2 fatalities

16 Feb 2011: CESSNA 172S (N6345L) — Phoenix East Aviation — New Smyrna Beach, FL

New Smyrna Beach, FL, United States

On 16 Feb 2011, a CESSNA 172S (registration N6345L) operated by Phoenix East Aviation was involved in an aviation accident near New Smyrna Beach, FL. 2 people were killed. Investigators recorded the probable cause as: The flight instructor's failure to recognize or implement adequate remedial action to counter the effects of spatial disorientation. Contributing to the accident was the spatial disorientation experienced by one or both pilots. This summary draws on records from NTSB; 17 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On February 16, 2011, a Cessna 172S operated by Phoenix East Aviation impacted ocean waters off New Smyrna Beach, Florida, during an instrument training flight. The flight instructor and private pilot sustained fatal injuries. Witnesses reported a near-vertical descent with no engine noise.

History of Flight

The flight departed Sarasota/Bradenton International Airport at 1606 eastern standard time, destined for Daytona Beach International Airport. The private pilot, seated in the left front seat, was working toward an instrument rating. The flight objective was to practice instrument flight rules (IFR) cross-country procedures, and a view-limiting device was required. According to the flight school, the airplane originally operated on an IFR flight plan to Melbourne International Airport, then to Daytona Beach. At 1818, a pilot contacted Daytona Approach Control, reporting an altitude of 7,000 feet. The controller advised to expect vectors for a visual approach to Runway 7 Left. At 1818:46, the IFR flight plan was canceled, with a pilot stating they would contact again in about 20 minutes. The final transmission at 1820:23 included "squawking VFR."

Radar data showed the airplane approximately 8 nautical miles inland and 20 nm south of Daytona Beach when first contacting approach control. It then turned northeast and descended, reaching the coastline at about 5,900 feet. The airplane followed the coastline northwest, then moved offshore. At 1826:14, about 700 yards offshore, it turned northeast and made a series of right turns, completing a circuit at altitudes between 4,300 and 4,500 feet. It then angled toward the shoreline, arriving overhead at 1827:10 at 3,800 feet, then turned north and headed out to sea again. Subsequent radar contacts showed rapid descent: from 4,100 feet at 1827:28 to 1,700 feet at 1827:51, with positions near shore. No primary radar returns were noted.

Two witnesses on a balcony facing the accident site reported seeing the airplane descending at a high rate in a nearly vertical, extreme nose-low attitude before impacting the water. They did not observe rotation, engine noise, smoke, or flames, and saw no items separating from the airplane.

Meteorological Information

Weather recorded at New Smyrna Beach Municipal Airport at 1818 included wind from 070 degrees true at 7 knots, visibility 5 statute miles in light mist, scattered clouds at 800 feet agl, broken clouds at 1,900 feet agl, temperature 15°C, dew point 15°C, altimeter 30.23 inHg. Sunset occurred at 1814, end of civil twilight at 1838. Moonrise at 1640, moonset at 2330, moon phase waxing gibbous with 96% illumination. At 1830, the moon was 21° above the horizon, about 85° true east of north.

Personnel Information

The certificated flight instructor (CFI), age 28, held a commercial pilot certificate with single-engine, multi-engine, and instrument ratings, and flight instructor certificates for single-engine, multi-engine, and instrument. His first-class medical was issued March 18, 2010, with no restrictions. His logbook was not recovered. According to operator records, he had 603.7 total flight hours, 378.7 as CFI. He had 18.0 hours of actual instrument time and 37.6 hours of simulated instrument time (unchanged from hire). On February 4, 2011, he flew 1.4 hours solo in a flight training device.

The private pilot under instruction, age 21, held a private pilot certificate with single-engine land rating issued December 28, 2010. His first-class medical was issued June 8, 2010, with no restrictions. His logbook was not recovered. School records showed 72.9 total flight hours, 0.8 actual instrument, 20.6 simulated instrument.

Aircraft Information

The Cessna 172S, serial number 172S10839, was a four-seat, high-wing, fixed-gear single-engine airplane manufactured in 2008, powered by a Lycoming IO-360-L2A 180-horsepower engine. The most recent 100-hour inspection was on February 4, 2011, at 1,694.2 airframe/engine hours. The airplane had an electronic multifunction display and backup air-driven flight instruments.

Wreckage and Impact Information

The majority of wreckage was recovered from the Atlantic Ocean on February 22, 2011, from a depth of about 16 feet, approximately 150 yards from shore. Recovered components included the engine, firewall, instrument panel, cabin floor, vertical stabilizer with rudder, and right horizontal stabilizer with elevator. Not recovered were the wings, center wing forward spar, cabin doors, cargo door, left horizontal stabilizer and elevator. Fragments of wing tips, tail cone, interior plastic, cowling, and left outboard aileron were also recovered. The left landing gear strut had aft bending; the right strut was not bent aft. The engine appeared impact-separated; the vacuum pump was intact. The airspeed indicator indicated 91 knots. The propeller remained attached with rotational crush signatures; both blades slightly bent aft. The instrument panel left side bent aft; left pilot seat had aft damage. The left wing exhibited accordion crushing of the leading edge. No evidence of in-flight fire.

Medical and Toxicological Information

Autopsies performed on both pilots at the Florida Office of the Medical Examiner determined cause of death as "multiple blunt traumatic injuries." Toxicological testing by the FAA showed no anomalies for either pilot.

Additional Information

FAA publications discuss aerodynamic factors such as overbanking tendency and spiral dives, as well as spatial disorientation. The Pilot's Handbook of Aeronautical Knowledge notes that a prolonged uncontrolled spiral can result from loss of horizon reference or inability to control by instruments. Advisory Circular 60-4A describes spatial disorientation and notes that it can take up to 35 seconds to establish full control after loss of visual reference. Another publication, Medical Facts for Pilots, describes a "graveyard spiral" illusion.

Contributing factors

Causes

Instructor/check pilot

Other contributing factors

Flight crewRelated operating infoEffect on personnel