# NTSB LAX01FA129: Cessna 172N, N2838E, Santa Monica, CA, March 29, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 28, 2001, 18:58 local (Mar 29, 2001, 02:58 UTC) - Place: Santa Monica, CA - Coordinates: 34.021667, -118.581947 - Nearby events: https://openairdocs.org/map.md?lat=34.0217&lon=-118.5819&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration, Lycoming Engine - NTSB case key (mKey): 51986 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA129 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/51986/pdf - Page: https://openairdocs.org/ntsb/LAX01FA129 ## Probable cause the pilot's loss of airplane control while maneuvering due to spatial disorientation. Contributing factors were the dark night, the marine cloud layer that restricted the pilot's cruising altitude, and the pilot's lack of familiarity with nighttime flight over the ocean. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - turn to reverse direction - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - spatial disorientation, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - lack of total experience in type operation, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis The airplane impacted the water descending at a high rate of speed. On a dark moonless night, the noninstrument rated private pilot rented an airplane and flew below a marine layer of clouds along the coastal shoreline. The pilot initiated a course reversal turn, during which the airplane turned away from the city lights. During the turn, seconds after the airplane was headed nearly perpendicular to the shoreline, the pilot commenced a descending right turn with a vertical descent rate of over 2,100 feet per minute. A witness about 1 mile away reported that the airplane looked as though it was falling straight down into the water. The pilot had taken his primary flight lessons from a Texas-based school, and he was, by his own admission, not familiar with flying around marine cloud layers. No evidence of mechanical malfunction or failures was noted during the wreckage examination. ## Factual narrative HISTORY OF FLIGHT On March 28, 2001, at 1858 Pacific standard time, a Cessna 172N, N2838E, descended into an area of the Pacific Ocean known as the Santa Monica Bay, near Santa Monica, California. The private pilot had rented the airplane from Justice Aviation, a Santa Monica based flight school, which operated it. The airplane was destroyed upon impacting the ocean. The pilot and two passengers were fatally injured. The flight was performed under the provisions of 14 CFR Part 91, and no flight plan had been filed. Visual meteorological conditions existed at the Santa Monica Municipal Airport, about 7 nautical miles (nm) east of the crash site, from where the flight originated at 1852. According to Justice Aviation personnel, the pilot had rented the airplane for a 1- to 2-hour-long personal flight over the local Los Angeles area. Prior to taking off, at 1851:40, the pilot advised the Santa Monica control tower's local controller that he intended to perform a flight under visual flight rules. Regarding the pilot's planned route, he advised the controller that he intended to fly "up and down the shoreline." Federal Aviation Administration (FAA) recorded radar data indicates that at the commencement of the airplane's takeoff roll, the airplane's Mode C transponder altitude was indicating the approximate 175-foot mean sea level (msl) airport elevation. During the initial climb, upon passing the end of runway 21, the airplane's altitude was approximately 500 feet. The airplane continued tracking in southwesterly and westerly directions until reaching the shoreline whereupon it turned to a northwesterly course, which paralleled the coastline. The FAA radar data further indicates that the airplane cruised about 1/2 mile offshore while maintaining between 900 and 1,100 feet. After passing the Pacific Palisades area, while cruising west of Pacific Coast Highway 1, the airplane turned away from the city lights and began flying along a southerly course, nearly perpendicular to the shoreline. Seconds later, between 1857:07 and 1857:21, the airplane descended from about 1,000 to 500 feet while in a right turn, and the radar track ended. During this period, the airplane's rate of descent was over 2,100 feet per minute. At the time of the last recorded radar hit, the airplane was about 1 mile south of the Topanga State Beach, at the following coordinates: 34 degrees 01 minute 26 seconds north latitude by 118 degrees 34 minutes 40 seconds west longitude. A witness, located near the Topanga State Beach, reported observing red and white lights descending rapidly from the air toward the water about the time of the accident. The witness indicated that the aircraft flew nose first into the water. The witness described the descent profile to be like a falling rock. Because of his vantage point, he did not observe it contact the water. Thereafter, the witness called 911 to report an airplane accident. U.S. Coast Guard personnel and Los Angeles County lifeguards subsequently observed fragmented portions of airplane wreckage near this vicinity. The main wreckage was found about 0.24 miles from its last recorded radar position. PERSONNEL INFORMATION Pilot Qualifications. The pilot's logbook was not located and/or provided to the National Transportation Safety Board for examination. A review of records maintained by the FAA indicated that the pilot was issued a private pilot certificate with an airplane single engine land rating on July 27, 2000. The pilot was not instrument rated. On the application for his airman's certificate the pilot reported that his total flight time was 99.1 hours. Additionally, he reported that his pilot-in-command time was 24.4 hours, his instrument time was 3 hours, and he had received 4.7 hours of instruction while flying at night. The pilot obtained his flight training at airports located near Dallas, Texas. A review of the pilot's medical records on file with the FAA indicated that on November 28, 2000, when he applied for his most recent third-class aviation medical certificate, he reported that his total flight time experience was 135 hours. Also during the preceding 6 months he had flown 48 hours. According to the airplane operator, at the time of the accident the pilot had a total of approximately 150 hours of flight time. About 50 hours were in the accident make and model airplane. Flight Training. Three days before the accident flight, on March 25, the pilot received a daytime check out in the accident model of airplane by a certified flight instructor (CFI) who worked at Justice Aviation. The Safety Board investigator interviewed the CFI. According to the CFI, the pilot satisfactorily completed the 1.5-hour-long checkout in the Cessna, and thereafter was authorized to rent Cessna 172s for both day and night flights. The CFI did not indicate that during the checkout flight he had assessed the pilot's instrument flying skill. Also, the CFI reported that he had discussed typical weather patterns along the coast and had noted the presence of the marine layer of clouds. The pilot indicated that, having received his flight training in Texas, he had no experience flying in coastal weather conditions. AIRCRAFT INFORMATION A CFI, who worked for Justice Aviation, reported that she had flown N2838E the day before it crashed. The CFI reported that during her flight "all instruments were working, especially the attitude indicator. There were no squawks for the airplane...." METEOROLOGICAL INFORMATION Visual meteorological conditions existed at the time of the accident pilot's takeoff from the Santa Monica Municipal Airport. The airport is located about 6.5 nautical miles east (080 degrees, magnetic) of the crash site. About 7 minutes before the accident, Santa Monica Airport's weather was reported, in part, as follows: Overcast sky condition with the cloud base at 1,200 feet above ground level; 7 miles visibility; wind from 240 degrees at 4 knots; and temperature/dew point of 15/13 degrees Celsius. According to U.S. Naval Observatory data, the end of civil twilight on March 28 was at 1837. The moon was a waxing crescent with 14 percent of the visible disk illuminated. A pilot, who was flying in the vicinity and who possessed an instrument rating, reported to the Safety Board investigator that about 1830, when he departed from the Santa Monica airport, the cloud bases were about 1,100 feet msl, and the top of the cloud layer was about 1,700 feet msl. Visibility below the cloud layer was about 5 to 6 miles. It was a dark night, and no moon was visible. Another pilot, who was flying over the Los Angeles basin between Hawthorne and Torrance between 1900 and 2000, reported that a marine layer extended over the airports. The cloud base was between 1,400 to 1,600 feet, and the top of the layer was between 2,200 and 2,400 feet. What he particularly noticed was that it was a very dark night. No moon was visible. Also the cloud layer was so dense that you could not see city lights through the clouds. It was a "horizonless" night. Hawthorne Automated Flight Service Station reported that no services were provided to the accident pilot/airplane from 1500 to 1800 on the night of the accident. WRECKAGE AND IMPACT INFORMATION Airplane recovery personnel reported to the Safety Board investigator that the main wreckage was located at the following global positioning satellite coordinates: 34 degrees 01 minute 18.8 seconds north latitude by 118 degrees 34 minutes 55.4 seconds west longitude. MEDICAL AND PATHOLOGICAL INFORMATION The pilot possessed a third-class aviation medical certificate that was issued on November 28, 2000. No restrictions or limitations were indicated on the certificate. On March 28, 2001, at 1700, an employee of Justice Aviation spoke with the pilot at the airport. The employee reported that the pilot sounded coherent a ## Aircraft - Registration: [N2838E](https://openairdocs.org/deregistered/N2838E-2002-01-11), registration cancelled 2002-01-11, S/N 17271340, built 1978 (OpenAirDocs) - Reported make and model: Cessna 172N - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17271340 - Airframe hours: 8751 - Engines: Lycoming O-320-H2AD 160 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Justice Aviation, Inc., doing business as Justice Aviation - Registered owner: Bill Bryan, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 8, 2001, 64 hours before - Departed: SMO, Santa Monica, CA - Destination: SMO, Santa Monica, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; last flight review July 27, 2000; toxicology performed; flight hours: 150 total, 50 in this make and model, 75 as pilot in command ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 240° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 59 °F, dew point 55 °F - Altimeter: 29.92 inHg - Observed at: SMO, 7 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 20010328040069A](https://openairdocs.org/incident/20010328040069A), Mar 28, 2001: Cessna 172N, Santa Monica, CA, Destroyed, 3 fatal. (-23) Pilot with two passengers departed Santa Monica airport at 1858 PST for a sightseeing flight "up and down the shoreline". Cloud bases from shore westward… 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.