# NTSB IAD02FA037: Cessna 172P, N96811, Ocean City, MD, March 16, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 15, 2002, 19:35 local (Mar 16, 2002, 00:35 UTC) - Place: Ocean City, MD - Coordinates: 38.293609, -75.100555 - Nearby events: https://openairdocs.org/map.md?lat=38.2936&lon=-75.1006&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report May 30, 2003 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, FAA/FSDO, Textron Lycoming - NTSB case key (mKey): 54350 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD02FA037 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54350/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54350 - Page: https://openairdocs.org/ntsb/IAD02FA037 ## Probable cause The pilot's spatial disorientation, which resulted in his subsequent loss of control of the airplane. A factor was the dark night, over water visual conditions. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base turn - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - light condition - dark night (contributing factor) - terrain condition - water (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The airplane was over water, making a night VFR approach to a coastal airport. Witnesses observed it suddenly transition from horizontal flight, to a vertical descent into the ocean. According to a witness flying in the area at the time, the accident airplane went over a "black hole," and he saw "strobe over strobe" before it disappeared. The witness also noted that disorientation around the airport at night was common because of the ocean. The accident occurred on a clear, dark night, with no illumination from the moon. Examination of the airframe, systems, avionics, and engine did not reveal any evidence of a pre-impact mechanical malfunction. Post-accident examination of the wreckage revealed that the left wing leading edge was crushed aft, to the wing spar. The pilot was not instrument-rated, but had received instrument training under a hood in VFR conditions. ## Factual narrative HISTORY OF FLIGHT On March 15, 2002, about 1935 eastern standard time, a Cessna 172P, N96811, was destroyed when it impacted the Atlantic Ocean while on approach to Ocean City Municipal Airport (OXB), Ocean City, Maryland. Two passengers were fatally injured, and the certificated private pilot/owner and a third passenger were presumed lost at sea. Night visual meteorological conditions prevailed for the flight that originated at Bay Bridge Airport (W29), Stevensville, Maryland. No flight plan was filed for the personal flight conducted under 14 CFR Part 91. According to a witness, a certificated airline transport pilot, he was approaching the Ocean City Airport in a twin-engine turbo-prop airplane at the same time as the accident airplane. He became aware of the accident airplane when the accident pilot transmitted on the Ocean City Airport UNICOM frequency. The accident pilot's first radio call was about 10 miles from Ocean City to the north, when he called for a taxicab. The witness answered the radio call, and told the accident pilot that the airport closed at sunset, and that he would have to wait to get on the ground to call for a cab. The accident pilot acknowledged the radio call. When the witness was within 4 miles of the Ocean City beacon, he heard the pilot announce a left downwind for landing on runway 20, then transmit, "Is that right?" The witness watched the accident airplane as it passed abeam the departure end of runway 14, and suddenly transitioned from "horizontal flight to vertical flight." The airplane went out over a "black hole," then disappeared. The witness wasn't close enough to see if the airplane was spinning during its descent. Immediately before the descent, the witness saw both wing tip strobe lights flash at the same time, one over top of the other, as if the airplane were in a 90-degree bank. The witness was asked to describe the weather and the light levels around the Ocean City Airport at the time of the accident. He stated that it was a clear, but dark night and that there was no moon; it was a "black hole." The witness further stated: "They probably were spatially disoriented, because when you get on downwind and head out over the ocean like that, you may as well get on the instruments, and stay on the instruments, until you turn final." A second witness said she was in her home on the shore, when she saw the airplane's strobe lights through the window. The position of the airplane seemed unusual, as she was familiar with the usual positions of airplanes and helicopters when they flew around the airport traffic pattern. At first, she thought it was a helicopter because of its low altitude. The airplane traveled south to north along the coast, then turned east, out to sea. The airplane completed a "half turn," then descended straight down into the water. The airplane was not yet abeam the airport when it turned out to sea, and the witness thought the pilot was lost, disoriented, or just unfamiliar with the area. According to the witness: "It just seemed unusual to me because, if it was a plane, it was low. And if it was a helicopter, that was unusual because of the time of night. It was clear, but it was dark. You couldn't see a horizon. He made that half turn out over the ocean, and then he went straight down." PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single-engine land rating. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued on November 19, 2000. He reported 300 hours of flight experience on that date. During an interview, a friend of the pilot who was also a certified flight instructor, stated that he had been acquainted with the pilot for a number of years. The flight instructor had provided instrument flight instruction to the pilot since October 2001. Instruction included academics, and instrument flight maneuvers, navigation, holding, precision and non-precision approaches, unusual attitude recoveries, and emergency procedures. All training was conducted under a training hood, in VFR conditions. Examination of the flight instructor's notes revealed that he and the accident pilot flew together on eight training flights for a total of 17.4 hours. Three training flights were conducted between October 9 and October 18, 2001. Training resumed on February 25, 2002, after the pilot completed a tour at sea as a merchant marine. The latest training flight occurred on March 8, 2002. When questioned about the pilot's technique for traffic-pattern flight, the flight instructor said that he was a "pretty sharp guy," but one time, at Bay Bridge Airport, on the downwind leg, at traffic pattern altitude, and he flew out to mid-span of the Chesapeake Bay Bridge before turning base. It made the flight instructor nervous, so they went to another airport and worked on traffic patterns. Once at the other airport, the flight instructor gave the pilot detailed instruction on the geometry of traffic patterns, and techniques that would provide consistent results. AIRCRAFT INFORMATION The airplane was a 1984 Cessna 172P. Examination of the airplane's maintenance records revealed that the most recent annual inspection was completed on September 10, 2001, at 10,868.4 aircraft hours. According to the pilot's flight instructor, the airplane was equipped with wingtip-mounted position strobes. METEOROLOGICAL INFORMATION The weather reported at Ocean City Municipal Airport at 1753, included clear skies with winds from 210 degrees at 15, gusting to 19 knots. Official sunset was at 1808, and the end of civil twilight was at 1834. Only 3 percent of the moon's visible disk was illuminated, and the moon set at 1941. WRECKAGE AND IMPACT INFORMATION Airplane tires, cowlings, fairings, upholstery, and paperwork associated with the accident airplane were recovered along the shore in the days following the accident. The main wreckage was located in mid-April 2002, at 38 degrees, 17.62 minutes north latitude, 75 degrees, 6.04 minutes west longitude. The airplane wreckage was subsequently examined at the United States Coast Guard Station, Ocean City, Maryland, on April 19, 2002. All major components of the airplane were accounted for. The right wing and spar, main spar, and the left wing spar were all connected. The left wing and the left wing spar outboard the wing strut mount were separated from the wing spar assembly. The leading edge of the left wing was crushed aft in compression, and flattened against the spar. The left wing fuel cell was not located. Approximately 2 feet of the outboard left wing was torn away, and not located. Control cable continuity was established from the left aileron to the point of wing separation, where the cable ends were broomstrawed. The right wing was largely intact, and exhibited only slight leading-edge deformation. The bottom wing skin in the area of the fuel cell was not installed, and the fuel cell was absent from the wing. The bottom wing skin remained from about the wing strut attach point out to the wing tip. The skin exhibited hydraulic deformation upwards, towards the top of the wing. Control cable continuity was established from the aileron out to the point of wing separation, where the cable ends were broomstrawed. The engine, firewall, and instrument panel were connected when recovered. Salvage operators separated the engine from the firewall and instrument panel during recovery. The instrument panel was completely destroyed by impact. The cockpit and cabin area were completely destroyed, with only the cabin roof, and approximately 2 square feet of cabin floor recovered. The landing gear box structure, with both left and right landing gear attached, was separated from the cabin and the empennage. The empennage skin was separated from the landing gear box structure and the tail s ## Aircraft - Registration: [N96811](https://openairdocs.org/deregistered/N96811-2013-02-26), registration cancelled 2013-02-26, S/N 17276118, built 1984 (OpenAirDocs) - Reported make and model: Cessna 172P - 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: 17276118 - Airframe hours: 10868.4 - Engines: Lycoming O-320 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Columbus Swonger - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 10, 2001 - Departed: W29, Stevensville, MD - Destination: OXB, Ocean City - Airport: OXB, Ocean City Municipal Airport, runway 20, 3,201 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; toxicology performed; flight hours: 300 total ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 210° at 15 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 55 °F - Altimeter: 29.95 inHg - Observed at: OXB, 2 nm away ## 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 20020315018769A](https://openairdocs.org/incident/20020315018769A), Mar 15, 2002: Cessna 172P, Ocean City, MD, Destroyed, 4 fatal. (-23) On March 15, 2002 at about 1935 EST, Cessna 172P, N96811, crashed into the atlantic Ocean while on approach to the Ocean City airport, Ocean City, MD.… ## Docket (10 files) The files NTSB released with the investigation on April 17, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54350. 10.7 MB in all. - Interview Summaries (item 1, .PDF, 465 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393407&FileExtension=.PDF&FileName=Interview%20Summaries-Redacted.PDF - Wreckage Diagrams (item 2, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176783&FileExtension=.PDF&FileName=Wreckage%20Diagrams-Master.PDF - Cessna Party Representative Supplemental Factual Information (item 3, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393408&FileExtension=.PDF&FileName=Cessna%20Party%20Representative%20Supplemental%20Factual%20Information-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393409&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393410&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Engine as recovered from Ocean (item 6, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176786&FileExtension=.PDF&FileName=Engine%20as%20recovered%20from%20Ocean-Master.PDF - Prop view with chordwise scratches (item 7, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176787&FileExtension=.PDF&FileName=Prop%20view%20with%20chordwise%20scratches-Master.PDF - Starter case with rotational scoring (item 8, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176788&FileExtension=.PDF&FileName=Starter%20case%20with%20rotational%20scoring-Master.PDF - Wreckage Layout A (item 9, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176789&FileExtension=.PDF&FileName=Wreckage%20Layout%20A-Master.PDF - Wreckage Layout B (item 10, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176790&FileExtension=.PDF&FileName=Wreckage%20Layout%20B-Master.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.