IAD98FA070

NTSB accident investigation · Cessna 172N · Ocean City, MD · June 22, 1998

Accident · FatalField investigationFinal report
Date
June 21, 1998, 21:55 local (Jun 22, 1998, 01:55 UTC)
Place
Ocean City, MD
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5944ECessna 172N
Weather
Instrument (IMC) · Night/dark
Status
Completed · report December 1, 1999
Report
Approved by Office Director
FAA report
19980621014369A
Case key
28255

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to maintain control of the aircraft due to spatial disorientation. Contributing factors wer fog, dark night conditions, lack of recent experience, inadequate preflight planning, and flight into known adverse weather.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightGo-around (vfr)
Weather condition - fogFactor
Light condition - dark nightFactor
Aircraft control - not maintainedPilot in commandCause
Spatial disorientationPilot in command
Preflight planning/preparation - inadequatePilot in commandFactor
Flight into known adverse weather - initiatedPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilot had planned to make three takeoffs and landing for night currency. The pilot did not contact Flight Service for a weather briefing nor did he file a flight plan. When the pilot took off, visibility was poor due to heavy mist. A witness said visibility worsened when a wall of fog covered the airfield while the airplane was in the traffic pattern. He heard the airplane at full power, and watched it fly about 100 feet over the hangars where the landing gear was illuminated by the rotating beacon. The witness stated 'he throttled up to do a go-around' and heard the airplane all the way to impact. Emergency crews from four different municipalities required 1 hour and 20 minutes to locate the wreckage on the airport due to heavy fog. The airspeed indicator needle was crushed against the face at the 160 knot striation. The engine tachometer needle was crushed against the face at the 3200 RPM striation, 500 RPM above the placarded redline. A review of the pilot's logbook revealed he had 135 hours of total flight experience. He had logged 1.8 hours in the month before the accident. Prior to that, he had not flown in 7 months, and his last night experience was 18 months prior to the accident. He was not instrument rated.

Factual narrative

History of flight

On June 21, 1998, at 2155 eastern daylight time, a Cessna 172N, N5944E, was destroyed during a collision with terrain following an uncontrolled descent at the Ocean City Municipal Airport (OXB), Ocean City, Maryland. The airplane came to rest adjacent to the intersection of runways 20 and 14. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed for the personal flight that originated at OXB, approximately 2140. No flight plan was filed for the flight conducted under 14 CFR Part 91.

According to the airplane's owner, the purpose of the flight was for the pilot to complete three takeoffs and landings at night. After the third landing, the pilot was to board two passengers and fly to an undetermined location.

In a telephone interview, one witness said he landed at OXB approximately 2130, during "twilight". The witness observed the accident pilot checking the fuel tanks during preflight. After deplaning, the witness walked around the apron area near the hangars on the east side of the airport. He heard the airplane depart approximately 2140, and said it sounded as if the pilot used runway 14. The witness stated:

"After he took off I could see this wall of fog rolling in. It was coming off the ocean and coming in. When the fog came in you couldn't see anything, anything at all. I believe the man was coming in to land on 14 and couldn't find the airport. The airplane was at full power and it was flying really low. He flew over the hangers at about one hundred feet and the landing gear was illuminated by the rotating beacon. He throttled up to do a go-around and that's when the fog was rolling in. It was rolling. It was probably giving him a false horizon. It was unique when it was rolling in. I heard the airplane all the way to impact. It did rev up right before impact."

A flight instructor at Ocean City Municipal reported landing at OXB, approximately 2030. He stated the visibility at that time was approximately 3 miles. He said:

"The ceiling was going scattered to broken at about 500 feet. I departed the airfield in my car about 2050, and visibility was approximately 1/2 mile in heavy mist. [The pilot] had not yet arrived. I drove the 15 miles north to my house and the predominant visibility was 1/4 mile all the way home."

According to the Maryland State Police (MSP), a third witness reported hearing the airplane take off and gain altitude over the southeast corner of the airport. He stated:

"The engine died and didn't restart. I did not hear a crash or anything. This sound was unusual to me because I normally hear the planes overhead."

A fourth witness told the MSP, "Heard the motor go out. Ten seconds later heard a bang."

Emergency crews from four different municipalities required 1 hour and 20 minutes to locate the wreckage due to heavy fog.

The accident occurred during the hours of darkness approximately 38 degrees, 18 minutes north latitude, and 75 degrees, 7 minutes west longitude.

Personnel information

The pilot held a private pilot's certificate with a rating for airplane single-engine land. A review of the pilot's logbook revealed he had 135 hours of total flight experience, 57.7 hours of which were in make and model. The pilot logged two flights in May, 1998, for a total of 1.8 hours. Prior to that, he had not flown in 7 months. His most recent flight experience at night was for .5 hours in October, 1996.

The pilot logged 20 hours of instrument flight training that ended in October, 1997. The pilot did not possess an instrument rating.

His most recent Federal Aviation Administration (FAA) Third Class Medical Certificate was issued on August 1, 1997.

Meteorological information

According to the Federal Aviation Administration, the pilot did not contact Flight Service for a weather briefing nor did he file a flight plan. The airplane was not in contact with Air Traffic Control.

At the time of the accident, weather reported at Cape May, New Jersey (WWD), 40 miles north of OXB was: measured ceiling 100 overcast with 1 mile visibility. The winds were from 090 at 6 knots. The temperature was 70 degrees and the dewpoint was 68 degrees.

Weather at Salisbury, Maryland, 20 miles inland from Ocean City was: sky clear with 1.5 miles visibility and mist. The temperature was 70 degrees and the dewpoint was 70 degrees with no wind.

Wreckage and impact information

The wreckage was examined at the site on June 22, 1998. There was a strong odor of fuel and all major components were accounted for at the scene. The wreckage path was oriented 200 degrees magnetic and covered a distance of approximately 150 feet. The wreckage path was divided into 1 foot increments called wreckage points (WP).

The initial ground scar, WP zero, began approximately 20 feet left of the centerline of the wreckage path. It was a linear ground scar, approximately 20 feet long, that intercepted the wreckage path at WP 17 on a 30 degree angle. Red lens fragments were embedded in the earth at the point of initial ground contact. An elliptical impact crater, approximately 10 feet long and 8 feet wide, was at WP 17.

The nose wheel and landing strut were at WP 36, 15 feet right of centerline. A piece of the right wing flap was at WP 45. The engine starter ring gear was at WP 50. The right aileron and the right upper engine cowling were at WP 102 and WP 105 respectively. A portion of the engine mount was at WP 118 and the aircraft battery was at WP 124.

The propeller was separated from the airplane's engine and found at WP 130, approximately 8 feet right of centerline. The propeller blades displayed similar twisting, bending, leading edge gouging and chordwise scratching. The engine was free of its mounts and came to rest at WP 133.

The main wreckage came to rest at WP 145, with the empennage and tail sections oriented approximately 140 degrees. The left and right wings were separated from the airframe but still attached by cables. Both wings came to rest on the left side of the airframe. The right wing skin was detached beneath the right wing fuel tank. The metal wing tank exhibited hydraulic deformation and was opened along the seams of the tank. The left wing was destroyed and entangled in the main wreckage. The firewall, instrument panel, and control quadrants were all crushed into the aft cabin area.

Examination of the airspeed indicator revealed the instrument glass had crushed the indicating needle against the face at the 160 knot striation. The inner bezel of the airspeed indicator showed 180 miles per hour. The instrument glass on the engine tachometer crushed the needle against the face at the 3200 RPM striation, 500 RPM above the placarded redline.

Medical and pathological information

An autopsy was performed on the pilot by Dr. Theodore King of the Office of the Chief Medical Examiner, Baltimore, Maryland, on June 22, 1998.

The toxicological testing for the pilot was performed by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.

Tests and research

The engine was examined at the scene on June 23, 1998. The external oil filter and vacuum pump were separated and the single drive dual-magneto was destroyed by impact. The engine was rotated through the vacuum pump drive and valvetrain continuity was established to the #1, #3, and #4 cylinders. Continuity was established to the #2 intake valve. The pushrod for the #2 exhaust valve was destroyed by impact, however, the #2 exhaust lifter was displaced by the cam lobe when the engine was rotated. Compression was verified using the thumb method. Examination of the spark plugs revealed the electrodes were intact and light tan and gray in color.

The attitude indicator was destroyed by impact. Disassembly revealed the gimbles were free to rotate in all axis. Evidence of scoring was noted in the

Aircraft

Registration
N5944E
Reported as
Cessna 172N
Category
Airplane
Serial number
17271970
Airframe hours
4,199
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
William A. Weber
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 24, 1998 · 20 hours before
Departed
OXB
Airport
OXB · Ocean City Municipal, runway 14, 4,070 × 75 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
137 total · 57 in this make and model · 83 as pilot in command · 2 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
90° at 6 knots
Visibility
1 statute miles
Lowest ceiling
100 ft overcast
Temperature
70 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
WWD, 40 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.