# NTSB ERA14FA283: Cessna 172S, N5524L, Daytona Beach, FL, June 10, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 9, 2014, 21:58 local (Jun 10, 2014, 01:58 UTC) - Place: Daytona Beach, FL - Coordinates: 29.174444, -81.054725 - Nearby events: https://openairdocs.org/map.md?lat=29.1744&lon=-81.0547&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 12, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming, Textron Aviation - NTSB case key (mKey): 89402 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14FA283 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89402/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89402 - Page: https://openairdocs.org/ntsb/ERA14FA283 ## Probable cause A partial loss of engine power during the initial climb after takeoff for reasons that could not be determined due to the postaccident condition of the wreckage. Contributing to the accident was the pilots' decision to turn back to the airport, which led to the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall while maneuvering. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna 172S, 25 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2072439), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 16 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2072439), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 13 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072439), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Not specified (probable cause); cases with it: [Cessna 172S, 206 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072439), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Not specified; 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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 172S, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2072439), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072439), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/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 flight instructor and a private pilot receiving instruction were conducting a night proficiency flight and had completed two touch-and-go landings. A witness reported that, during the initial climb after the second touch-and-go landing, the airplane experienced a series of engine "backfires," followed by an audible loss of rpm. The airplane struggled to gain altitude and airspeed as it continued on an easterly heading. He then observed the airplane's right wing dip, followed by a right turn back toward the airport, after which the airplane stalled and then entered a nose-down descent. After the airplane impacted the ground, it was destroyed by a postcrash fire. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation; however, the postaccident condition of the wreckage precluded a functional check of the engine and its accessories. There was no evidence that medical issues, medications, or toxic substances impaired the flight instructor or contributed to the accident. Toxicology testing on the pilot receiving instruction detected concentrations of tetrahydrocannabinol (THC), the active component in marijuana, in cavity blood but not in the brain. In addition, and THC's primary metabolite was detected in cavity blood and urine but not in the brain. Given that no THC was detected in the pilot's brain, it is likely that some of the THC detected in the cavity blood resulted from postmortem redistribution. However, the investigation found no operational evidence of impairment for the pilot. Therefore, although the pilot had used marijuana at some time before the flight, there was no evidence that he was impaired by it at the time of the accident. ## Factual narrative The four-seat, high-wing airplane, serial number 172S11378, was manufactured in 2014. It was powered by a Lycoming model IO-360-L2A, 180-horsepower engine equipped with McCauley 1A170E propeller. A review of maintenance logbook records showed a 100-hour inspection was completed on June 4, 2014, about 5 hours prior to the accident. At the time of the inspection, the airplane had been operated for about 100 total hours since new. Another company flight instructor reported that the airplane experienced a rough running engine and a loss of 400 rpm on climb out while conducting a touch-and-go landing on June 6, 2014. The airplane was taken out of service and inspected. The spark plugs were removed, and no defects were noted. An engine run-up was conducted and a normal rpm drop was noted. A magneto check was conducted and was reported as "good." After the inspection was completed, the airplane was returned to service. It was subsequently flown on an instructional flight during the morning of the accident, without any discrepancies noted. On June 9, 2014, about 2158 eastern daylight time, a Cessna 172S, N5524L, experienced a partial loss of engine power and impacted the ground during the initial climb after takeoff from Daytona Beach International Airport, Daytona Beach (DAB), Florida. The flight instructor and the private pilot receiving instruction were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. The airplane was registered to Bravo Leasing LLC and operated by Phoenix East Aviation, under the provisions of 14 Code of Federal Regulations Part 91, as an instructional flight. Night, visual meteorological conditions prevailed for the flight and no flight plan was filed. The airplane was operated by Phoenix East Aviation flight school and based at DAB. The flight instructor was conducting a night proficiency flight for the private pilot, who was training for his commercial pilot certificate. A review of the pilots training logs revealed that this was the third instructional flight with the flight instructor. A review of the air traffic control voice transcription revealed that the call sign for the accident airplane was Phoenix 35 (PX35). At 2145, PX35 was cleared for a full stop or touch-and-go landing on runway 7L, at the pilot's discretion. One of the pilots then replied that they would perform a touch-and-go landing. The airplane was subsequently instructed to follow another airplane in the traffic pattern and cleared for a second full stop or touch-and-go landing, about 2153. PX35 acknowledged the air traffic control request and approximately 3 minutes later requested to return to land. This was the last transmission made by PX35. A DAB airport employee observed the accident from a vehicle on the taxiway. He stated that the airplane performed a touch-and-go landing, and then experienced a series of engine "backfires," followed by an audible loss of rpm during the subsequent initial climb. The airplanestruggled to gain altitude and speed as it continued on an easterly heading, and reached a maximum altitude of 250 to 300 feet above the ground. He then observed the airplane's right wing dip, followed by a left turn, and an immediate stall. The airplane entered a nose-down descent and disappeared behind a tree line. He drove in the direction of the airplane and located it off of the airport property engulfed in flames. Another witness reported that she observed the airplane fly over the tree line. It looked as if the pilot was turning back towards the airport, when the airplane entered an "aerodynamic stall," and then impacted the ground. An autopsy was performed on the CFI by the Office of the Medical Examiner, Daytona Beach, Florida. Forensic toxicology was performed on specimens from the CFI, by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated that no carbon monoxide was detected in blood (cavity), no ethanol was detected in vitreous, and no drugs were detected in the urine. An autopsy was performed on the pilot receiving instruction by the Office of the Medical Examiner, Daytona Beach, Florida. Forensic toxicology was performed on specimens from the pilot receiving instruction, by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated that no carbon monoxide was detected in the blood cavity and no ethanol was detected in vitreous. Tetrahydrocannabinol (marihuana) in concentrations of 0.00136 (ug/ml, ug/g) was detected in the blood cavity. Tetrahydrocannabinol Carboxylic Acid (marihuana) in concentrations of 0.0484 (ug/ml, ug/g) was detected in the urine. Tetrahydrocannabinol Carboxylic Acid (marihuana) in concentrations of 0.0021 (ug/ml, ug/g) was detected in the blood cavity. The reported weather at DAB, elevation of 34 feet, included wind from 160 degrees at 3 knots, 10 statute miles visibility, few clouds at 4,500 feet above ground level (agl), temperature 27 degrees Celsius (C); dew point 22 degrees C, and an altimeter setting of 29.97 inches of mercury. The certificated flight instructor (CFI), age 22, held a CFI certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane issued on December 10, 2013. She reported that her flight experience included 960 total hours, and 320 hours in last six months, at the time of her most recent Federal Aviation Administration (FAA) first-class medical examination, which was performed on January 28, 2014. Pages of the CFI's logbook were discovered within the cockpit and were destroyed by the postcrash fire. A review of flight school records revealed that the CFI had accumulated about 1,170 total flight hours, of which 101 hours were flown at night. The pilot receiving instruction, age 22, held a private pilot certificate with a rating for airplane single-engine land. A review of his flight training records revealed that he had 139 total flight hours, 63hours as pilot-in-command, and 14 hours within the 90 days that preceded the accident. It was also noted that he had logged approximately 12 hours of night flight experience. The pilot receiving instruction held an FAA first-class medical certificate, which was issued on October 11, 2012. His logbook was discovered within the cockpit and was destroyed by the postcrash fire. The accident site was located about 220 feet south of the runway 7R centerline in an open field. The airplane came to rest in a flat, upright attitude, on a heading of about 060 degrees magnetic. The cockpit, cabin, instrument panel and instruments were consumed by fire. Examination of the left wing revealed that the outboard section was buckled, and the wing was shifted forward. Examination of the flap revealed that it was in the retracted position. The aileron remained attached at one of the two attachment points and was buckled. Flight control cable continuity was established to the cockpit flight controls. The fuel tank was fire-damaged and the fuel cap was secure. Examination of the right wing revealed that the outboard section of the wing was buckled and fire-damaged. The flap was in the retracted position and fire-damaged. The aileron remained attached and was fire-damaged. Flight control cable continuity was established to the cockpit flight controls. The fuel tank was fire-damaged and fuel cap was secure. The empennage aft of the rear window was buckled. The vertical and horizontal stabilizers remained attached to empennage. The right horizontal stabilizer was buckled. The rudder remained attached to the vertical stabilizer and the control cables were traced to the cockpit. The elevators remained attached to the horizontal stabilizers and control cable continuity was confirmed to the cockpit flight controls. Examination of the engine revealed that it was heavily fire-damaged. The oil sump was breached and fire-damaged. The rear mounted accessories were destroyed by fire. The engine was partially dissembled to facilitate further examination. The connecting rods rotated freely on the crankshaft rod journals. No damage was noted to the camshaft or lifters. The rear main bearing exhibited fire damage, but no rotational scoring or wiping. The cylinders were removed and no damage was noted on the valves or in the valve guides. When the valves were compressed they moved freely in the valve guides. No damage was noted within the cylinders. Examination of the fuel injector servo revealed that it was impact-separated from the engine and fire-damaged. The servo rubber diaphragms were fire-damaged. No debris was noted within the fuel inlet screen. The flow divider remained attached to the engine. The rubber diaphragm was melted and air passed freely through the fuel injector lines. Examination of the fuel injector nozzles noted that they were unobstructed. No fuel was observed in the engine fuel lines or its components. Examination of the spark plugs revealed that when comparedto the Champion Aviation Check-A-Plug chart, they displayed normal signatures. The magnetos and ignition harnesses were destroyed by fire. The propeller remained attached to the engine crankshaft flange. The crankshaft flange was impact-separated from the crankshaft. The propeller and flange were located in front of the engine, and both blades displayed chordwise scoring. ## Aircraft - Registration: [N5524L](https://openairdocs.org/deregistered/N5524L-2020-10-03), registration cancelled 2020-10-03, S/N 172S11378, built 2014 (OpenAirDocs) - Reported make and model: CESSNA 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S11378 - Year built: 2014 - Airframe hours: 104 - Engines: Lycoming IO-360-L2A 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Phoenix East Aviation - Registered owner: Bravo Leasing LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 4, 2014, 4 hours before - Departed: DAB, Daytona Beach, FL - Destination: DAB, Daytona Beach, FL - Airport: DAB, Daytona Beach International, runway 7R, 3,195 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 22; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 10, 2013; seat: right; restraint: 3-point; toxicology performed; flight hours: 1,168 total, 1,168 in this make and model, 1,079 as pilot in command - Student pilot; age 22; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 9, 2014; seat: right; restraint: 3-point; toxicology performed; flight hours: 139 total, 139 in this make and model ## Weather - Conditions: Visual (VMC), Night - Wind: 160° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 72 °F - Altimeter: 29.96 inHg - Observed at: DAB ## 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 20140609009049A](https://openairdocs.org/incident/20140609009049A), Jun 9, 2014: Cessna 172S, Daytona Beach, FL, Destroyed, 2 fatal. Aircraft departed flight school at approx. 2100 with CFI and private pilot working on commercial rating. This was the 2nd flight instruction of the course.… ## Docket (19 files) The files NTSB released with the investigation on June 29, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89402. 51.9 MB in all. - Air Traffic Control Voice Transcription (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441818&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Voice%20Transcription-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441819&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - CFI Flight Log Records (item 3, .PDF, 18.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441820&FileExtension=.PDF&FileName=CFI%20Flight%20Log%20Records-Master.PDF - Student Pilot Flight Logs (item 4, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441821&FileExtension=.PDF&FileName=Student%20Pilot%20Flight%20Logs-Master.PDF - Employee Statement CFI (item 5, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441822&FileExtension=.PDF&FileName=Employee%20Statement%20CFI-Master.PDF - Employee Statement Chief Flight Instructor (item 6, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441823&FileExtension=.PDF&FileName=Employee%20Statement%20Chief%20Flight%20Instructor-Master.PDF - Daytona Aircraft Service/Discrepancy and Corrective Action Compliance (item 7, .PDF, 201 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441824&FileExtension=.PDF&FileName=Daytona%20Aircraft%20Service%2FDiscrepancy%20and%20Corrective%20Action%20Compliance-Master.PDF - DAS Repair Invoices (item 8, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441825&FileExtension=.PDF&FileName=DAS%20Repair%20Invoices-Master.PDF - Witness Statement (item 9, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441826&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - DAB Accident/Incident Report (item 10, .PDF, 812 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441827&FileExtension=.PDF&FileName=DAB%20Accident%2FIncident%20Report-Master.PDF - DAB Accident/Incident Report Operation Agent Statement (item 11, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441828&FileExtension=.PDF&FileName=DAB%20Accident%2FIncident%20Report%20Operation%20Agent%20Statement-Master.PDF - Airframe Logbooks (item 12, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441829&FileExtension=.PDF&FileName=Airframe%20Logbooks-Master.PDF - Engine Logbook Records (item 13, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441830&FileExtension=.PDF&FileName=Engine%20Logbook%20Records-Master.PDF - Propeller Records (item 14, .PDF, 601 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441831&FileExtension=.PDF&FileName=Propeller%20Records-Master.PDF - Toxicological Report - CFI (item 15, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441832&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20CFI-Master.PDF - Toxicological Report - Student Pilot (item 16, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441833&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Student%20Pilot-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441834&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Accident Photo Array (item 18, .PDF, 13 photos, 14.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441835&FileExtension=.PDF&FileName=Accident%20Photo%20Array-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441836&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.