# NTSB ERA23FA323: Cessna 172, N697FL, Pembroke Pines, FL, August 4, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 4, 2023, 12:00 local (16:00 UTC) - Place: Pembroke Pines, FL · Off runway 10 - Coordinates: 25.999628, -80.233676 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.9996&lon=-80.2337&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming, Textron - NTSB case key (mKey): 192794 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23FA323 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192794/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192794 - Page: https://openairdocs.org/ntsb/ERA23FA323 ## 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 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 · Instructor/check pilot (probable cause); cases with it: [Cessna 172P, 76 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072436), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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 172P, 3 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072436), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna 172P, 10 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072436), [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 172P, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072436), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N697FL), registered now, S/N 17276100 (OpenAirDocs) - Reported make and model: CESSNA 172 (P) - Registry model: [Cessna 172P](https://openairdocs.org/model/cessna-172p) (registry code 2072436) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17276100 - Year built: 1984 - Airframe hours: 20373 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: fatal; 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= ## 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 20230804021859A](https://openairdocs.org/incident/20230804021859A), Aug 4, 2023: Cessna 172P, Pembroke Pines, FL, Destroyed, 2 fatal. Unauthorized part 91 air tour flight crashed shortly after takeoff from runway 10R at hollywood North Perry Airport (hwo). Three souls on board, a CFI rated… ## Docket (15 files) The files NTSB released with the investigation on November 21, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192794. 131 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17196485&FileExtension=pdf&FileName=NTSB%20Report%20N697FL_Redacted-Rel.pdf - W&b with POH excerpt (item 2, PDF, 3 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17289226&FileExtension=pdf&FileName=W%26B%20with%20POH%20Excerpt_Redacted-Rel.pdf - Maintenance records excerpt (item 3, PDF, 8 pages, 29.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17091067&FileExtension=pdf&FileName=Maintenance%20Records%20Excerpt_Redacted-Rel.pdf - ADS-B tabular data (item 4, XLSX, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17088017&FileExtension=xlsx&FileName=ADS-B%20Tabular%20Data-Rel.xlsx - Flight track data and graphic (item 5, JPG, 750 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17087168&FileExtension=jpg&FileName=ADS-B%20Flight%20Track%20Graphic-Rel.jpg - Video study (item 6, PDF, 11 pages, 865 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17351480&FileExtension=pdf&FileName=Pembroke_Pines_video_study_1_final-Rel.pdf - Video of takeoff and accident (item 7, MOV, 23.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17085579&FileExtension=MOV&FileName=KWBG6384-Rel.MOV - Aft view video of accident sequence (item 8, MP4, 65.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17085428&FileExtension=mp4&FileName=20230804%2012.00.00%20through%2012.03.59-Rel.mp4 - Record of conversation - mother of passenger (item 9, PDF, 2 pages, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17880997&FileExtension=pdf&FileName=ROC_Mother%20of%20Passenger_Redacted-Rel.pdf - NTSB examination summary (item 10, PDF, 5 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17879689&FileExtension=pdf&FileName=NTSB%20ERA23FA323%20Accident%20and%20Exam%20Report_Redacted-Rel.pdf - Investigative photographs (item 11, PDF, 8 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17085986&FileExtension=pdf&FileName=Photo%20Array_N697FL-Rel.pdf - Toxicological report (item 12, PDF, 1 page, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17087999&FileExtension=pdf&FileName=2023_129_001%20Tox%20Report_Pilot_Redacted-Rel.pdf - Hwo surface weather observations (item 13, PDF, 1 page, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17326994&FileExtension=pdf&FileName=METAR%20Weather%20Report-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 11 pages, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17088425&FileExtension=pdf&FileName=Master%20Party%20Forms%20Signed_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16395340&FileExtension=pdf&FileName=N697FL%20Wreckage%20Release%20Signed_Redacted-Rel.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.