ERA09LA413

NTSB accident investigation · Cessna 152 · Ponce, PR · July 19, 2009

Accident · FatalLimited investigationFinal report
Date
July 18, 2009, 23:15 local (Jul 19, 2009, 03:15 UTC)
Place
Ponce, PR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N5518PCessna 152
Defining event
Maneuvering-low-alt flying: Unknown or undetermined
Weather
Visual (VMC) · Night/dark
Status
Completed · report December 20, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
74338

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 airplane’s impact with water for undetermined reasons.

Findings · 1

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.

Not determinedNot determined › Not determined · Unknown/Not determinedCessna 152: 15 casesAll aircraft: 2,247 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

Shortly after the pilot took off in night conditions from a coastal island airport the airplane impacted the sea. There was neither low-level radar coverage of the area nor any known radio transmissions from the airplane. The pilot had intended to fly along the coast, toward his home airport to the west, but his body was recovered near the mouth of a river south of the departure airport. The only airplane wreckage recovered was a tire. The pilot, who had a reported 162 hours of flight experience, obtained his private pilot certificate about 6 weeks before the accident and purchased the airplane about 4 weeks before the accident. The pilot had delayed his flight for several hours due to en route weather and had declined several offers of ground transport. Weather at the time included a few clouds at 3,000 feet and visibility of 8 miles. Two tenths of the moon was illuminated. The departure airport had one runway, and with the prevailing winds, the pilot likely took off from runway 12, which would have resulted in a turn over water, back toward the west. Given the pilot’s relatively low experience level, the overwater flight path and the dim lighting conditions, spatial disorientation likely resulted. However, because the airplane was not recovered, a mechanical anomaly cannot be excluded.

Factual narrative

On July 18, 2009, sometime after 2315 Atlantic standard time, a Cessna 152, N5518P, was lost at sea in the vicinity of Ponce, Puerto Rico. The certificated private pilot was fatally injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the flight, from Mercedita Airport (TJPS), Ponce, Puerto Rico, to Antonio Juarbe Pol Airport (TJAB), Arecibo, Puerto Rico. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to a flight instructor, the pilot, a medical doctor, originally departed Arecibo for Ponce at 1745, with the purpose of picking up some flu vaccine for some friends. The airplane departed with 17 gallons of fuel onboard, or approximately 3 hours' flight duration. A half hour later, the pilot called the flight instructor to say he had arrived in Ponce. At 1900, the flight instructor called the pilot to advise him that the weather was deteriorating, especially in some of the interior regions, and the pilot responded that he was aware of it and was monitoring Doppler radar. The flight instructor called the pilot again about 2000, and told him that there was weather in the vicinity of Arecibo, and the pilot responded that he'd wait 1 to 2 hours for the weather to improve. The flight instructor then offered to drive over and pick up the pilot, but the pilot told him no, and that he would wait. About 2230, the flight instructor again called the pilot to inform him that there was weather east and north of Ponce. The flight instructor had also called the pilot's wife, who subsequently offered to retrieve the pilot by car, but the pilot also declined her offer. In later discussions, the pilot told the flight instructor that he planned to fly along the coast to the west, via Mayaguez and Aguadilla, and if the weather deteriorated, he could land and the flight instructor could then pick him up. At 2300, the pilot called the flight instructor to advise him that he was about to depart, and to the flight instructor's knowledge, the airplane departed about 2315. As time passed, the flight instructor attempted to contact the pilot multiple times, and about 0100, he and others began to contact authorities about the missing airplane. There was no low level radar coverage of the area, and no known radio transmissions from the airplane. The Federal Aviation Administration (FAA) subsequently issued an Alert Notice (ALNOT), and on July 20, 2009, about 2000, the pilot's body was located near the mouth of Rio Inabon, south of the departure airport. Several days later, a wheel from the airplane was also found. The pilot, age 52, held a private pilot certificate, and according to the flight instructor, had about 162 hours of total flight time. FAA records indicated that the pilot was issued his private pilot certificate on June 3, 2009. A copy of a sales contract indicated that the pilot purchased the airplane on July 9, 2009. Maintenance records revealed that theairplane’s latest annual inspection was completed on November 20, 2008, and that an overhauled engine was installed at that time. The departure airport had one runway, 12/30, which was 6,904 feet long and 150 feet wide. Airport elevation was 29 feet above mean sea level. On July 21, 2009, a postmortem examination of the pilot was performed at the Instituto de Ciencias de Puerto Rico, San Juan, Puerto Rico, with the cause of death reported as, “severo trauma corporal.” The autopsy report also noted multiple fractures of the pelvis, and only 8 ml of urine in the bladder. Local toxicology testing performed in conjunction with the autopsy noted 0.03 percent alcohol in urine, and no alcohol in central blood. According to shipping documentation, toxicological samples were shipped from Puerto Rico on July 28, 2009, and arrived at the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, on the following day. Testing revealed 2.642 ug/ml of acetaminophen in the pilot’s blood, and the presence of ethanol, N-butanol, and N-propanol in multiple fluid and tissue samples, with putrefaction noted. Weather, recorded at Ponce at 2258, included a few clouds at 3,000 feet, visibility 8 statute miles, and winds from 070 degrees true at 5 knots. U.S. Naval Observatory data indicated that approximately 2/10 of the moon was illuminated. According to the FAA’s “Pilot’s Handbook of Aeronautical Knowledge,” FAA-H-8083-25, “spatial disorientation specifically refers to the lack of orientation with regard to the position, attitude, or movement of the airplane in space.” In addition, “under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. The Handbook further states: “Prevention is usually the best remedy for spatial disorientation. Unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when a horizon is not visible should be avoided.”

Aircraft

Registration
N5518P
Reported as
Cessna 152
Category
Airplane
Serial number
15284964
Airframe hours
17,781
Engine
Lycoming O-235 Series, 115 horsepower, reciprocating
Damage
Destroyed
Fire
Unknown
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · November 20, 2008
Departed
TJPS · Ponce, PR
Destination
TJAB · Arecibo, PR

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
52
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3
Toxicology
Performed
Flight hours
162 total · 62 as pilot in command

Weather

Conditions
Visual (VMC) · Night/dark
Wind
70° at 5 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 73 °F
Altimeter
30.04 inHg
Observed at
TJPS

Docket · 5

The files NTSB released with the investigation on August 17, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 503 KB in all.