# NTSB LAX08LA191: Cessna 172S, N2436F, Oceanside, CA, June 23, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: June 22, 2008, 17:10 local (Jun 23, 2008, 00:10 UTC) - Place: Oceanside, CA - Coordinates: 33.226112, -117.45417 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.2261&lon=-117.4542&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-aerobatics: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 68291 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08LA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68291/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68291 - Page: https://openairdocs.org/ntsb/LAX08LA191 ## Probable cause Failure of the pilot to regain airplane control during an intentional stall/spin maneuver. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172S, 206 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072439), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2072439), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-aerobatics: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Cessna 172S, 8 cases](https://openairdocs.org/ntsb-events/600/sequence.md?model=2072439), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Maneuvering-aerobatics: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072439), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172S, 118 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Witnesses flying in a second airplane reported that the two airplanes left their home airport earlier in the day. They flew to another local area airport for a snack where they discussed the return flight (the accident flight). The accident pilot told his peers that he was going to do a spin on the way back to their home airport. He said that he had done spins before with a flight instructor and a passenger in the back. The two airplanes departed the local airport and were en route back to the home airport when the accident airplane radioed the other airplane indicating that he was setting up for the stall/spin maneuver. The pilots in the other airplane watched as the accident airplane began a climb from 5,500 feet to 7,500 feet and commenced with the stall/spin. After one full turn, the airplane returned to normal flight. The accident pilot radioed the other pilots and told them he was going to do another stall/spin, and was going to let it spin a "little more before he start[ed] the recovery." The witnesses observed the accident airplane set up for another spin, enter the spin, and watched as the airplane continued to spin until it crashed into the ocean. According to Cessna, intentional spins are prohibited when the rear seat(s) are occupied. Three people were on board the accident airplane. The airplane and two of its occupants were not located despite efforts by the United States Coast Guard and a private diving company. ## Factual narrative HISTORY OF FLIGHT On June 22, 2008, about 1710 Pacific daylight time, a Cessna 172S, N2436F, impacted the ocean about 2.5 miles west of Oceanside, California. San Diego Flight Training International, Inc., operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal rental flight. The pilot and one passenger are presumed to have been killed; another passenger sustained serious injuries, and was rescued by nearby boaters. The airplane has not been located and is presumed destroyed. The flight departed Long Beach Airport (Daugherty Field - LGB), Long Beach, California, with a planned destination of Montgomery Field (MYF), San Diego, California. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed. The United States Coast Guard (USCG) conducted a search for the missing pilot, passenger, and the airplane. USCG personnel responded to the latitude/longitude coordinates provided by the airborne witnesses. No debris field was present. A search was conducted; however, the USCG suspended their search efforts. A research ship, the Outer Limits, and its crew volunteered to search the last identified area of the accident location for the airplane and its missing crew. Their attempt, along with the USCG, was unsuccessful. WITNESS INFORMATION Two airborne witnesses were in contact with the accident pilot and observed the accident. According to both witnesses, they had flown from MYF to LGB earlier in the day. As they were having a snack, they discussed the flight back, where the accident pilot reported that he was going to perform a stall/spin on the return flight to MYF. He also indicated that he had done a stall/spin maneuver before with his flight instructor and a passenger in the back. After takeoff from LGB, both airplanes climbed to 5,500 feet for the flight back to MYF. About 5 nautical miles (nm) south of Dana Point, the witnesses reported that the accident airplane climbed from 5,500 feet to 7,500 feet to set up for a stall/spin maneuver. They watched as the airplane performed one complete spin and then recovered to normal flight. The witnesses then saw them set up for another spin, enter the spin, and watched as the airplane continued to spin until it crashed into the ocean. During the maneuvers, the accident pilot was in contact with the other airplane. After the first spin, the accident pilot stated that he was going to "do it one more time," and he was going to let it spin a "little more before he start[ed] the recovery." The witnesses reported that the duration between the first stall/spin maneuver and the accident stall/spin maneuver was about 5 minutes. After the airplane crashed into the ocean, the airborne witnesses contacted southern California (SoCal) approach control and reported the downed airplane. They circled the area providing a location to SoCal approach, and then returned to MYF. They were not able to see the airplane in the water due to a low cloudlayer between their airplane and the water. PERSONNEL INFORMATION A review of the Federal Aviation Administration (FAA) airman and medical records on file in Oklahoma City, Oklahoma, revealed that the 19-year-old pilot held a private pilot certificate with an airplane single engine land rating. His certificate was issued on June 19, 2008. On his Airman Certificate and/or Rating Application, FAA form 8710-1, dated June 18, 2008, he reported his total flight time as 70 hours. According to the Pilot/Operator Report (NTSB Form 6120) filed by the Operator, the pilot had an additional 2 hours of flight time for a total flight time of 72 hours. The pilot had been issued a first-class medical on January 30, 2008, with the limitation that he must wear corrective lenses. No personal flight records were recovered for the pilot. AIRCRAFT INFORMATION The airplane was a 2006 Cessna 172S, serial number 172S10145, with a Lycoming IO-360-L2A, serial number L-32653-51E installed. According to the operator, the last 100-hour inspection was signed off on June 16, 2008. The total airframe time recorded at the last 100-hour inspection was 1,009 hours. ADDITIONAL INFORMATION According to the Cessna Information Manual for the 172S NAV III Skyhawk, the accident airplane, under section 4 titled NORMAL PROCEDURES subsection titled SPINS; intentional spins are approved when the airplane is operated in the utility category. Spins are not approved when the rear seat(s) are occupied. It also states that spins will progress at a fairly rapid rate of rotation and steep attitude if they are in excess of 2 rotations. During extended spins, the spin tends to change into a spiral, particularly to the right, which will be accompanied by an increase in airspeed and gravity loads on the airplane. ## Aircraft - Registration: [N2436F](https://openairdocs.org/deregistered/N2436F-2017-04-18), registration cancelled 2017-04-18, S/N 172S10145, built 2006 (OpenAirDocs) - Reported make and model: CESSNA 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S10145 - Airframe hours: 1009 - Engines: Lycoming IO-360-L2A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: San Diego Flight Training International, Inc. - Registered owner: San Diego Flight Training International, Inc. - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, June 16, 2008, 9 hours before - Departed: LGB, Long Beach, CA - Destination: MYF, San Diego, CA - Airport: OKB, Oceanside Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 19; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, with waivers/limitations; last flight review June 1, 2008; seat: left; flight hours: 72 total, 72 in this make and model, 10 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 8 knots - Visibility: 9 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 64 °F - Altimeter: 29.88 inHg - Observed at: OKB, 3 nm away ## Docket (5 files) The files NTSB released with the investigation on February 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68291. 1.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 737 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307494&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements - Record of Conversations (item 2, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307495&FileExtension=.PDF&FileName=Witness%20Statements%20-%20Record%20of%20Conversations-Redacted.PDF - Witness Statements (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307496&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Radar Data Plots (item 4, .PDF, 433 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307538&FileExtension=.PDF&FileName=Radar%20Data%20Plots-Master.PDF - SoCal TRACON Audio Communication and Radar Data Files (item 5, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40307539&FileExtension=.PDF&FileName=SoCal%20TRACON%20Audio%20Communication%20and%20Radar%20Data%20Files-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.