# NTSB ERA16FA309: Cessna 172, N6091E, Hollywood, FL, September 3, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 3, 2016, 09:50 local (13:50 UTC) - Place: Hollywood, FL - Coordinates: 26.046667, -80.061943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.0467&lon=-80.0619&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 20, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming, Textron, FAA-FSDO - NTSB case key (mKey): 93938 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA309 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93938/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93938 - Page: https://openairdocs.org/ntsb/ERA16FA309 ## Probable cause The pilot's inadequate preflight and in-flight weather planning, which resulted in continued flight into a thunderstorm and a subsequent loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172N, 3 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=2072434), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Convective weather: thunderstorm](https://openairdocs.org/ntsb-findings/03033010): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 172N, 2 cases](https://openairdocs.org/ntsb-findings/03033010/cases.md?model=2072434), [All aircraft, 100 cases](https://openairdocs.org/ntsb-findings/03033010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172N, 150 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072434), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390) (defining event); cases with it: [Cessna 172N, 2 cases](https://openairdocs.org/ntsb-events/390/sequence.md?model=2072434), [All aircraft, 224 cases](https://openairdocs.org/ntsb-events/390/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna 172N, 45 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072434), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172N, 134 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072434), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot did not receive a weather briefing before beginning the cross-country flight. After takeoff, the pilot requested from air traffic control to fly below 500 ft above ground level along the ocean shoreline. The controller approved the request but advised of heavy precipitation (a thunderstorm) at the airplane's 12-o'clock position and 4 miles ahead. The controller further advised that the pilot should turn left and fly offshore 3 miles to avoid the thunderstorm. Although the pilot acknowledged the instructions, a review of radar and GPS data for the flight revealed that he continued on course. About 3 minutes later, the pilot reported the he was reversing direction, and no further communications were received from the pilot. Review of the airplane's GPS track overlaid on weather radar plots revealed that the airplane flew into an area of extreme intensity precipitation and then entered a rapid descent and impacted the ocean. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions. It is likely that the pilot lost control of the airplane when it encountered strong downdrafts and heavy rain associated with the thunderstorm. ## Factual narrative According to FAA and aircraft maintenance records, the airplane was issued an airworthiness certificate on December 13, 1978. It was powered by a Lycoming O-320-H2AD engine that was driving a McCauley propeller. According to maintenance records, the most recent annual inspection was completed on February 16, 2016, at a total time in service of 5,047.8 hours. At that time, the engine had accumulated 38.3 hours since major overhaul. At the time of the accident, the airplane had flown about 105 hours since the last annual inspection. On September 3, 2016, about 0950 eastern daylight time, a Cessna 172N, N6091E, was destroyed when it impacted the Atlantic Ocean while maneuvering near Hollywood, Florida. The private pilot and the pilot-rated passenger were fatally injured. The airplane was owned by Volux Aviation LLC, and operated by the private pilot. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. The airplane departed from Pompano Beach Airpark (PMP), Pompano Beach, Florida, at 0932 and was destined for Ocean Reef Club Airport (07FA), Key Largo, Florida. While flying south along the shoreline, the pilot contacted the air traffic control tower at the Fort Lauderdale/Hollywood International Airport (FLL) and requested to fly through the tower's airspace below 500 ft above ground level. The air traffic controller approved the request but advised the pilot of "heavy precipitation at the 12 o'clock position and 4 miles ahead" and stated, "you should turn left and go off shore 3 miles to avoid the thunderstorm." The pilot acknowledged the communication, and 3 minutes later, the pilot reported, "I am turning back to the north." The air traffic controller approved the turn, and no further communications were received from the airplane. Review of radar and GPS data that were downloaded from a portable GPS receiver, revealed that the pilot did not turn left and fly offshore as the air traffic controller advised. The data showed that the airplane instead maintained a southerly heading. The airplanes final GPS-derived position was recorded at 0950, with the airplane at a GPS altitude of 440 feet, a groundspeed of 85 knots, and tracking southbound. About 0951, when the pilot advised the controller that he was turning around and heading north, and when the airplane was about 3 miles east of FLL, radar contact was lost at a reported altitude of 200 feet with the airplane tracking eastbound. A search was initiated, and the airplane wreckage was located about 2 miles east of the shoreline submerged in the Atlantic Ocean in about 15 ft of water. The Broward County Medical Examiner, Fort Lauderdale, Florida, performed an autopsy on the pilot by. The autopsy findings included "multiple blunt force injuries." The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted forensic toxicology on specimens from the pilot.The toxicology report stated that no carbon monoxide was detected in the blood, and no drugs were detected in the urine. There was no record of the pilot receiving any preflight weather briefing from flight service or a direct user access terminal. At 0953, FLL reported wind from 150° at 10 knots, visibility 10 statute miles in light rain, scattered clouds at 1,500 ft and 6,000 ft, ceiling broken at 10,000 ft, broken clouds at 25,000 ft, temperature 27°C, dew point temperature 23°C, and altimeter 30.06 inches of Hg. The remarks section of the observation stated that rain began at 0952, and there were cumulonimbus clouds overhead through the north and from the west to northwest moving northeast. A thunderstorm was reported at FLL at 0956 with occasional in-cloud lightning to the north. The thunderstorm ended at 1023 with 0.01 inch of rain reported at the airport and with no significant change in flight conditions or wind gusts. The National Weather Service Miami (KAMX) Weather Surveillance Radar – 1988, Doppler (WSR-88D) was operating in the severe storm precipitation mode surrounding the time of the accident. KAMX WSR-88D composite reflectivity images at 0938, 0943, 0948, and 0953 depicted a band of heavy-to-extreme intensity echoes along the southeast Florida coast and immediately east of FLL during the period, with the echoes in the immediate vicinity of the accident site reaching maximum intensity and then decreasing in intensity with time and moving north-northeastward. The lowest 0.5°-elevation scan depicted the conditions immediately above the airplane between 870 to 3,220 ft and depicted echoes between 40 to 52 dBZ (heavy-to-extreme intensity). Overlaying the airplane's GPS track on the 0953 0.5°-base reflectivity image (see figure 1) indicated that the airplane traveled into a small but intense reflectivity core of 51dBZ (extreme intensity) precipitation. Figure 1 - KAMX WSR-88D Composite Reflectivity Image at 0953 with the airplane's 0950 GPS-derived position superimposed in magenta. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with an airplane single-engine land rating. His most recent FAA third-class medical certificate was issued on July 6, 2015. At that time, he reported a total flight experience of 795 hours. A review of the pilot's logbook revealed that he had accumulated a total of 818.4 hours of flight experience before the accident flight, and had flown 3.5 hours in the previous 90 days. The airplane was recovered from the water and examined. The left and right wings were separated from the fuselage at their roots and exhibited aft crushing along their leading edges. Flight control cable continuity was established from the cockpit area to all flight control surfaces. The measurement of the elevator trim actuator corresponded to a nose-down trim. Engine valve train continuity was verified, and thumb compression on all cylinders was established by rotating the propeller.All flight control surfaces remained at least partially attached to their respective attachment points. The flaps were in the "up" position. Both fuel tanks were breeched and exhibited signs of hydraulic deformation. The left main landing gear was separated from the fuselage. All seats were separated from their mounting points. ## Aircraft - Registration: [N6091E](https://openairdocs.org/deregistered/N6091E-2019-11-04), registration cancelled 2019-11-04, S/N 17271989, built 1978 (OpenAirDocs) - Reported make and model: CESSNA 172 (N) - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17271989 - Year built: 1978 - Airframe hours: 5153.2 - Engines: LYCOMING O-320 SERIES 160 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 9, 2016, 105 hours before - Departed: PMP, POMPANO BEACH, FL - Destination: 07FA, KEY LARGO, FL - Equipment: Stall warning system, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 27, 2014; seat: left; restraint: 3-point; toxicology performed; flight hours: 819 total, 700 in this make and model, 2.5 in the last 90 days, 0.7 in the last 30 days, 0 in the last 24 hours - Pilot-rated passenger; age 66; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review March 15, 2014; seat: right; restraint: 3-point; toxicology performed; flight hours: 198 total, 175 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 81 °F, dew point 73 °F - Altimeter: 30.05 inHg - Turbulence: Unknown - Observed at: FLL, 8 nm away ## 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 20160903014869A](https://openairdocs.org/incident/20160903014869A), Sep 3, 2016: Cessna 172N, Fort Lauderdale, FL, Destroyed, 2 fatal. Aircraft Cessna C-172N, N6091E with two private pilots departed pompano beach airpark airport (pmp) to ocean reef club airport (oca) approaching Fort… ## Docket (14 files) The files NTSB released with the investigation on July 11, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93938. 23.9 MB in all. - Global Positioning System Device - Specialist's Factual Report (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454087&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Attachment 1 to Global Positioning System - Specialist's Factual Report (item 2, .CSV, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454088&FileExtension=.csv&FileName=Attachment%201%20to%20Global%20Positioning%20System%20-%20Specialist%27s%20Factual%20Report-Master.csv - Maintenance Records (item 3, .PDF, 10.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454089&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Excerpts from Pilot Logbook (item 4, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454090&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%20Logbook-Master.PDF - Meteorology Factual Report (item 5, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454091&FileExtension=.PDF&FileName=Meteorology%20Factual%20Report-Master.PDF - Meteorology - Attachment 1 Composite Reflectivity Animation (item 6, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454092&FileExtension=.PDF&FileName=Meteorology%20-%20Attachment%201%20Composite%20Reflectivity%20Animation-Master.PDF - Meteorology - Attachment 2 - WSR-88D Base Reflectivity Animation (item 7, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454093&FileExtension=.PDF&FileName=Meteorology%20-%20Attachment%202%20-%20WSR-88D%20Base%20Reflectivity%20Animation-Master.PDF - Air Traffic Control Radar and Radio Communications Replay (item 8, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454094&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Radar%20and%20Radio%20Communications%20Replay-Master.PDF - Investigative Photographs (item 9, .PDF, 4 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454095&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Toxicological Report - Pilot-Rated Passenger (item 10, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454096&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Rated%20Passenger-Master.PDF - Toxicological Report - Pilot (item 11, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454097&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454098&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Evidence Control Form (item 13, .PDF, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454099&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454100&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.