MIA05FA140

NTSB accident investigation · Cessna 172S · Key West, FL · July 31, 2005

Accident · FatalField investigationFinal report
Date
July 30, 2005, 21:20 local (Jul 31, 2005, 01:20 UTC)
Place
Key West, FL
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N65982Cessna 172S
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 25, 2007
Report
Approved by Office Director
Parties
FAA-MIDO, FAA Flight Standards District Office, Textron Lycoming, Cessna Aircraft Company, Honeywell, Sigma Tek, Inc.
FAA report
20050730016789A
Case key
62085

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 failure of the pilot-in-command to maintain directional control of the airplane during the dark, night flight over water, resulting in the uncontrolled descent and in-flight collision with the water. A contributing factor in the accident was the pilot's distraction with the inappropriately set transponder.

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 flightTakeoff - initial climb
Light condition - dark night
Improper use of equipment/aircraftPilot in command
Transponder - not setPilot in command
Diverted attentionPilot in commandFactor
Aircraft control - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - water

Analysis

Adverse weather delayed the instrument rated but not instrument current pilot's departure to her home airport. Additionally, lodging accommodations in Key West could not be obtained. The pilot elected to depart in night visual flight rules (VFR) conditions for a nearby airport at approximately 2118. After takeoff, while flying over water during the dark night, the pilot established two-way radio communications with Navy Key West Approach Control. The radar facility did not receive the assigned discrete transponder code (0210), despite several attempts by the controller to get the pilot to reset the transponder. The pilot did not make any distress calls. The aircraft crashed into the Straits of Florida, and some of the wreckage was located the following day. Several days later the majority of the wreckage was located; the left wing was not recovered. Examination of the recovered wreckage revealed no evidence of pre-impact failure or malfunction of the flight controls, engine, airframe, and attitude gyro. No evidence of fire or sort was noted on any of the recovered components. The transponder was found set to "SBY" or standby position; the transponder does not transmit in that position. No servicing or maintenance was performed to the airplane while at Key West. During the inbound flight into Key West, the flight was radar identified using the transponder. Prior to departure, the pilot talked with a dispatcher from the operator and did not advise that person of any discrepancy related to the airplane.

Factual narrative

History of flight

On July 30, 2005, about 2120 eastern daylight time, a Cessna 172S, N65982, registered to MFH Leasing, Inc., operated by Epic Aviation, crashed in the Straits of Florida shortly after takeoff from Key West International Airport, Key West, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR part 91 personal flight from Key West International Airport (KEYW), to The Florida Keys Marathon Airport (KMTH), Marathon, Florida. The airplane was destroyed, and the commercial-rated pilot and three passengers were fatally injured. The flight originated about 2118, from Key West International Airport.

According to a transcription of communications with Navy Key West Approach Control, at 2118:45, an occupant of the airplane established contacted with their facility and provided the airplane registration number. The controller replied, "squawk zero two one zero wind one three zero at seven Navy Key West altimeter three zero zero four say type Cessna destination and requested altitude." The next comment was from the controller advising the pilot to say the type of aircraft, the destination, and again advised the transponder code was 0210. At 2119:21, an occupant of the airplane replied, "Squawking zero two one zero. It's a Cessna Skyhawk six five nine eight two. We like southbound to transition your airspace to the south on a cross country to Marathon, yeah." The controller again advised the pilot to "squawk" 0210, to which an occupant replied at 2119:48 "zero two one zero Cessna six five nine eight two." The controller advised the pilot that the "transponder not observed reset and squawk zero two one zero." The pilot did not reply and there were no further recorded transmissions from the occupant of the accident airplane. The controller attempted numerous times to communicate with the pilot; the results were negative. There was no recorded distress call made by the pilot.

According to the "Radar Supervisor/Approach Controller" at Navy Key West Terminal Radar Approach Control (TRACON), after advising the pilot a second time to apply discrete transponder code 0210, he waited a few scans of the radar but he was never able to radar identify the flight. Additionally, he did not see a primary target departing KEYW. He attempted to communicate with the airplane on VHF guard (121.5) and also UHF guard (243.0) frequencies but there was no response. Knowing the KEYW air traffic control tower was closed, he also attempted to establish contact with the pilot on the KEYW Common Traffic Advisory Frequency (118.2 MHz); there was no response.

Review of recorded radar data from Miami Air Route Traffic Control Center revealed there was no radar target associated with the assigned transponder code 0210. Two radar targets with beacon code 0201 were observed. The first radar target occurred at 2116:47, and the second target occurred at 2117:11, both were located over KEYW.

The controller who was talking with the pilot of the accident airplane contacted Miami Air Route Traffic Control Center (Miami ARTCC) about 2135, and questioned whether Miami ARTCC had established two-way communications with the accident airplane; the response was they had not. The controller also contacted fire rescue at Key West International Airport about 2145, and asked to have a ramp search performed. The individual reported that he advised the controller that the flight had departed at 2112, but a ramp check would be performed. Additionally, the Miami ARTCC reportedly established contact with personnel from KMTH, and requested a ramp search to be performed. Ramp searches were performed at KEYW and KMTH; the results were negative. On the evening of the accident, the U.S. Coast Guard was advised by the Monroe County Sheriff's Office of a report of a boater seeing a flash and hearing a loud sound. The U.S.C.G. dispatched a boat in the area and the crew of that boat later reported seeing lighting and hearing thunder from a nearby storm, but no wreckage was located. The following morning at approximately 0813, a boater contacted the U.S.C.G. and advised seeing a portion of one of the wings partially submerged. The U.S. Coast Guard contacted Monroe County Sheriff's office on July 31, 2005, at 0930, and requested underwater assistance with the aircraft wreckage. The wing was recovered and a search for the airplane and the occupants was then performed by the U.S. Coast Guard, Monroe County Sheriff's Office, U.S. Navy Police, Florida Fish and Wildlife Conservation Commission (FWC), and NOAA. The wreckage consisting of the fuselage was located on August 2, 2005.

Personnel information

The pilot was the holder of a commercial pilot certificate with ratings airplane single engine land, and instrument airplane, which was issued last on August 17, 2002. She was the holder of a first-class medical certificate issued on February 7, 2005, with the restriction or limitation "must wear corrective lenses." Her last "Flight Review" conducted in accordance with 14 CFR Part 61.56, occurred on July 27, 2005. The flight review was given by a flight instructor with Epic Aviation in a Cessna 172S.

The flight review consisted of 1.0 hour ground, and 1.4 hours of flight. According to the flight instructor who performed the flight review, the ground review consisted of airplane performance, systems of the airplane, review of speed, airspace, VFR weather minimums, and emergency engine procedures. The flight instructor stated that the pilot was "...found to be very knowledgeable on covered topics." The flight review was conducted to the commercial practical test standards, and consisted of steep turns, slow flight, power-on departure stall, and several touch-and-go landings.

NTSB review of the pilot's pilot logbook that contained entries from July 24, 1999, to the last entry dated July 27, 2005 (Flight Review), revealed her logged total time was 260.4 hours, of which 144.4 hours were as pilot-in-command. There were only 2 logged flights in Cessna type airplanes. Her total logged night time was listed as 9.4 hours. There were no logged flights between October 14, 2002, and the last logged flight on July 27, 2005. No determination could be made whether the pilot was current to fly at night.

A review of the application for the pilot's last medical certificate dated February 7, 2005, revealed she listed a total flight time of 900 hours.

Aircraft information

The airplane was manufactured by Cessna aircraft Company in 2004, as a model 172S, and was designated serial number 172S9766. The airplane was certificated in the normal and utility categories, and was equipped with a McCauley fixed pitched propeller, model 1A170E/JHA7660, and a 180-horsepower Lycoming IO-360-L2A engine. The airplane was also equipped with a two-axis autopilot with altitude preselect and two engine-driven vacuum pumps, which provide vacuum necessary to operate the attitude indicator and directional gyro.

A review of the airplane maintenance records revealed the airplane was last inspected in accordance with a "Phase II" inspection, which was signed off as being completed on July 29, 2005. The airplane had accumulated approximately 1.8 hours since the inspection at the time the airplane was rented by the accident pilot. Further review of the maintenance records revealed no entry indicating removal, replacement, or repair of the transponder.

At the time of rental by the accident pilot, the installed hour meter indicated 653.2. At the time of the accident, the hour meter indicated 656.9.

There was no record of fuel servicing or maintenance being performed to the airplane while at KEYW.

Meteorological information

A METAR weather observation taken at 2053, at Key West International Airport, or approximately 26 minutes before the accident, indicates the wind was from 100 degrees at 11 knots, the visibility was 10 sta

Aircraft

Registration
N65982
Reported as
Cessna 172S
Category
Airplane
Serial number
172S9766
Airframe hours
496.2
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Epic Aviation, Inc.
Registered owner
MFH Leasing, Inc.
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Continuous airworthiness · July 1, 2005
Departed
KEYW · Key West, FL
Destination
KMTH · Marathon, FL
Airport
KEYW · Key West International

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
21
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
260 total · 144 as pilot in command

Weather

Conditions
Visual (VMC) · Night/dark
Wind
100° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 73 °F
Altimeter
30.03 inHg
Observed at
KEYW

Docket · 43

The files NTSB released with the investigation on July 23, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports. 18.4 MB in all.

Supplement SItem 1 · .PDF · 28 KBVideo/Image Factual ReportItem 2 · .PDF · 168 KBTranscript of Radio CommunicationsItem 3 · .PDF · 552 KBReports from Federal Agencies-FAAItem 4 · .PDF · 54 KBReports from State Agencies-Florida Fish and Wildlife Conservation CommissionItem 5 · .PDF · 455 KBReports from Local Agencies-Monroe County Sheriff's officeItem 6 · .PDF · 831 KBReports from Parties to the Investigation-Sigma Tek, Inc.Item 7 · .PDF · 1.2 MBReports from Parties to the Investigation-HoneywellItem 8 · .PDF · 508 KBReports from Parties to the Investigation-Cessna Aircraft CompanyItem 9 · .PDF · 379 KBMaintenance recordsItem 10 · .PDF · 1.7 MBPersonnel StatementsItem 11 · .PDF · 355 KBKNQX Daily Record of Facility Operation Log SheetItem 12 · .PDF · 36 KBRadar Plot and Radar DataItem 13 · .PDF · 100 KBKey West Approach Control Flight Progress StripItem 14 · .PDF · 9 KBFlight Plan InformationItem 15 · .PDF · 27 KBStatement from Captain Eric SellersItem 16 · .PDF · 45 KBKEYW Fire Department Daily Activity ReportItem 17 · .PDF · 82 KBExcerpts from pilot logbookItem 18 · .PDF · 3.0 MBDocuments provided by Epic AviationItem 19 · .PDF · 563 KBStatement from Gretchen EvansItem 20 · .PDF · 40 KBStatement from Robert AcerraItem 21 · .PDF · 73 KBSun and Moon dataItem 22 · .PDF · 30 KBRecord of NTSB conversationsItem 23 · .PDF · 270 KBMiami Air Route Traffic Control Center RadarItem 24 · .PDF · 536 KBCoast Guard ReportItem 25 · .PDF · 176 KBStatement of Party Representatives to NTSB InvestigationItem 26 · .PDF · 167 KBToxicological ReportItem 27 · .PDF · 93 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 28 · .PDF · 108 KBPhoto 1: NTSB digital photograph. Right rear quartering view of the empennage/fuselage.Item 29 · .PDF · 394 KBPhoto 2: NTSB digital photograph. View of the empennage and portion of the fuselage.Item 30 · .PDF · 420 KBPhoto 3: NTSB digital photograph. Left side view of the fuselage/empennage.Item 31 · .PDF · 409 KBPhoto 4: NTSB digital photograph. Left side view of the fuselage/empennage.Item 32 · .PDF · 413 KBPhoto 5: NTSB digital photograph. Left forward quartering view of the fuselage/empennage.Item 33 · .PDF · 408 KBPhoto 6: NTSB digital photograph. Right forward quartering view of the fuselage/empennage.Item 34 · .PDF · 413 KBPhoto 7: NTSB digital photograph. View of the firewall/instrument panel.Item 35 · .PDF · 430 KBPhoto 8: NTSB digital photograph. View of the right wing.Item 36 · .PDF · 368 KBPhoto 9: NTSB digital photograph. View of the instrument panel.Item 37 · .PDF · 435 KBPhoto 10: NTSB digital photograph. View showing the separated transponder.Item 38 · .PDF · 419 KBPhoto 11: NTSB digital photograph. View showing the upper vacuum pump and vacuum pump drive gear.Item 39 · .PDF · 397 KBPhoto 12: NTSB digital photograph. View of the upper vacuum pump rotor and rotor vanes.Item 40 · .PDF · 421 KBPhoto 13: NTSB digital photograph. View of the propeller.Item 41 · .PDF · 443 KBPhoto 14: Digital photograph provided by Lycoming. View of the engine.Item 42 · .PDF · 680 KBPhoto 15: Digital photograph provided by Lycoming. View of the engine.Item 43 · .PDF · 723 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.