# NTSB ERA23LA328: Cessna 172, N13384, Charlotte Amalie, CB, August 4, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: August 4, 2023, 21:17, time zone not recorded - Place: Charlotte Amalie, CB · Last ADS-B location - Coordinates: 18.3281, -65.1208 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=18.3281&lon=-65.1208&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, NATCA, FAA/FSDO - NTSB case key (mKey): 192822 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA328 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192822/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192822 - Page: https://openairdocs.org/ntsb/ERA23LA328 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Flight crew (probable cause); cases with it: [Cessna 172M, 4 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2072418), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Experience/qualifications: total instrument experience](https://openairdocs.org/ntsb-findings/02031030): Personnel issues › Experience/knowledge · Flight crew (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/02031030/cases.md?model=2072418), [All aircraft, 66 cases](https://openairdocs.org/ntsb-findings/02031030/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna 172M, 8 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2072418), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cessna 172M, 2 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2072418), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Cessna 172M, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=2072418), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Enroute-climb to cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172M, 47 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072418), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172M, 100 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072418), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N13384), registered now, S/N 17262719, built 1973 (OpenAirDocs) - Reported make and model: CESSNA 172 (M) - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17262719 - Year built: 1974 - Airframe hours: 4235.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: fatal; 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 - Co-pilot; age 19; injuries: fatal; 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 $= ## 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 20230804019569A](https://openairdocs.org/incident/20230804019569A), Aug 4, 2023: Cessna 172M, St. Thomas, VI, Destroyed, 2 fatal. On August 4, 2023, at around 9:17PM local time, a Cessna 172M, serial number 17262719, was flying under 14 CFR part 91, on an instrument flight plan from bqn… ## Docket (15 files) The files NTSB released with the investigation on August 20, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192822. 352 MB in all. - Memorandum for the record - FAA inspector (item 1, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18923074&FileExtension=pdf&FileName=MFR1-Rel.pdf - USCG statement (item 2, PDF, 2 pages, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18826510&FileExtension=pdf&FileName=USCG%20Statement_Redacted-Rel.pdf - Instrument approach chart (item 3, PDF, 1 page, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18860425&FileExtension=pdf&FileName=05005IL10%20Approach%20Procedure%20Caution-Rel.pdf - Commercial pilot logbook excerpt (item 4, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18826421&FileExtension=pdf&FileName=Pilot%20Logbook%20Excerpt_Redacted-Rel.pdf - Private pilot flight record (item 5, PDF, 1 page, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18860844&FileExtension=pdf&FileName=Oswald%20Fuentes%20Flight%20Record%20Buiqui%20Aerospace-Rel.pdf - Maintenance records annual inspection (item 6, PDF, 3 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18826769&FileExtension=pdf&FileName=Logbook%20Annual%20Inspection_Redacted-Rel.pdf - Google earth file (kml) - ADS-B plot of accident flight (item 7, KML, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18859506&FileExtension=kml&FileName=N13384%20-%20KML%20FLIGHTRADAR24-Rel.kml - ATC - group chairman's factual report (item 8, PDF, 21 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19122632&FileExtension=pdf&FileName=ATC%20-%20Group%20Chairman%27s%20Factual%20Report%20-%20FINAL-Rel.pdf - ATC - attachment 1 - interview transcripts (item 9, PDF, 337 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19123220&FileExtension=pdf&FileName=ATC%20-%20Attachment%201%20-%20Interview%20Transcripts%20-%20Redacted-Rel.pdf - ATC - attachment 2 - certified audio (item 10, ZIP, 320 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19123017&FileExtension=zip&FileName=ATC%20-%20Attachment%202%20-%20Certified%20Audio-Rel.zip - ATC - attachment 3 - ADS-B data (item 11, ZIP, 837 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19123258&FileExtension=zip&FileName=ATC%20-%20Attachment%203%20-%20ADS-B%20Data-Rel.zip - ATC - attachment 4 - accident package (item 12, PDF, 84 pages, 9.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19123399&FileExtension=pdf&FileName=ATC%20-%20Attachment%204%20-%20Accident%20Package%20-%20Redacted-Rel.pdf - Statement of party representatives to NTSB investigation Textron (item 13, PDF, 9 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18826779&FileExtension=pdf&FileName=Textron%20Party%20Form_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation - natca (item 14, PDF, 14 pages, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19133622&FileExtension=pdf&FileName=NATCA%20Party%20Form_Redacted-Rel.pdf - FAA medical facts for pilots (item 15, PDF, 6 pages, 546 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18826431&FileExtension=pdf&FileName=FAA%20Medical%20Facts%20for%20Pilots-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.