# NTSB MIA95FA094: Cessna 172N, N2196E, Venice, FL, March 28, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 28, 1995, 08:20 local (13:20 UTC) - Place: Venice, FL - Coordinates: 27.089574, -82.429023 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.0896&lon=-82.4290&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious, 1 minor - Status: Completed, report November 30, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 37645 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA95FA094 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37645/pdf - Page: https://openairdocs.org/ntsb/MIA95FA094 ## Probable cause INTENTIONAL VFR FLIGHT INTO IMC BY THE PILOT-IN-COMMAND, FAILURE OF THE PILOT TO MAINTAIN AIRCRAFT CONTROL, SPATIAL DISORIENTATION, AND ALTITUDE INADEQUATE FOR RECOVERY FOLLOWING THE IN FLIGHT LOSS OF CONTROL. ## 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 - vfr flight into imc - intentional, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - altitude - inadequate, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis THE PILOT WAS BRIEFED ABOUT 2 HOURS BEFORE TAKEOFF THAT FOG EXISTED NEAR HIS DESTINATION AIRPORT AND TO CALL BACK FOR A WEATHER UPDATE; HE DID NOT. THE PILOT TOLD THE SURVIVORS BEFORE TAKEOFF 'WE'RE A LITTLE OVER WEIGHT, I'M NOT SURE IF WE'RE GOING TO TAKEOFF.' AFTER TAKEOFF THE FLIGHT WAS OBSERVED TO FLY INTO THE FOG SEVERAL TIMES AND THE AIRPLANE FLEW OVER THE AIRPORT 3 TIMES. AFTER THE THIRD PASS THE PILOT TOLD THE SURVIVORS HE WAS GOING TO LAND ON THE NEXT ATTEMPT. THE FLIGHT AGAIN ENTERED THE FOG FOR A LONGER DURATION THIS TIME AND THE SURVIVORS STATED THAT THEY AGAIN HEARD THE STALL WARNING HORN. THE PILOT APPLIED POWER BUT THE AIRPLANE DESCENDED NOSE AND RIGHT WING LOW. THE AIRPLANE IMPACTED THE WATER ABOUT 5-10 SECONDS AFTER THE STALL WARNING HORN WAS HEARD. WITNESSES AND THE SURVIVORS STATED THAT THE ENGINE SOUNDED NORMAL THE ENTIRE FLIGHT. THE AIRPLANE WAS RECOVERED AND EXAMINATION OF THE FLIGHT CONTROLS REVEALED NO EVIDENCE OF PREIMPACT FAILURE OR MALFUNCTION. THE PILOT'S MEDICAL CERTIFICATE EXPIRED AFTER DECEMBER 31, 1990, AND HE WAS NOT INSTRUMENT RATED. ## Factual narrative HISTORY OF FLIGHT On March 28, 1995, about 0820 eastern standard time, a Cessna 172N, N2196E, crashed in the Gulf of Mexico just offshore of the Venice Municipal Airport, Venice, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was substantially damaged and the private noninstrument-rated pilot and one passenger were fatally injured. One passenger sustained serious injuries and one passenger sustained minor injuries. The flight originated about 0805 from the Venice Municipal Airport, Venice, Florida. About 0609, the pilot contacted the St. Petersburg Automated Flight Service Station (PIE AFSS) by telephone and requested a weather briefing for a proposed round trip flight to the Charlotte County Airport, Punta Gorda, Florida. The proposed time of departure was 0830. The pilot was advised in part that fog existed at two airports near the destination airport and an Airmet was in effect though not for the departure airport, for fog. The pilot was advised that VFR flight was not recommended and the forecast for improvement was after 1000. The pilot was advised to call back for a weather update before departure; however, he did not call back. The survivors and one witness stated the pilot performed a preflight of the airplane which included verifying fuel quantity by measurement using a dipstick. The pilot stated to the witness and survivors that the fuel tanks contained about 2 hours of fuel. An engine run-up was accomplished and shortly before takeoff the pilot stated to the survivors "we're a little overweight, I'm not sure if we are going to takeoff." The flight departed and flew over the water then encountered fog. According to the survivors and numerous witnesses, the pilot flew into and out of the fog several times. One of the witnesses estimated that the fog base was at least 300 feet with a visibility at least 5 miles below the fog. The survivors stated and the airplane was observed by one witness to fly over the airport three times. The survivors stated that the airplane was not aligned with any runway when the airplane flew over the airport. One witness stated that during one of the passes the airplane was aligned with runway 4 and was about 75 feet above ground level at the approach end of the runway. The survivors stated that the pilot then advised them "we are going to land on the next pass." The pilot flew toward the Gulf of Mexico, again encountered fog at the shoreline and remained in the fog for a longer duration this time. The pilot executed a "very slow left bank then even slower left bank again." They then heard a "buzzer" sound which the male survivor associated with the stall warning horn. The airplane then descended nose and left wing low and the pilot responded by applying power. The airplane impacted the water about 5-10 seconds after hearing the "buzzer" sound. Numerous witnesses and the survivors stated the engine sounded normal during taxi, takeoff, and while in flight. Additionally, the survivors heard the "buzzer" sound several times during the flight. PERSONNEL INFORMATION Information pertaining to the pilot is contained in the NTSB Factual Report-Aviation. Review of the pilot's airmen file revealed that he was not instrument rated. Review of a certified copy of the pilot's medical file from February 11, 1986, to May 3, 1995, revealed that the pilot's last medical certificate was dated December 13, 1989. The limitations of that medical certificate indicated that it was not valid after December 31, 1990. METEOROLOGICAL INFORMATION Information pertaining to the weather is contained in the NTSB Factual Report-Aviation. An Automated Weather Observing System (AWOS) was located on the Venice Municipal Airport, and recorded about 1 minute after the accident, the following: ceiling 500 feet overcast with 7 miles visibility, temperature and dew point were each 73 degrees F., and the wind was from 280 degrees at 5 knots. The AWOS weather is not reported to the St. Petersburg (AFSS). Additionally, the pilot of another airplane was executing a non-precision instrument approach to the airport about the time of the accident. The pilot reported that the ceiling of the clouds was about 600 feet and the visibility was about 3 to 5 miles beneath the lowest layer of clouds. WRECKAGE AND IMPACT INFORMATION The wreckage was located in the Gulf of Mexico about 200 yards offshore, west-southwest of the approach end of runway 04. The wreckage was recovered for further examination. Examination of the airframe revealed evidence that the airplane impacted the water in a right wing and nose low attitude. The wings, engine assembly, and instrument panel were found to be separated from the airframe. Examination of the right wing revealed leading edge chordwise crushing near the wingtip and the lift strut. The leading edge of the left wing was relatively intact. Examination of the aileron, elevator, and rudder flight controls revealed no evidence of preimpact failure or malfunction. The flaps were confirmed to be in the fully retracted position. Examination of the engine revealed crankshaft, camshaft, and valve train continuity. The throttle and mixture control cables were connected to their respective control arms at the carburetor. Examination of the carburetor revealed that the throttle was 3/4 open, and the mixture was found to be near full rich. Each magneto to engine timing and internal timing of the magnetos was correct with no evidence of preimpact failure or malfunction of the magnetos. Thumb suction and compression were noted in all cylinders. Examination of the vacuum pump revealed that the driven components were intact and internally the rotor and rotor vanes were intact. MEDICAL AND PATHOLOGICAL INFORMATION Post-mortem examinations of the pilot and right front seat passenger were performed by James C. Wilson, M.D., at the Sarasota Medical Examiner Facility. The cause of death for the pilot was drowning. The cause of death for the right front seat passenger was multiple severe blunt traumatic injuries. No abdominal bruising was noted on either the pilot or right front seat passenger. Toxicological analysis was performed on specimens of the pilot by the FAA Toxicology and Accident Research Laboratory. The results were negative for carbon monoxide, cyanide, volatiles, and tested drugs. The results were positive in the urine for Diltiazem. ADDITIONAL INFORMATION The wreckage was released to Mr. Dale Kraus of the Venice Flying Service on March 29, 1995. ## Aircraft - Registration: [N2196E](https://openairdocs.org/deregistered/N2196E-2013-07-08), registration cancelled 2013-07-08, S/N 17271184, 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: 17271184 - Airframe hours: 1943 - Engines: LYCOMING O-320-H2AD 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Johnson, R. Verle - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, March 16, 1994, 15 hours before - Destination: PGD, PUNTA GORDA, FL - Airport: VNC, Venice Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 80; private; airplane ratings: single-engine land; medical: expired; seat: left; toxicology performed; flight hours: 490 total ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 5 knots - Visibility: 7 statute miles - Lowest ceiling: 500 ft overcast - Temperature: 73 °F, dew point 73 °F - Altimeter: 30.00 inHg - Observed at: VNC, 1 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 19950328005769A](https://openairdocs.org/incident/19950328005769A), Mar 28, 1995: Cessna 172N, Venice, FL, Substantial damage, 2 fatal. Departed under low clouds and sea fog. Tried land twice. Climbed into fog stalled into gulf. VFR not recommended. 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.