ERA23LA328

NTSB accident investigation · Cessna 172 · Charlotte Amalie, CB · August 4, 2023

Accident · FatalClass 3 · LimitedFinal report
Date
August 4, 2023, 21:17, time zone not recorded
Place
Charlotte Amalie, CB · Last ADS-B location
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N13384Cessna 172
Defining event
Enroute-climb to cruise: Loss of control in flight
Weather
Visual (VMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, NATCA, FAA/FSDO
FAA report
20230804019569A
Case key
192822

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 pilots’ loss of airplane control due to spatial disorientation. Contributing to the accident was both pilots’ lack of experience in operating in actual instrument meteorological conditions.

Findings · 4

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.

Experience/qualifications: total instrument experiencePersonnel issues › Experience/knowledge · Flight crewCessna 172M: 1 caseAll aircraft: 66 casesProbable cause
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on personnelCessna 172M: 8 casesAll aircraft: 448 cases
Ceiling/visibility/precip: low visibilityEnvironmental issues › Conditions/weather/phenomena · Effect on personnelCessna 172M: 2 casesAll aircraft: 175 cases

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 purpose of the night, cross-country flight over open water was for the one of the pilots, who was a certificated private pilot, to accumulate hours of flight experience for an instrument rating. The other pilot held a commercial pilot certificate with an instrument rating, but had only accrued 4.9 hours of actual instrument flight experience. The airplane flew uneventfully on an instrument flight rules (IFR) flight plan for 1 hour, 34 minutes, from the departure airport to another island airport where the flight crew performed a practice instrument approach and missed approach. During the return flight leg back to the departure airport, about 7 minutes after the missed approach, the airplane diverged from its on-course heading while climbing to its assigned altitude of 6,000 ft mean sea level (msl). The airplane began turning to the right as it entered an area of light to heavy precipitation. The airplane turned through 540° and climbed to an altitude of 6,450 ft msl before it entered a right-turning spiral descent. Radar contact with the airplane was lost as it descended through 4,700 ft, and the pilots made no transmissions to air traffic control indicating any distress or abnormalities. The airplane occupants and wreckage were not located or recovered, and the airplane was presumed to have impacted the water shortly after radar contact was lost. Given that the airplane was operating over open water at night, and in an area of precipitation, the pilots’ ability to determine the airplane’s attitude using outside visual references would have been greatly diminished. While the pilots were operating on an IFR flight plan, one of the pilots was not instrument rated and the other had logged less than 5 hours of flight experience in actual instrument meteorological conditions. It could not be determined which of the pilots was flying the airplane at the time of the accident, though their combined lack of total instrument flight experience would have increased the potential for a loss of control in flight given the restricted visibility environment they were operating in. The airplane’s final moments of maneuvering flight, particularly the turning spiral descent that occurred during the final 25 seconds of its flight track, was consistent with a loss of control due to spatial disorientation. Based on the available information, it is likely that the pilots lost control of the airplane while flying in reduced visibility conditions as a result of their spatial disorientation.

Factual narrative

On August 4, 2023, at 2117 Atlantic standard time, a Cessna 172M, N13384, was presumed destroyed when it was involved in an accident near Charlotte Amalie, St. Thomas, United States Virgin Islands (USVI). The commercial pilot and the private pilot were not located and were presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to an FAA inspector, the purpose of the flight was for the private pilot to accumulate additional hours of flight experience toward an instrument rating. Review of ADS-B and air traffic control data revealed that the airplane departed Rafael Hernandez Airport (BQN), Aguadilla, Puerto Rico, about 1933. The airplane was en route to Cyril E. King Airport (STT), Charlotte Amalie, USVI, on an instrument flight rules flight plan at 5,000 ft msl. At 2043:25, the flight crew requested the ILS Runway 10 approach at STT, followed by the missed approach procedure, and a return to BQN. The San Juan approach controller issued missed approach instructions to turn right to a 250° heading and climb and maintain 3,000 ft msl. The flight crew acknowledged this with a correct readback and no further transmissions were received from the flight crew. After the missed approach, at 2109:31, the controller instructed the flight crew to climb and maintain 6,000 ft msl and proceed directly to BQN. At 2114:30, ADS-B track data depicted the airplane deviating from its on-course heading in the climb, turning to the right as it entered an area of isolated, light to heavy precipitation (the airplane had flown through the same area on the inbound flight leg to STT, 13 minutes before, at 2101:19). The airplane turned through 540° and reached 6,450 ft msl before it entered a right-turning spiral descent (see figure). At 2117:25, track data for the airplane ended at 4,700 ft msl. The approach controller attempted to contact the flight crew at 2119:30, and six additional times over the subsequent 5 minutes. Figure 1 - Overhead view of the final segment of the accident flight track overlaid onto aerial image (note that clouds depicted are not representative of the conditions at the time of the accident). The airplane’s position and altitude are annotated with numbered dots and a corresponding table. The United States Coast Guard searched about 6,400 square miles by ship and helicopter for a combined total of 45 hours before suspending its search on August 7, 2023. Neither the airplane nor its occupants were recovered. The pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, rotorcraft-helicopter, and instrument airplane and helicopter. The pilot’s FAA first-class medical certificate was issued on May 24, 2023, and he declared 327 total hours of flight experience on that date. A review of his pilot logbook revealed an estimated 437 total hours of flight experience, of which 4.9 hours were in actual instrument meteorological conditions.On the copilot’s FAA airman certificate application dated April 19, 2023, he declared 94.5 total hours of flight experience. The copilot’s logbook was not recovered. According to FAA and maintenance records, the FAA performed a ramp inspection of the airplane on June 15, 2023. On June 29, 2023, at 4,235,6 total aircraft hours, maintenance personnel corrected the discrepancies noted during the ramp inspection and completed an annual inspection of the airplane.

Aircraft

Registration
N13384
Reported as
Cessna 172 (M)
Category
Airplane
Serial number
17262719
Built
1974
Airframe hours
4,235.6
Engine
Lycoming O-320-E2D, 150 hp, reciprocating
Damage
Destroyed
Fire
Unknown
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 29, 2023
Departed
BQN · Aguadilla, PR
Destination
BQN · Aguadilla, PR
Flight plan
IFR
Airport
STT · Cyril E King
Equipment
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
436.8 total · 100 in this make and model
Role
Co-pilot
Age
19
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
95 total · 45 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
70° at 6 knots
Visibility
10 statute miles
Temperature
82 °F, dew point 79 °F
Altimeter
30.02 inHg
Observed at
TIST, 8 nm away
METAR
METAR TIST 050053Z 07006KT 10SM FEW021 SCT048 28/26 A3002 RMK AO2 SLP166 T02830261 $=

Docket · 15

The files NTSB released with the investigation on August 20, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 352 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.