ERA10LA421

NTSB accident investigation · Cessna 172R · Key West, FL · August 14, 2010

Accident · Serious injuriesLimited investigationFinal report
Date
August 13, 2010, 21:10 local (Aug 14, 2010, 01:10 UTC)
Place
Key West, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N2435XCessna 172R
Defining event
Maneuvering: Loss of visual reference
Weather
Visual (VMC) · Night/dark
Status
Completed · report April 7, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA South Florida FSDO
FAA report
20100813048309A
Case key
76962

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 non-instrument-rated pilot's spatial disorientation during night, over-water, low-ambient-light conditions, which resulted in the airplane impacting the ocean.

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 · Contributed to outcomeCessna 172R: 3 casesAll aircraft: 448 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172R: 3 casesAll aircraft: 1,310 cases
Terrain: waterEnvironmental issues › Physical environment · Not specifiedCessna 172R: 1 caseAll aircraft: 97 cases

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 non-instrument rated pilot performed a touch-and-go practice takeoff and landing at an airport located on an island at night. Thereafter, the flight continued over water at a low altitude. A pilot of a commercial flight inbound to the island observed the accident airplane on his traffic collision and avoidance system (TCAS) and additionally noticed the reflection of its landing light on the water. When the reflection disappeared, the TCAS contact also disappeared, likely due to the airplane impacting the water. After rescue, the pilot could not recall much of the event, but did remark that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident, the moon's phase was waxing crescent with 18 percent of the disk illuminated. Federal Aviation Administration Advisory 60-4A states that, "The attitude of an aircraft is generally determined by reference to the natural horizon or other references on the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. ...Spatial disorientation to a pilot means simply the inability to tell which way is up....Lack of natural horizon or surface reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions."

Factual narrative

On August 13, 2010, at 2110 eastern daylight time, a Cessna 172R, N2435X, registered to Island City Flying Service, Inc., collided with the Atlantic Ocean while maneuvering in a traffic pattern at Key West International Airport (EYW), Key West, Florida. Night visual meteorological conditions prevailed, and no flight plan was filed. The airplane incurred substantial damage, and the certificated, non-instrument-rated private pilot sustained serious injuries. The local personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the first officer (FO) of an American Eagle flight that was inbound for landing at EYW, he and the captain overheard the accident pilot advise Navy Key West Approach Control that he would be conducting touch-and-go landings at EYW. After the subsequently switching to the EYE advisory frequency, the FO contacted the pilot over the radio. The pilot informed him that he had departed runway 9, that he was upwind at 200 feet, south bound, and that he would stay out of their way. The FO informed the pilot that they would be in front of him for landing. The pilot then stated that he was turning to the east and the FO observed the airplane on the traffic collision and avoidance system (TCAS). The FO also observed the landing light come on as the airplane started the turn. The landing light was reflecting off the water, and the FO asked the pilot if that was him. The pilot replied "yes" in a calm voice. About 10 seconds after the light came on, the landing light went out and the flight was no longer showing on TCAS. Further attempts by the FO to contact the pilot were unsuccessful. The pilot stated in an interview from a trauma center that he did not remember talking to the American Eagle flight or the collision with the Atlantic Ocean. He only remembered "bits and pieces" after the accident, and trying to remain afloat until he was rescued. The pilot did not report any mechanical malfunctions, and according to the owner of the airplane, the pilot related to him that "the engine did not quit." Review of the sun and moon data obtained from the U.S. Naval Observatory revealed that the moon's phase was "waxing crescent" with 18 percent of the disk illuminated. The FO, who flew both his own, as well as the accident airplane from EYW, wrote in a statement that there was very little moonlight and "a turn to the south with no light on the horizon can cause severe vertigo and disorientation." Federal Aviation Administration Advisory Circular 60-4A states, "The attitude of an aircraft is generally determined by reference to the natural horizon or other references on the surface. If neither horizon nor surface reference exists, the attitude of an aircraft must be determined by artificial means from the flight instruments. ...Spatial disorientation to a pilot means simply the inability to tell which way is up....Lack of natural horizon or surface reference is common on over water flights, at night,and especially at night in extremely sparsely populated areas, or in low visibility conditions". The wreckage was not recovered and search efforts were terminated by the insurance company. The pilot reported that his logbooks were in the airplane.

Aircraft

Registration
N2435X
Reported as
Cessna 172R
Category
Airplane
Serial number
17280837
Airframe hours
4,832
Engine
Lycoming I0360-L2A, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Edgar H. Hinkle Jr.
Registered owner
Island City Flying Service Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 16, 2010 · 40 hours before
Departed
EYW · Key West, FL
Destination
EYW · Key West, FL

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
55
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
600 total

Weather

Conditions
Visual (VMC) · Night/dark
Wind
50° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 77 °F
Altimeter
29.94 inHg
Observed at
EYW

Docket · 8

The files NTSB released with the investigation on January 2, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 788 KB 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.