilight occurred at 1655.

Aircraft

Registration
N2337F
Reported as
Cessna 172S
Category
Airplane
Serial number
172S10537
Airframe hours
694
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Panorama Flight Services
Registered owner
Dimitri Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · November 18, 2008
Departed
HPN · White Plains, NY
Destination
GON · Groton, CT
Airport
GON · Groton, runway 33, 4,000 × 100 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
72
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2
Last flight review
September 17, 2008
Seat
Right
Flight hours
4,200 total · 2,000 in this make and model · 2,900 as pilot in command
Role
Student pilot
Age
54
Injuries
Minor
Certificate
Student
Medical
Class 3
Seat
Left

Weather

Conditions
Visual (VMC) · Night
Wind
330° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
25 °F, dew point 10 °F
Altimeter
29.95 inHg
Observed at
GON, 1 nm away

Docket · 7

The files NTSB released with the investigation on February 11, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 MB in all.

FAA reports on this event · 1

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