# NTSB ERA23FA358: Cirrus SR20, N420PB, Toms River, NJ, September 3, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 2, 2023, 22:18 local (Sep 3, 2023, 02:18 UTC) - Place: Toms River, NJ - Coordinates: 39.92018, -74.3148 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.9202&lon=-74.3148&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO, Cirrus Aircraft - NTSB case key (mKey): 192992 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23FA358 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192992/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192992 - Page: https://openairdocs.org/ntsb/ERA23FA358 ## Probable cause The pilot's failure to maintain a positive climb rate after takeoff due to spatial disorientation (somatogravic illusion), which resulted in impact with trees and terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Cirrus Design SR20, 5 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2130000), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cirrus Design SR20, 5 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2130000), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=2130000), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Not specified (probable cause); cases with it: [Cirrus Design SR20, 3 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2130000), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cirrus Design SR20, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2130000), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The student pilot was endorsed by his instructor for solo night flight to a nearby airport. ADS-B track data indicated that the accident occurred during the pilot’s fourth takeoff following three full-stop landings. ADS-B data showed the airplane at 275 ft mean sea level (msl) and 62 knots (kts) groundspeed as it climbed over the runway. The airplane climbed to 425 ft at a groundspeed of 56 kts before it leveled between 425 and 500 ft msl and accelerated to 90 kts groundspeed for about 30 seconds. The airplane then began a descending, accelerating right turn until the target disappeared at an altitude of about 150 ft msl and at a groundspeed about 128 kts. Airport surveillance videos showed the airplane in a shallow climb after takeoff and descending below the tree line, followed by a postimpact fire. Examination of the accident site revealed that the airplane impacted heavily wooded terrain in a wings-level, shallow descent, with cut tree limbs in the area consistent with the engine producing power at the time of impact. The airplane was mostly consumed by postimpact fire; however, examination revealed no evidence of mechanical malfunctions that would have precluded normal operation. Another pilot, who was flying in the airport traffic pattern around the time of the accident, stated that the area past the departure end of the runway was dark, and that “instrument monitoring was essential on climb out.” Such lighting conditions are highly conducive to the development of spatial disorientation. Further, the altitude profile depicted by the ADS-B data and the near-wings-level attitude and high speed at impact were consistent with the pilot experiencing a form of spatial disorientation known as somatogravic illusion. This type of spatial disorientation occurs when a pilot errantly perceives the airplane's acceleration as increasing pitch attitude, and efforts to hold the nose down or arrest the perception of increasing pitch attitude can exacerbate the situation. Such an illusion can be especially difficult to overcome because it typically occurs at low altitudes after takeoff, which provides little time for recognition and subsequent corrective inputs, particularly in very low visibility conditions. ## Factual narrative According to FAA Safety Briefing Magazine, Vestibular Illusions, Accidents can occur due to a combination of vestibular illusions and poor visibility. When the body is subjected to certain forces that cause a vestibular illusion, vision is often the only sense that can contradict these false perceptions. However, in darkness or other poor visibility conditions, it is much easier to be deceived by an illusion, often making it difficult for a pilot to tell which way is up. When this occurs it’s important to ignore the conflicting signals your body is giving you and instead rely on your experience and trust your instruments. The somatogravic illusion occurs during rapid acceleration and creates the same feeling as tilting your head backward. Pilots experiencing this feeling can mistake it for a climb, especially while flying IFR. This disorientation could make you want to push the aircraft into a nose-low or dive attitude… When you make a sudden return to straight and level flight after a climb, it can feel like you are tumbling backward. This is known as inversion illusion. The disorientation you feel from this might lead you to push your aircraft abruptly into a nose-low attitude, which can intensify the illusion. According to the Pilot’s Operating Handbook, the airplane’s best rate of climb airspeed at sea level at an estimated aircraft weight of 2,500 lbs was 88 kts. An Alpha Systems angle-of-attack (AOA) indicator with a glareshield-mounted display was installed during the most recent annual inspection. According to the airframe logbook entry that detailed the annual inspection, an on-ground calibration procedure was performed, and an “in-flight calibration procedure needs to be performed I/A/W Alpha Systems Operation Manual.” No maintenance logbooks for the airplane were recovered. Copies of discrepancy logs and maintenance log entries were provided by the maintainer and dated back to September 2022. It could not be determined if the AOA indicating system calibration flight was completed. MJX was equipped with two intersecting runways oriented 06/24 and 14/32. Runway 06/24 was 5,950 ft long and 100 ft wide, and runway 14/32 was 3,599 ft long and 100 ft wide. The asphalt runways intersected at the southwest corner of the airport property near the departure end of runway 24. MJK was a non-tower-controlled airport with precision and non-precision instrument approach procedures available. The airport was located about 12 miles west of the Atlantic Ocean in the northeast quadrant of the Pinelands National Reserve, about 1.1 million acres of mostly undeveloped forest. On September 2, 2023, at 2218 eastern daylight time, a Cirrus SR20, N420PB, was destroyed when it was involved in an accident near Toms River, New Jersey. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 solo instructional flight. The accident pilot’s flight instructor reported that he received a message from the pilot,who stated that he was going flying that night. The instructor stated that he had endorsed the pilot for solo flight at night to Ocean County Airport (MJX). ADS-B track data indicated that the accident occurred during the student pilot’s fourth takeoff following three left traffic patterns on the east side of the runway to full-stop landings. ADS-B data showed the airplane at 275 ft mean sea level (msl) and 62 kts groundspeed as it climbed above the runway to 425 ft before it leveled for about 30 seconds between 425 ft and 500 ft. The airplane’s groundspeed in the climb slowed and was steady at 56 kts. Once level, the airplane accelerated slowly to about 90 kts groundspeed, where it initiated a descending, accelerating right turn over forested terrain until the last data target, which showed the airplane at 150 ft and 128 kts groundspeed. Two separate airport surveillance videos captured the airplane; the first video showed the airplane in a shallow climb after takeoff before the airplane continued out of frame. The second showed the airplane in a descent below the tree line, followed by a postimpact fire. Other pilots operating at and around MJX on the night of the accident stated that the accident pilot was communicative over the airport’s common traffic advisory frequency and identified his airplane as “Cirrus” rather than by its registration number. The pilots described a clear night with wind estimated “from the west” about 10 kts. One of the pilots reported that it was very dark past the departure end of runway 24, and that “instrument monitoring was essential on climb out” due to the lack of ground references at night. The horizon to the east included a brightly illuminated coastline and a rising moon. The Ocean County Medical Examiner, Toms River, New Jersey, ruled the cause of death for the pilot as blunt force injuries and the manner of death as accident. Toxicological testing of postmortem specimens from the pilot revealed no tested-for illicit substances detected. At 2156, the weather observed at MJX included clear skies and 10 miles of visibility. The wind was from 210° at 7 kts. Sun and moon data for Toms River, New Jersey, at the time of the accident revealed that the moon was in the eastern sky at 090° and was 13° above the horizon at the time of the accident. The pilot was issued a third-class FAA medical certificate on March 9, 2022. He reported 0 hours of flight experience on that date. Pilot logbooks were not recovered, but the pilot’s flight instructor estimated that the pilot had accrued between 65 and 70 hours of total flight experience, all of which was in the accident airplane. The instructor provided a record of the training he provided to the accident pilot, which began on May 29, 2023, and included 23.6 total hours of flight instruction, 3.8 hours of which were at night. The records provided indicated that the instructor had flown to MJX at night with the accident pilot on 2 occasions, once on August 27, 2023, andagain on August 31, 2023. The instructor documented 3 hours of simulated instrument training with the pilot over 2 separate flights about 1 month before the accident. The airplane came to rest in densely wooded state forest property covering over 1 million acres adjacent to MJX. The wreckage was examined at the accident site and all major components were accounted for at the scene. The composite airplane was fragmented along a 300-ft long wreckage path, which was oriented about 290° magnetic, and the wreckage was consumed by postcrash fire. The accident ignited a wildfire that prevented access to the wreckage for about 36 hours. The initial impact point was identified as 40 ft-tall trees that displayed damage consistent with a shallow, wings-level descent to ground contact. Pieces of angularly cut wood were found along the wreckage path. The cockpit instruments and components were consumed by fire and contained no usable information. The engine was found inverted, with both propeller blades loose in their hubs. The blades displayed similar twisting, bending, and tip curling as well as thermal damage. The engine case was heavily damaged by impact and fire. The wreckage was recovered from the site and flight control cables, pulleys, turnbuckles, bellcranks, and the flap actuator were laid out for examination. Aileron control continuity could not be confirmed due to impact and thermal damage. Rudder and elevator control continuity was established through several breaks consistent with impact and fire. Measurement of the flap actuator revealed dimensions consistent with the flaps being fully retracted. The Cirrus Airframe Parachute System (CAPS) was deployed and displayed evidence of deployment due to impact forces. The engine was rotated by hand at the propeller. Continuity was established from the powertrain through the valvetrain to the accessory section. Compression was confirmed on all but the No. 5 cylinder using the thumb method. The No. 5 intake valve boss was fractured by impact and the valve was separated from its guide. Examination of the cylinders revealed normal wear and combustion deposits. The magnetos were destroyed by fire. The high-pressure fuel pump was displaced by impact, removed, and partially disassembled. The pump rotated smoothly, and the internal vanes were intact. The flow divider was opened; it contained fuel, and the screen and diaphragm were intact. The No. 1 upper aft crankcase through-bolt was displaced by impact, and the nut on the case side was fractured. The external oil filer was destroyed by impact and fire. The internal oil filter screen was clean of obstruction or debris. Oil was present throughout the engine. A more detailed examination of the propeller system revealed wave-bend signatures observed with tree-strike events, compound bending in the forward/thrust direction, and twisting of blade #1 towards high pitch. These features were consistent with a propeller being rotated by engine power. An impactsignature on preload plate number two suggested the propeller governing at a blade angle consistent with moderate-to-high power. ## Aircraft - Registration: [N420PB](https://openairdocs.org/aircraft/N420PB), registered now, S/N 1288, built 2003 (OpenAirDocs) - Reported make and model: CIRRUS SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1288 - Year built: 2003 - Airframe hours: 1692.5 - Engines: Teledyne Continental IO-360-ES 200 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 18, 2023 - Destination: Same as departure - Airport: MJX, Ocean County, runway 24, 5,950 × 100 ft, asphalt - Equipment: ADS-B, Angle of attack indicator ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 61; injuries: fatal; student; medical: class 3, with waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 65 total, 65 in this make and model, 23.6 in the last 90 days, 13.6 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 210° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 61 °F - Altimeter: 30.09 inHg - Observed at: MJX, 1 nm away - METAR: KMJX 030156Z AUTO 21007KT 10SM CLR 19/16 A3009 RMK AO2 SLP193 T01890156 TSNO ## 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 20230902013049A](https://openairdocs.org/incident/20230902013049A), Sep 2, 2023: Cirrus Design Corp SR20, Lacey Township, NJ, Destroyed, 1 fatal. On 09/02/2023 at approximately 10:30PM EDT, a student pilot flew from monmouth county executive airport (kblm) to Ocean County Airport (kmjx) to practice night… ## Docket (11 files) The files NTSB released with the investigation on August 20, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192992. 25.6 MB in all. - Witness statements (item 1, PDF, 6 pages, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172465&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Flight instructor interview summary (FAA) (item 2, PDF, 3 pages, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172058&FileExtension=pdf&FileName=FAA%20ROC%20with%20Flight%20Instructor_Redacted-Rel.pdf - Airport surveillance video (item 3, MOV, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18171765&FileExtension=mov&FileName=Airport%20Surveilance%20Video-Rel.mov - ADS-B flight track illustration (item 4, PDF, 1 page, 990 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172218&FileExtension=pdf&FileName=ERA23FA358%20ADS-B%20Track%20Illustration-Rel.pdf - ADS-B track data (item 5, CSV, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172034&FileExtension=csv&FileName=62684_20230903012500_Once-Rel.csv - Annual inspection and AOA system install (item 6, PDF, 1 page, 831 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172044&FileExtension=pdf&FileName=Annual%20and%20AOA%20Install_Redacted-Rel.pdf - Engine examination summary (item 7, PDF, 1 page, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172677&FileExtension=pdf&FileName=Accident%20%23%20ERA23FA358%20Engine%20Evaluation%20Continental%20I0360ESS6%20BR-Rel.pdf - Propeller examination (item 8, PDF, 7 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172078&FileExtension=pdf&FileName=Hartzell%20Propeller%20Exam%20II_Redacted-Rel.pdf - Moon location (item 9, PDF, 1 page, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18171775&FileExtension=pdf&FileName=Moon%20Location-Rel.pdf - Photo array (item 10, PDF, 5 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18172054&FileExtension=pdf&FileName=ERA23FA358%20Photo%20Array-Rel.pdf - Electronic devices - specialist's factual report (item 11, PDF, 8 pages, 656 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18203862&FileExtension=pdf&FileName=ERA23FA358%20electronic%20devices%20-%20final-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.