ERA23FA323

NTSB accident investigation · Cessna 172 · Pembroke Pines, FL · August 4, 2023

Accident · FatalClass 3 · FieldFinal report
Date
August 4, 2023, 12:00 local (16:00 UTC)
Place
Pembroke Pines, FL · Off runway 10
Injuries
2 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N697FLCessna 172
Defining event
Initial climb: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming, Textron
FAA report
20230804021859A
Case key
192794

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 flight instructor’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall and subsequent rapid descent into terrain.

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 · Instructor/check pilotCessna 172P: 76 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172P: 3 casesAll aircraft: 990 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 instructor and two passengers were departing for a local flight when the accident occurred. Airport security video showed that shortly after the takeoff roll the airplane rotated and lifted off normally, but the airplane’s pitch rapidly increased during the initial climb, which continued to an altitude of about 125 ft. The airplane then began a roll to the left that quickly developed into a steep descent to impact with the flat terrain on airport property. Postaccident examination of the airframe and engine revealed that the propeller blades exhibited damage signatures indicative of engine power during impact. The cockpit front seat rails and their associated seat frame latches displayed no anomalies or evidence of aft seat slippage that would account for the high pitch angle during initial climb, and the weight and balance was within limits. The examination did not reveal evidence of any preimpact mechanical malfunctions or failures of the flight controls or other airframe components that would preclude normal operation. The surviving passenger could not recall any details about the flight, and there was no onboard recorded electronic data available for review. A video study was performed using the security video footage and concluded that during takeoff and initial climb, there was a large wing angle of attack (AOA) preceding a bank to the left. Immediately before the left bank, the AOA was estimated to be 14.5°. Given this information, is likely that during the initial climb, the airplane exceeded its critical angle of attack, which resulted in a power-on aerodynamic stall and subsequent loss of control at an altitude that was too low to recover.

Factual narrative

On August 4, 2023, at 1200 eastern daylight time, a Cessna 172P, N697FL, was substantially damaged when it was involved in an accident at North Perry Airport (HWO), Pembroke Pines, Florida. The flight instructor and front seat passenger sustained fatal injuries, and the rear seat passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The operator reported that the purpose of the flight was an introductory/instructional flight. According to family members of the passengers, the purpose of the flight was a scenic tour of downtown Miami, Florida. One of the passengers occupied the front left seat, the flight instructor occupied the right front seat, and the other passenger occupied the rear seat. Neither of the passengers held pilot certificates and there was no luggage. Following the accident, the surviving rear seat passenger was unable to recall any details about the flight. The airplane departed HWO on runway 10R, a 3,255 ft-long by 100 ft-wide, asphalt runway. Two security cameras from different angles showed the airplane’s takeoff ground roll, and rotation. During the initial climb, the airplane’s pitch increased rapidly before reducing several seconds later until the airplane reached about 125 ft above ground level. The airplane then began a left descending turn, rolled further to the left, and descended steeply until impacting level terrain on airport property about 650 ft northeast of the departure end of the runway. Figure 1 (below) depicts select still frames from the airport surveillance video showing the airplane’s takeoff, climb, and left roll and descent. Figure 1 – Select still video frames of the takeoff roll (top left), initial climb (bottom left) and left descending turn (right). ADS-B data provided by the Federal Aviation Administration (FAA) showed the airplane on the takeoff roll as its ground speed increased to about 45 knots. There was about a 10-second gap in track and groundspeed data until the ADS-B data resumed and showed the airplane at about 74 knots and an altitude of 50 ft msl. The highest ground speed recorded was 75 knots before the speed decreased immediately preceding the left turn and descent. The wind speed and direction were fluctuating before and shortly after the accident. The airport’s surface observation report, recorded about 7 minutes before the accident, showed a wind from 170° at 6 kts, which would have resulted in a headwind component of 2 kts and a right crosswind component of 5.6 kts. About 4 minutes after the accident, the wind had shifted to 210° and 9 kts, which would have resulted in a right crosswind with a tail wind component of about 3 knots. In addition, there was a reported thunderstorm in the area; however, video recording of the flight did not show any precipitation or a thunderstorm over the airport. The airplane impacted the ground in a steep, left-wing-low, nose-down attitude before coming to rest upright; thewreckage was oriented on a heading of 287° at an elevation of 12 ft. Both wings were impact separated downward. The wreckage path was compact, and all major components and flight control surfaces remained attached. There was no postimpact fire. The fuselage was buckled and deformed through about 50% of the cockpit area, with the most severe damage in the front seat area and floorboards. The engine compartment was significantly compromised by impact forces, displacing the engine and propeller upward and aft into the firewall, which also displaced the instrument panel. The empennage remained relatively undamaged from about 2 ft aft of the cabin area. The front seat tracks/rails exhibited impact damage. Examination of the seat tracks/rails confirmed one track/rail of each front seat exhibited a circular latch pin gouge mark, then gouge marks going forward and to the side of the track/rail. There were no signatures of aft seat slippage on either seat. Flight control continuity was confirmed from the cockpit to all control surfaces. There was a break in the right aileron drive cable that exhibited tensile overload signatures consistent with impact. The elevator trim was found in the 20° trim tab trailing edge up (nose down) position. Examination of the elevator trim jackscrew revealed impact damage that destroyed the trim control unit. The elevator trim control position indicator in the cockpit was severely damaged by impact forces. The instrument panel exhibited impact damage. The flap handle was found in the UP detent. The flap indicator was found between 10° and 20°. The flap motor/actuator was found in the full retracted/flaps up position. A total of about 22 gallons of aviation fuel (100 LL) was recovered from both fuel tanks. Subsequent fuel testing yielded negative results for the presence water and there were trace amounts of foreign debris in the gascolator. The carburetor was removed, and the brass floats contained hydraulic deformation consistent with the presence of fuel in the bowl during impact. The engine crankshaft was manually operated via the accessory section through several full rotations. There was no binding or limitations to movement and crankshaft continuity was confirmed. Continuity was confirmed on all pistons, valve springs, and pushrods, which operated normally. Compression was attained on each of the 4 cylinders. Both left and right magnetos were removed and manually operated; both left and right magnetos produced spark at each of the posts. All the spark plugs displayed normal coloration and normal electrodes as compared to the Champion Aerospace AV-27 Check-A-Plug chart. The two-blade propeller remained partially attached to the propeller flange. One blade showed evidence of abrasive polishing on the outer 12 inches of blade tip and contained a compound S-bend and twist and bending in the opposite direction of rotation and chordwise scratch marks. The other blade exhibited leading edge polishing and a 30° bend to thenon-camber side. Weight and balance calculations indicated that the airplane was within its center of gravity and weight limits at the time of the accident. A multi-function display was recovered from the wreckage and forwarded to the National Transportation Safety Board (NTSB) Recorders Laboratory. No flight, engine or performance data was recorded on the device. An autopsy of the flight instructor was performed by the Broward County Medical Examiner, Fort Lauderdale, Florida. The flight instructor’s cause of death was multiple blunt force injuries, and the manner of death was an accident. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory did not detect any substance that would be considered impairing. Additional testing was conducted postmortem by the Broward County Office of the Medical Examiner and Trauma Services, Fort Lauderdale, Florida and was negative for alcohol and illicit substances. A video study was conducted by the NTSB’s Office of Research and Engineering based on visual information obtained from airport security camera footage. The objective of the study was to estimate the airplane’s altitude, pitch angle, and wing angle of attack. Taking a simulated Cessna 172P for the program model, along with security camera footage and ADS-B data, the study concluded that during takeoff and initial climb there was a large wing AOA preceding a bank to the left. Immediately before the left bank, the AOA was estimated to be 14.5°. The large wing angle of attack was caused primarily by the large airplane pitch angle. When the airplane started banking to the left, its ground speed was a constant 61 knots.

Aircraft

Registration
N697FL
Reported as
Cessna 172 (P)
Category
Airplane
Serial number
17276100
Built
1984
Airframe hours
20,373
Engine
Lycoming O-320-D2G, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Aeroflyin Corp
Registered owner
Aeroflyin Corp
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 8, 2023
Airport
HWO · North Perry, runway 10R, 3,255 × 100 ft
Equipment
Electronic multifunction display, ADS-B

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
31
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 27, 2023
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
900 total · 98 in the last 90 days · 24 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
3,400 ft broken
Temperature
90 °F, dew point 77 °F
Altimeter
29.99 inHg
Observed at
KHWO
METAR
METAR KHWO 041553Z 17006KT 10SM BKN034 BKN110 32/25 A2999 RMK AO2 SLP156 T03170250=

Docket · 15

The files NTSB released with the investigation on November 21, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 131 MB 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.