NYC08FA133

NTSB accident investigation · Cessna 172 · Indiantown, FL · March 13, 2008

Accident · FatalField investigationFinal report
Date
March 13, 2008, 09:00 local (13:00 UTC)
Place
Indiantown, FL
Injuries
4 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N284SPCessna 172
Defining event
Maneuvering-low-alt flying: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report December 28, 2008
Report
Approved by Office Director
Parties
FAA/FSDO, Cessna Aircraft Company, Lycoming Engines
FAA report
20080313857629A
Case key
67658

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 an adequate airspeed while maneuvering at low altitude. Contributing to the accident was the overweight condition of the airplane and the inoperative stall warning horn.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Aircraft capability: maximum weightAircraft › Aircraft oper/perf/capability · Capability exceededCessna 172S: 6 casesAll aircraft: 152 casesProbable cause
Navigation system: stall warning systemAircraft › Aircraft systems · FailureCessna 172S: 1 caseAll aircraft: 4 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172S: 16 casesAll aircraft: 1,681 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The purpose of the flight was to conduct aerial surveys of bird activity. During a circling pass, at an altitude about 300 feet above ground level (agl), a witness observed the nose of the airplane drop. The airplane then banked to the right with an accompanying increase in engine noise, and descended into the ground. The airplane had flown approximately 1.5 hours since being serviced with fuel on the morning of the accident flight. The airplane was 5 pounds over maximum gross weight based on the measured weight of the contents. Fuel was observed in the surrounding areas of the accident site, and as such, the maximum gross weight was considered higher than the measured value. Impact damage on the nose, wings, and fuselage were consistent with a stall/spin and subsequent collision with terrain. Postaccident examination revealed that the stall warning device was inoperative at the time of the accident. Two pilots who had previously flown the bird surveying missions, reported that they were instructed by the research leader to fly the airplane at altitudes between 200 and 500 feet agl. They further reported that the type of maneuvers and low airspeeds required to perform the missions would often cause the stall warning horn to sound. Aside from the stall warning horn, no other preimpact mechanical malfunctions were identified with the accident airplane.

Factual narrative

History of flight

On March 13, 2008, at 0900 eastern daylight time, a Cessna 172S, N284SP, operated by Kemper Aviation Incorporated, was substantially damaged when it impacted flat terrain in Indiantown, Florida. The certificated airline transport pilot and three passengers were killed. The aerial observation flight departed Okeechobee County Airport (OBE), Okeechobee, Florida, at 0802 and was operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed.

The operator’s dispatch records revealed that the pilot was scheduled to embark one passenger at Palm Beach County Airpark, West Palm Beach, Florida, at 0630, and subsequently embark two additional passengers at OBE.

About 0900, a witness reported observing the airplane make multiple passes over cattle pastures near Indiantown. During one of the passes, at an estimated altitude of 200 to 250 feet above ground level (agl), the witness observed the nose of the airplane drop. The airplane then banked to the right with an accompanying increase in engine noise, and descended into the ground.

Handheld global positioning systems (GPS), Garmin GPSMAP 295, and Garmin GPSMAP 76, were recovered from the airplane. The GPS units were sent to the National Transportation Safety Board Office of Research and Engineering for data extraction. The data revealed that on the day of the accident, the airplane departed OBE at 0802 and flew southeast along the shore of Lake Okeechobee at a GPS altitude of 500 ft mean sea level (msl) (about 470 ft agl). Starting about 0815, the airplane began to fly an S-turn pattern progressing to the north. The airplane further continued to make multiple circling passes at two intermediate locations. During these circling passes, the airplane’s groundspeed varied between 42 and 100 mph, and the altitude varied between 297 and 615 ft msl. About 0856, the airplane began to circle a third time. After the third orbit, the airplane began to rapidly lose altitude from about 350 ft msl. The final descent rate, based on altitude lost between the final two GPS update points, was in excess of 3,000 feet per minute (fpm). The last GPS position location was recorded at 0900:03. The last calculated and recorded airplane velocity was 53 mph groundspeed, with a course of 053 degrees true.

Personnel information

The pilot, age 36, held an airline transport pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate, with ratings for airplane single-engine, airplane multiengine land, and instrument airplane. Investigators were not able to locate the pilot’s logbook. Flight records recovered from the operator revealed that the pilot had flown a total of 331.6 hours with the operator’s aircraft since January 9, 2007, 6.3 hours of which were flown in the accident airplane. On his latest Federal Aviation Administration (FAA) first-class medical application, dated January 31, 2007, the pilot stated that he had amassed 2,900 hours of total flight time.

The pilot was the co-owner of Kemper Aviation Incorporated.

Aircraft information

The four-seat, high-wing, fixed-gear airplane, serial number 172S8235, was manufactured in 1999. It had accrued a total time in service of 5240.3 hours at the time of the accident. Review of the airplane maintenance records documented that an airframe and engine annual inspection was completed on January 23, 2008, at 72.5 flight hours prior to the accident. The Lycoming IO-360-L2A 180-horsepower engine, serial number L-29492-51A, had accumulated a total time in service of 3,421.9 hours. The engine had accrued 72.5 flight hours since the most recent major overhaul, which was performed in December 2007.

The operator's dispatch log for the airplane documented an initial engine tachometer hour meter reading of 5,238.8 prior to the departure from West Palm Beach. The tachometer hour meter reading observed on the rpm gauge at the wreckage location was 5,240.3.

The Safety Board investigator-in-charge (IIC) reviewed the maintenance squawk records for the accident airplane. On February 20, 2007 and June 10, 2007, at 4472.4 and 4624.5 hours respectively, pilots operating the airplane reported an inoperative stall warning horn. The records state that on both occasions maintenance personnel inspected the system and found it to be operative.

Meteorological information

The closest official automated weather observation system (AWOS) was located at OBE, about 17 miles northwest of the accident site. The elevation of the AWOS was 34 feet msl. An aviation routine weather report was issued at 0901. It stated: winds from 300 degrees at 4 knots; visibility 7 statute miles; clear skies; temperature 15 degrees Celsius; dew point 13 degrees Celsius; altimeter 30.07 inches of mercury.

Wreckage and impact information

The airplane wreckage was observed inverted, and oriented on a bearing of 225 degrees magnetic. The initial impact point was characterized by a 2-foot-wide divot in soft dirt, followed by a 5-foot-long section of excavated grass. A debris path continued along a bearing of 025 degrees, for approximately 90 feet, to the main wreckage.

All flight control surfaces were accounted for at the accident site. The lower section of the fuselage, forward of the main landing gear, exhibited accordion crushing damage. The right wing tip was found separated from the wing, and a chordwise crease was observed 1 foot inboard of the right wing strut attach point. Outboard of the crease, the wing exhibited upward buckling through to the wing tip. The right main landing gear remained attached to the fuselage and was bent upwards at an angle parallel to the right wing strut. The tail section remained attached to the airframe and was canted about 15 degrees to the left. The flap actuator thread was measured, and according to a Cessna Aircraft Company technical representative, the measurement corresponded to a flap setting of 15 degrees. The elevator trim actuator thread was measured and corresponded to a 5-degree elevator tab up position. Control continuity was confirmed from the rudder to the forward lower section of the cabin, and from the ailerons and elevator to the yoke.

The engine was separated from its mount, and remained partially attached to the airframe by the throttle and mixture control cables. The fuel injector servo and fuel line from the servo output to the flow divider sustained impact damage. Postimpact fire damage was observed in the lower forward section of the engine aft of the alternator.

The crankshaft was rotated and valve train continuity was confirmed through to the accessory case. The top spark plugs were removed; the spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. Both magnetos were rotated by hand and produced sparks at their respective terminals.

The propeller was separated from the engine at the crankshaft flange. One propeller blade exhibited chordwise abrasions and torsional S-bending. The other blade exhibited chordwise abrasions and slight aft bending.

Fuel and vent lines from both wing tanks were separated at the wing roots. During the airplane recovery, approximately 5.5 gallons of clear blue fluid, consistent in appearance and odor with aviation gasoline, were removed from the left tank, and 4 gallons were removed from the right tank. After the airplane was recovered, a strong smell of aviation gasoline was detected in the soil areas that were underneath the wing roots.

The stall warning horn was visually inspected at the accident site and observed undamaged. The horn was tested with suction in accordance with the Cessna Normal Procedures Checklist, and did not produce a clearly audible tone.

Medical and pathological information

Aircraft

Registration
N284SP
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S8235
Airframe hours
5,240.3
Engine
Lycoming IO-360, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial observation · Part 91
Operator
Kemper Aviation Inc., doing business as Kemper Aviation
Registered owner
Rohan Aviation Inc.
Airworthiness certificate
Standard, Utility
Last inspection
Annual · January 1, 2008 · 72.5 hours before
Departed
OBE · Okeechobee, FL
Destination
OBE · Okeechobee, FL
Airport
OBE · Okeechobee County Airport

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
36
Injuries
Fatal
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
June 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
2,900 total

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 4 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 57 °F
Altimeter
30.06 inHg
Observed at
OBE, 17 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.