# NTSB ERA18LA094: Cessna 172, N615JA, Ocean City, MD, March 1, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: February 28, 2018, 19:30 local (Mar 1, 2018, 00:30 UTC) - Place: Ocean City, MD - Coordinates: 38.288055, -75.091941 - Nearby events: https://openairdocs.org/map.md?lat=38.2881&lon=-75.0919&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Loss of visual reference](https://openairdocs.org/ntsb-events/402) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 19, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming Engines, Cessna/Texton Aviation - NTSB case key (mKey): 96817 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA094 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96817/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96817 - Page: https://openairdocs.org/ntsb/ERA18LA094 ## Probable cause The pilot's flight in dark night visual meteorological conditions, which resulted in an impact with water for reasons that could not be determined based on the available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (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) - [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) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); 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) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); 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. - [Enroute-descent: Loss of visual reference](https://openairdocs.org/ntsb-events/402) (defining event); cases with it: [Cessna 172S, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=2072439), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/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 non-instrument-rated private pilot rented the airplane on the day of the accident for a night visual flight rules cross-country flight in visual meteorological conditions. A review of radar track data showed that the airplane initiated a descent from 3,500 ft mean sea level (msl) about 15 nautical miles (nm) from the destination airport; the last recorded radar track data showed the airplane at an altitude of 1,350 ft msl about 3 nm from the destination airport. The airplane was reported missing the following morning, and an oil slick was subsequently discovered about 2 miles from the end of the runway at the destination airport. Divers located the wreckage; however, it was not recovered, and an examination of the airplane could not be performed. Sun and moon data revealed that the moon was 98% illuminated about 45 degrees above the horizon to the east about the time of the accident; however, overcast clouds would have obscured its illumination. The dark night conditions combined with a an approach to the airport over water would have increased the difficulty associated with the tasks of maintaining aircraft attitude control and maintaining awareness of the airplane's height above the water while maneuvering to land. It is likely that the pilot either lost control due to spatial disorientation or inadvertently descended into the water; however, without track information from the final moments of the flight, there is insufficient information from which to determine which scenario was more likely involved in the accident. ## Factual narrative According to the FAA Airplane Flying Handbook, FAA-H-8083-3, Chapter 10: Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning. Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane. Crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, not only from the standpoint of landing (ditching) in the water, but also because with little or no lighting the horizon blends with the water, in which case, depth perception and orientation become difficult. During poor visibility conditions over water, the horizon will become obscure, and may result in a loss of orientation. Even on clear nights, the stars may be reflected on the water surface, which could appear as a continuous array of lights, thus making the horizon difficult to identify. According to Advisory Circular 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further stated that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions. The single-engine airplane was manufactured in 2007 and was powered by a Lycoming IO-360-L2A engine rated at 180 horsepower, equipped with a McCauley 2-bladed propeller. The most recent annual inspection was completed on January 16, 2018 at a tachometer time of 6,206.9 hours. A review of the maintenance logbooks revealed that the last altimeter pitot-static system and transponder test was performed on April 13, 2017; the records also indicated that all applicable Airworthiness Directives for the airframe, engine, propeller, and accessories had been completed. Fueling records revealed that the airplane was last fueled on the day of the accident with 11.08 gallons of 100LL aviation fuel. A review of the airplane's dispatch record for the accident flight revealed that there were no open discrepancies noted on the log. On February 28, 2018, about 1930 eastern standard time, a Cessna 172S, N615JA, was destroyed when it impacted the Atlantic Ocean about 2 miles east of Ocean City Municipal Airport (OXB), Ocean City, Maryland. The private pilot was fatally injured. The passenger was not located and was presumed fatally injured. The airplane was registered to Middle River Aviation and operated as a Title14 Code of Federal Regulations Part 91 personal flight. Night visual meteorological conditions prevailed, and no flight plan was filed for the flight, which departed Martin State Airport (MTN), Baltimore, Maryland, about 1753. According to information from MTN ground control, the pilot requested visual flight rules (VFR) flight following to OXB and departed from runway 15 at MTN. The pilot contacted the departure controller after takeoff and reported climbing past 1,600 ft mean sea level (msl). The controller identified the airplane 3 miles southeast of MTN and instructed the pilot to proceed on course below the Class B airspace and to maintain VFR. At 1805, the pilot reported reaching his cruise altitude of 3,500 ft and was issued the current altimeter setting. A review of radar track data showed the airplane approaching OXB from the northwest at an altitude around 3,500 ft msl before beginning a slow descent about 15 nautical miles (nm) northwest of OXB. The airplane continued its descent, and radar service was terminated about 3 nm northwest of OXB at an altitude of 1,350 ft msl. The airplane was reported missing the following morning, and a search was initiated. About 1030, a search flight conducted by the flight school discovered an oil slick about 2 miles from the approach end of runway 14 at OXB. According to the Maryland Natural Resources Police, on March 1, 2019, they were notified of an airplane that had gone missing en route to OXB. A search of the shoreline identified debris from the airplane. During the search, a fuel and oil slick was discovered that was still bubbling to the surface. They positioned their vessel around the highest concentration of fuel and oil and anchored. Divers subsequently discovered a wing and the fuselage of the airplane. Shortly thereafter, the pilot was found within the wreckage. Divers continued to search for the other victim, but the search was unsuccessful due to the deteriorating visibility and sea conditions. The Office of the Chief Medical Examiner, State of Maryland, performed an autopsy on the pilot. The cause of death was noted as drowning. Toxicology testing performed by the FAA's Forensic Sciences Laboratory was negative for carbon monoxide, cyanide, and tested-for drugs. The 1953 recorded weather at OXB, about 2 miles west of the accident site, included wind from 230° at 10 knots, 10 statute miles visibility, and overcast clouds at 10,000 ft above ground level. The temperature was 12°C, dew point 4°C, and the altimeter setting was 29.98 inches of mercury. According to the Astronomical Applications Department at the United States Naval Observatory, the sunset was at 1752, the end of civil twilight was at 1819, and moonrise was at 1631. The phase of the moon on the day of the accident was waxing gibbous, with 98% of the moon's visible disk illuminated. The pilot held a private pilot certificate with an airplane single-engine land rating that was issued on August 24, 2017. He held a FederalAviation Administration (FAA) first-class airman medical certificate that was issued on February 2, 2017. According to the operator, the pilot had accumulated about 81 hours of total flight experience. The pilot's logbooks were not available for review, and his night flying experience could not be determined. A review of the operator's rental minimums revealed that the pilot did meet the qualifications to rent the Cessna Skyhawk 172S. In addition, the rental agreement did not specify night flying minimums. A review of the dispatch record revealed that the estimated time of departure was 1351 and the return time was estimated at 1730. The wreckage was located in the Atlantic Ocean about 2 miles off the shoreline at a depth of 50 ft. The main wreckage was not recovered. Loose debris that was found in the area of the wreckage was collected and comprised the nose gear strut and wheel, main landing gear tire, flight manuals, fire extinguisher, back seat cover, wheel chock, pilot and passenger doors, and a red tag with the airplane's registration number that read, "remove before flight." Small pieces of the fuselage were also located along the shoreline. ## Aircraft - Registration: [N615JA](https://openairdocs.org/deregistered/N615JA-2018-06-14), registration cancelled 2018-06-14, S/N 172S10554, built 2007 (OpenAirDocs) - Reported make and model: CESSNA 172 (S) - 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: 172S10554 - Year built: 2007 - Airframe hours: 6206.9 - Engines: LYCOMING IO-360-L2A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Middle River Aviation LLC - Registered owner: Middle River Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 16, 2018, 68 hours before - Departed: MTN, BALTIMORE, MD - Destination: OXB, OCEAN CITY, MD - Airport: OXB, Ocean City Muni - Equipment: Stall warning system, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review August 24, 2017; toxicology performed; flight hours: 81 total, 81 in this make and model, 3 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 230° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 54 °F, dew point 39 °F - Altimeter: 29.97 inHg - Observed at: OXB, 2 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 20180228012119A](https://openairdocs.org/incident/20180228012119A), Feb 28, 2018: Cessna CE-172S, Ocean City, MD, Destroyed, 2 fatal. On Wednesday February 28, 2018, at approximately 1756 EST, Mr. Marcson ngwa, a non-instrument rated private pilot departed martin state airport, baltimore, MD… ## Docket (14 files) The files NTSB released with the investigation on April 2, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96817. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481884&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum of Record Operator Middle River Aviation (item 2, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481885&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20Operator%20Middle%20River%20Aviation-Master.PDF - Fuel Records (item 3, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481886&FileExtension=.PDF&FileName=Fuel%20Records-Master.PDF - Maryland Natural Resources Police Incident Report (item 4, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481887&FileExtension=.PDF&FileName=Maryland%20Natural%20Resources%20Police%20Incident%20Report%20-Master.PDF - Rental Agreement (item 5, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481888&FileExtension=.PDF&FileName=Rental%20Agreement-Master.PDF - Maintenance Records (item 6, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481889&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Memorandum Of Record: NTSB Weather Specialist Correspondence (item 7, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481890&FileExtension=.PDF&FileName=Memorandum%20Of%20Record%3A%20%20NTSB%20Weather%20Specialist%20Correspondence-Master.PDF - ATC Accident Summary and Transcript of Radio Communications (item 8, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481891&FileExtension=.PDF&FileName=ATC%20Accident%20Summary%20and%20Transcript%20of%20Radio%20Communications-Master.PDF - Radar Data Flight Track N615JA (item 9, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481892&FileExtension=.PDF&FileName=Radar%20Data%20Flight%20Track%20N615JA-Master.PDF - OXB Falcon Radar Data (item 10, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481893&FileExtension=.PDF&FileName=OXB%20Falcon%20Radar%20Data-Master.PDF - OpsVue Radar Data Track (item 11, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481894&FileExtension=.PDF&FileName=OpsVue%20Radar%20Data%20Track-Master.PDF - Photo Array (item 12, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481895&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Toxicological Report (item 13, .PDF, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481896&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481897&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.