ERA11FA332

NTSB accident investigation · Cessna 152 · Vero Beach, FL · June 9, 2011

Accident · FatalField investigationFinal report
Date
June 9, 2011, 10:14 local (14:14 UTC)
Place
Vero Beach, FL
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N48869Cessna 152
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming Engines, Cessna Aircraft Company
FAA report
20110609011319A
Case key
80723

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 pilot’s failure to maintain adequate airspeed while maneuvering, which resulted in an aerodynamic stall and subsequent spin.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 152: 115 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 152: 9 casesAll aircraft: 1,681 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 flight departed on a visual flight rules personal flight and did not return to the operator’s home base at its scheduled time. The operator began calling other airports trying to locate the airplane and cell phone companies in an attempt to locate the pilot by her cell phone. The Federal Aviation Administration issued an Alert Notice; after several hours of searching the wreckage was located. There were no witnesses to the accident. Review of radar data revealed that in the last few minutes of flight the airplane made several maneuvering turns. The reason the pilot chose to maneuver in that location is unknown. The final maneuvers included a 70-degree right turn to a heading of 180 degrees. About 2 minutes later, the airplane made a 360-degree left turn, and radar contact was lost. The radar data was consistent with cruise speed throughout the flight, except for the last return, which indicated that the airplane had slowed significantly. Postaccident wreckage signatures were consistent with a spinning descent and impact, indicating that the airplane likely entered an aerodynamic stall from which the pilot did not recover.

Factual narrative

HISTORY OF FLIGHT On June 9, 2011, about 1014 eastern daylight time, a Cessna 152, N48869, registered to N70FT Incorporated, and operated by Space Coast Aviation, collided with the ground after a loss of control in flight, in Vero Beach, Florida. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91, and no flight plan was filed. The certificated private pilot and passenger were fatally injured, and the airplane sustained substantial damage. The airplane departed from Merritt Island Airport (COI), Merritt Island, Florida, about 0930. There were no reported witnesses to the accident. According to personnel at Space Coast Aviation, the flight was due back at COI at 1400. About 1500, they began calling other airports trying to locate the airplane, and contacted cell phone companies in an attempt to locate the pilot by her cell phone. The Federal Aviation Administration (FAA) issued an Alert Notice (ALNOT) and a search was initiated at 1920. At 2130, the Civil Air Patrol (CAP) was notified of the missing airplane and obtained a mission briefing. The Incident Commander (IC) contacted the flight school at COI and was given the airplane’s probable flight path. He was informed that no flight plan was filed and no flight plan was left at the flight school. The IC launched aircraft on a probable flight path from COI to OBE at 2230, based on information from the flight school. A law enforcement detective called and informed the IC that a phone company had found a cell tower location, at the Yeehaw Junction Tower, located at N27 40.29, W080 48.35. The detective notified the Osceloa County Sheriff concerning a possible search area for the missing aircraft. The Air Force Rescue Coordination Center (AFRCC) then informed the IC of a location and probable flight path, based on radar data. At 00:30, the AFRCC sent an email to the IC of radar returns. The path started at COI and terminated at the southern edge of Blue Cypress Lake, just northeast of the Yeehaw Junction Tower and on a flight path between COI and OBE. Civil Air Patrol aircraft made radio contact with the Indian River Sheriff’s helicopter about 0115 and had acquired a weak emergency locator Transmitter (ELT) signal. The Indian River Sheriff's aircrew located the wreckage about 0154. Review of radar data revealed that at 10:12:02, the airplane made a right 70-degree turn to a heading of 180 degrees. At 10:14:26, the airplane then made a left 360-degree turn. The last radar return was at 10:14:26. A FAA inspector, who interviewed an FAA radar specialist that obtained radar data from a facility located 10 miles from the accident site, stated the radar specialist informed him the airplane's altitude information was missing and the airplane had a ground speed of approximately 90 to 95 knots for almost the entire time of the flight. In addition, he stated, "The ground speed gets very slow right at the very end of the flight path; that is, on the very lastradar return." PERSONNEL INFORMATION The private pilot, age 21, held a private pilot certificate with ratings for airplane single-engine land, issued on May 2, 2011 with the limitation, "Airplane single engine land limitation: English proficient, issued on the basis of and valid only when accompanied by United Kingdom Pilot License. All limitations and restrictions on the United Kingdom Pilot License apply." The pilot held a United Kingdom Civil Aviation Authority Joint Aviation Authorities Class 1 medical certificate, issued on August 13, 2009, with no restrictions. In addition, she held an FAA third-class medical certificate, issued on April 26, 2010, with the restriction, "Not valid for any class after." Review of the pilot’s logbook revealed the pilot had 165 total flight hours of which 117 hours were in make and model and as pilot in command. The pilot had flown 89 hours in the last 90 days, 79 hours in the last 30 days and 1 hour in the last 24 hours prior to the accident. AIRCRAFT INFORMATION The Cessna 152 was a two-place high-wing airplane with a fixed tricycle landing gear, serial number 15281014, manufactured in 1977. A Lycoming O-235-L2C, 118-horsepower, horizontally-opposed, four-cylinder engine powered the airplane. Review of the airplane logbooks revealed the last annual inspection was conducted on July 20, 2010, at a recorded tachometer time of 2505.0 hours. The total time on the airframe at the annual was 10345.0 hours. The last 100-hour inspection was conducted on June 1, 2011 at a recorded tachometer time of 2804.3 hours. At that time, the airframe had 10745.3 hours and the engine had 7459.3 hours. The propeller had 2552.3 hours. The total airframe hours at the time of the accident were 10767.6 hours. The airplane had flown 422.6 hours since the last annual inspection. The airplane had flown 21.7 hours since the last 100-hour inspection. METEOROLOGICAL INFORMATION The Vero Beach Municipal Airport (VRB) Vero Beach, Florida, 1053 surface weather observation was: wind 100 degrees at 10 knots, visibility 10 miles, scattered clouds, 2,400 feet, temperature 29 degrees Celsius, dew point temperature 22 degrees Celsius, and altimeter 30.03 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located .20 mile southwest of Blue Cypress Lake in the vicinity of Vero Beach, Florida. Examination of the crash site revealed the airplane collided with trees and a swamp in a nose down attitude left wing low and came to rest on a heading of 320 degrees magnetic. There was no crash debris line. The propeller spinner was crushed. The propeller remained attached to the crankshaft flange by one propeller bolt. The remaining bolts were unbroken, but the propeller flange bushings were fractured. The propeller flange was bent. One propeller blade exhibited paint scuffing on the leading edge. The remaining propeller blade was bent aft about 20 degrees at about 18 inches outboard of the hub. The engine cowling was damaged and remainedattached to the engine. The engine assembly remained attached to the engine mounts and the firewall. The propeller assembly and engine assembly and accessories were buried 3 feet below the surface of the ground with the accessory case level with the ground. The windshield was destroyed. The cabin doors were opened and remained attached at their hinge points. Both door windows were broken and both door latches were in the latched position. The instrument panel was fragmented. The attitude indicator indicated 5 degrees pitch up, and 5 degrees left wing low. The vertical speed indicator indicated 2,000 feet-per-minute down. The stall warning horn was an aural device. It was checked and functioned. The fuel selector valve was in the on position. The throttle and mixture control was full forward. The left and right cabin seats remained attached to the seat tracks. Both seatbelts and shoulder harness were in use. Continuity of the flight control surfaces was established from all flight control surfaces to the cockpit controls. The rear baggage compartment window was shattered. The left and right main landing gear remained attached to the fuselage and was buried below the surface of the ground. The right wing remained attached at the wing root. The leading edge of the right wing sustained accordion crush damage from the wing root, extending outboard to the wing tip. The right wing tip remained attached but was damaged. The upper wing skin sustained minor damage. The lower skin sustained accordion wrinkles from the leading edge to the rear spar. The right main fuel tank was ruptured with evidence of hydraulic action. The right main fuel cap was removed and had a tight seal. No browning of vegetation was present at the crash site. The right flap remained attached sustained minor damage and was in the retracted position. The right aileron remained attached at all hinge points and sustained minor damage. The right wing strut remained attached to the wing and the fuselage. The empennage was displaced to the right and downward from cabin area at the baggage compartment. The horizontal stabilizer sustained minor damage. The vertical stabilizer sustained minor damage and remained attached to the empennage. The rudder sustained minor damaged and was attached at all hinge points. The rudder balance weight was intact. Review of the wreckage indicated that the rudder stop modification, Service Bulletin SEB 01-1 and Service Kit SK 152-24A was improperly complied with. Specifically, the nut plate at the accident site was attached to the doubler on the inner surface of the tail cone bulkhead. It should have been attached to the outer side of the tail cone skin. The vertical tail and adjacent portion of the empennage was sent to the NTSB Materials Laboratory, Washington, DC, for further examination. The examination revealed the fracture was consistent with a shearing over stress separation. No indication of corrosion or preexisting cracking such as fatigue wasobserved. The right horizontal stabilizer was damaged and remained attached to the empennage assembly. The elevator remained attached to the stabilizer by the inboard and center hinge locations. Upper bending was present on the right stabilizer near mid-span. The elevator trim tab remained attached to the right elevator. The right elevator trim tab actuator was observed in the near neutral position. The right elevator balance weight was intact. The left horizontal stabilizer remained attached to the empennage and sustained minor damage. The elevator remained attached by all three hinge points. The balance weight was intact. The left wing remained attached at the wing root. The leading edge of the left wing sustained accordion crush from the wing root extending outboard to the wing tip. The left wing slide down the side of a tree and the forward and rear spars were broken. The left forward wing tip separated from the wing. The upper and lower wing skins sustained minor damaged between the forward and rear spars. The left main fuel tank was ruptured with evidence of hydraulic action. The left main fuel cap was removed and had a tight seal. No browning of vegetation was present at the crash site. The left flap was damaged and was in the retracted position. The left aileron remained attached at all hinge points and sustained minor damage. The left wing strut remained attached to the wing and separated at mid span. The engine was partially disassembled. The carburetor was fractured across the throttle bore and partially separated from the engine. The carburetor bowl screw safeties were intact. Fuel stains were not observed on the outside of the carburetor bowl. The carburetor was disassembled and a small amount of blue liquid with an odor consistent with that of aviation gasoline was present. No debris was present in the carburetor fuel inlet screen. Compression was noted on the outboard sides of the brass floats. A check of the liquid with water finding paste revealed no indication of the presence of water. The left magneto remained attached to the engine and was not damaged. The right magneto mounting flange was fractured and the magneto was partially separated from the engine. Both magnetos were removed and rotated by hand. Both magnetos produced spark from all ignition towers. The ignition harness was damaged. The upper spark plugs were removed and exhibited light gray coloration of the electrodes and worn normal condition when compared to the Champion Check-A-Plug chart. The lower were removed and exhibited light gray to light brown coloration and worn normal condition. Lead deposits were noted in the electrode wells of the lower. The electrode gaps were inconsistent. The starter and alternator remained attached to the engine. Radial score marks were noted on the starter nose case. The alternator was damaged. The alternator belt remained in place and was broken. The vacuum pump remained attached to the engine and was removed and disassembled.The carbon rotor, carbon vanes and the drive coupling were intact. The screw holding the internal drive spline to the carbon rotor drive was fractured and observed in the center cavity of the carbon rotor. Oil drained from the engine when it was lifted for examination. The oil filter was examined and no metallic debris was noted in the folds of the filter media. No debris was noted in the oil suction screen. The oil cooler remained attached to the rear baffle and the oil cooler hoses remained attached to the oil cooler. The engine was rotated by hand using a tool inserted in the vacuum pump drive pad and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Compression and suction were confirmed from all four cylinders. The interiors of all four cylinders were examined using a lighted bore scope and no anomalies noted. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Medical Examiner of District 19 of St Lucie, Martin, Indian River, and Okeechobee Counties in Florida conducted the autopsy on the pilot on June 11, 2011. The cause of death was multiple blunt force trauma. The FAA Bioaeronautical Sciences Research Laboratory performed toxicology testing on specimens from the private pilot. No carbon monoxide, cyanide or drugs were detected in the blood. Ethanol was detected in the muscle, blood and brain due to putrefaction. The Office of the Medical Examiner of District 19 of St Lucie, Martin, Indian River, and Okeechobee Counties in Florida conducted the autopsy on the passenger on June 13, 2011. The cause of death was multiple blunt force trauma. The Weusthoff Reference Laboratory, Melbourne, Florida, performed toxicology testing on specimens from the passenger. The specimens were negative for basic, acidic, and neutral drugs. Caffeine and acetaminophen was present in the urine. ADDITIONAL INFORMATION The Cessna 152 Pilot's Operating Handbook states in Section 5, Performance, STALL SPEEDS, at a weight of 1,670 pounds, with a 0-degree angle of bank and flaps retracted, the airplane will stall at 36 knots indicated airspeed (KIAS). At a 30-degree angle of bank the airplane will stall at 39 KIAS. At a 45-degree angle of bank the airplane will stall at 43 KIAS. At a 60 degree angle of bank the airplane will stall at 51 KIAS.

Aircraft

Registration
N48869
Reported as
Cessna 152
Category
Airplane
Serial number
15281014
Airframe hours
10,768
Engine
Lycoming O-235 SERIES, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Space Coast Aviation
Registered owner
N70ft Inc
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · June 1, 2011 · 2,804 hours before
Departed
COI · Merritt Island, FL
Destination
OBE · Okeechobee, 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
21
Injuries
Fatal
Certificates
Foreign, Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
May 4, 2011
Seat
Left
Toxicology
Performed
Flight hours
165 total · 117 in this make and model · 77 as pilot in command · 89 in the last 90 days · 79 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 72 °F
Altimeter
30.03 inHg
Observed at
VRB, 21 nm away

Docket · 39

The files NTSB released with the investigation on July 3, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.6 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 281 KBFAA Inspector StatementItem 2 · .PDF · 128 KBIndian River Sheriff ReportItem 3 · .PDF · 105 KBIndian River Sheriff's Incident ReportItem 4 · .PDF · 1.6 MBIndian River Sheriff Crime Scene Supplemental ReportItem 5 · .PDF · 1.2 MBExtract Civil Air Patrol ReportItem 6 · .PDF · 1.1 MBERA11FA332\ERA11FA332, N48869, June 9, 2011, Vero Beach ASR-11 Radar Site, 1338 - 1414 UTCItem 7 · .PDF · 216 KBERA11FA332\ERA11FA332, N48869, June 9, 2011, Vero Beach ASR-11 Radar Site, 1408 - 1414 UTCItem 8 · .PDF · 136 KBERA11FA332 N48869 June 9 2011 Vero Beach ASR-11 (VRB) Radar Data 1338-1414 UTC.csvItem 9 · .CSV · 34 KBVero Beach WeatherItem 10 · .PDF · 93 KBPilot CertificateItem 11 · .PDF · 36 KBUK Airman CertificateItem 12 · .PDF · 112 KBJAA Medical CertificateItem 13 · .PDF · 159 KBPilots flight log.Item 14 · .PDF · 31 KBExtract Pilot LogbookItem 15 · .PDF · 5.1 MBExtract Engine LogItem 16 · .PDF · 648 KBExtract Airframe RecordsItem 17 · .PDF · 443 KBPropeller LogbookItem 18 · .PDF · 168 KBFAA Airworthiness DirectivenessItem 19 · .PDF · 490 KBService Bulletin SEB 01 1 and Service Kit SK 152 24AItem 20 · .PDF · 376 KBFuel HistoryItem 21 · .PDF · 190 KBHobbs Time SheetItem 22 · .PDF · 32 KBExtract Pilot Operating HandbookItem 23 · .PDF · 74 KBStatement of Party Representatives to NTSB InvestigationItem 24 · .PDF · 106 KBToxicology ReportItem 25 · .PDF · 118 KBMaterials Laboratory 15 - Factual Report 11-085 (2 images)Item 26 · .PDF · 240 KBNTSB Wreckage ReleaseItem 27 · .PDF · 1.8 MBPhoto 1 Overhead view of crash site. Photo Sheriff Dept.Item 28 · .PDF · 65 KBPhoto 2 View of left wing where it slid down the side of a tree. Photo CessnaItem 29 · .PDF · 2.2 MBPhoto 3 Front view of left wing. Photo CessnaItem 30 · .PDF · 1.2 MBPhoto 4 View right wing. Photo CessnaItem 31 · .PDF · 1.6 MBPhoto 5 Rear view of left and right wings. Photo CessnaItem 32 · .PDF · 2.1 MBPhoto 6 Rear view of right wing. Photo CessnaItem 33 · .PDF · 1.7 MBPhoto 7 View of cabin area. Photo CessnaItem 34 · .PDF · 1.2 MBPhoto 8 View of right aft empennage. Photo CessnaItem 35 · .PDF · 2.0 MBPhoto 9 View of improperly installed doubler and nut plates. Photo CessnaItem 36 · .PDF · 1.1 MBPhoto 10 View of engine and propeller assembly after recovery. Photo LycomingItem 37 · .PDF · 578 KBPhoto 11 Front view of engine. Photo LycomingItem 38 · .PDF · 551 KBPhoto 12 Right side view of engine during examination. Photo LycomingItem 39 · .PDF · 387 KB

FAA reports on this event · 1

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