# NTSB NYC08FA133: Cessna 172, N284SP, Indiantown, FL, March 13, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 13, 2008, 09:00 local (13:00 UTC) - Place: Indiantown, FL - Coordinates: 27.167222, -80.60028 - Nearby events: https://openairdocs.org/map.md?lat=27.1672&lon=-80.6003&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report December 28, 2008 - Report: Approved by Office Director - Parties: FAA/FSDO, Cessna Aircraft Company, Lycoming Engines - NTSB case key (mKey): 67658 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA133 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67658/pdf - Page: https://openairdocs.org/ntsb/NYC08FA133 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna 172S, 6 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=2072439), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md) - [Navigation system: stall warning system](https://openairdocs.org/ntsb-findings/01023418): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/01023418/cases.md?model=2072439), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01023418/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 16 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2072439), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: 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) - [Maneuvering-low-alt flying: 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 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](https://openairdocs.org/deregistered/N284SP-2013-08-12), registration cancelled 2013-08-12, S/N 172S8235, built 1999 (OpenAirDocs) - Reported make and model: CESSNA 172 (S) - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming I0-360-B1E](https://openairdocs.org/engine/lycoming-i0-360-b1e) (registry code 41559, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S8235 - Airframe hours: 5240.3 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: fatal; 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 (OpenAirDocs). - [Accident 20080313857629A](https://openairdocs.org/incident/20080313857629A), Mar 13, 2008: Cessna 172S, Indian Town, FL, Destroyed, 4 fatal. On March 13, 2008, about 0900 eastern standard time, a Cessna 172S, N284SP, operated by kemper aviation incorporated, was destroyed when it impacted terrain… 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.