New Smyrna Beach, FL, USA
N6345L
CESSNA 172S
With sunset approaching and nearing coastal water, the flight instructor and the private pilot under instruction were completing a cross-country instrument training flight. One of the pilots contacted air traffic control and reported the airplane's altitude at 7,000 feet. The controller told the pilots to expect vectors for a visual approach to the destination airport. They cancelled their instrument flight rules flight plan, angled the airplane offshore, and completed a right-turning pattern before returning to the shoreline. About 13 minutes after sunset, the airplane again proceeded offshore and appeared to make a general, one and one-half, circle-like pattern to the left, with the last full circle much tighter than the first half circle. During the last full circle, the airplane's altitude decreased from 3,100 feet to 1,700 feet in 14 seconds, a rate of descent of about a 6,000 feet per minute. Witnesses stated that they saw the airplane descending at a high rate, not in a spin, but in a nearly vertical, extreme nose-low attitude before it impacted the water. Wreckage examination confirmed that the airplane impacted the water nose low, left wing down, and slightly inverted. No preexisting mechanical malfunctions or failures were noted with the airplane that would have precluded normal operation, and radar returns did not indicate that any objects detached from the airplane in flight. Weather observations recorded about 2 nm inland and about 10 minutes before the accident indicated visibility of 5 statute miles in light mist, scattered clouds at 800 feet above ground level (agl), and a broken cloud layer at 1,900 feet agl. With diminished lighting conditions, cloudy conditions inland, and a mostly overwater sight picture, it is likely that there was little or no discernible horizon. A loss of horizon reference is conducive to the onset of spatial disorientation. The pilot at the controls was likely not using or believing his instruments, instead, relying on his senses to determine airplane orientation. He then likely attempted to level the airplane by feel and by pulling back on the yoke while in the left turn, which made the turn tighter and lowered the airplane's nose until the airplane was in a vertical descent. It could not be determined which pilot was at the controls or whether both may have been at some point; however, the flight instructor had the ultimate responsibility to maintain safety of flight.
HISTORY OF FLIGHT On February 16, 2011, at 1828 eastern standard time, a Cessna 172S, N6345L, operated by Phoenix East Aviation, Inc., was substantially damaged when it impacted ocean waters just off New Smyrna Beach, Florida. The certificated flight instructor (CFI) and the private pilot under instruction were fatally injured. Twilight visual meteorological conditions prevailed, and at the time, the airplane was not operating on a flight plan. The instructional flight, which departed Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida, at 1606, destined for Daytona Beach International Airport (DAB), Daytona Beach, Florida, was operating under the provisions of 14 Code of Federal Regulations Part 91. According to the private pilot's training folder, he was working toward his instrument rating, and the flight objective was "to learn how to accurately plan and conduct an IFR [(instrument flight rules)] cross-country flight and become more familiar with IFR departure, en route and arrival procedures." A view limiting device was required. According to a flight school representative, the airplane was originally operating on an IFR flight plan from SRQ, to Melbourne International Airport (MLB), Melbourne, Florida, and then to DAB. The private pilot was in the left front seat, and per the lesson completion standard, "the student should have command of the airplane at all times during the flight." A Federal Aviation Administration (FAA) partial air traffic control transcript revealed that one of the pilots contacted Daytona Approach Control at 1818:15, and stated that the airplane was at 7,000 feet. The controller subsequently told the crew to expect vectors for a visual approach to runway 7 Left [at DAB]. At 1818:46, a pilot advised the controller of cancellation of the IFR flight plan, but that they would get back with him later to do an approach. After the controller confirmed the cancellation, a pilot stated that they would contact him in about 20 minutes. After a number of back and forth radio transmissions, a final transmission came from the airplane, at 1820:23, stating, "squawking v-f-r (unintelligible.)" Radar data indicated that when the crew initially contacted Daytona Approach Control, the airplane was about 8 nautical miles (nm) inland, and about 20 nm south of DAB. The airplane then turned to the northeast and descended, reaching the southeast-northwest ocean coastline at an altitude of about 5,900 feet. The airplane subsequently followed the coastline to the northwest, but gradually moved eastward and offshore. At 1826:14, when the airplane was about 700 yards offshore, it turned to the northeast, eventually making two right turns until it was then headed southeast, and turning again to the right until it completed a circuit just before 1826:51. Altitudes throughout the circuit generally ranged from 4,300 feet, to 4,500 feet, with the circuit completed about 4,000 feet. The airplane then angled toward the shoreline, arriving overhead at 1827:10, at an altitude of 3,800 feet. It subsequently turned to the north and angled out to sea again. The airplane continued north, until 1827:28, when it was approaching 400 yards offshore, at 4,100 feet (for report clarity, designated Point A.) There were four subsequent radar contacts: Point B: At 1827:33, altitude 3,600 feet, less than 100 yards southwest of Point A. Point C: At 1827:37, altitude 3,100 feet, less than 150 yards northeast of Point A. Point D: At 1827:46, altitude 2,300 feet, directly over Point A. Point E: At 1827:51, altitude 1,700 feet, about 125 yards northeast of Point A. No primary (skin paint) radar contacts were noted. According to an FAA inspector, he interviewed two witnesses who resided in a local condominium and who were sitting on their balcony directly in front of, and facing the accident site. The witnesses stated that they looked up and noticed an airplane descending at a high rate, in a nearly vertical, extreme nose-low attitude before it impacted the water. They did not see any rotation of the airplane and did not hear any engine noise. They also did not see any smoke or flames, and did not see any other items descend separately from the airplane. METEROLOGICAL INFORMATION Weather, recorded at New Smyrna Beach Municipal Airport (EVB), New Smyrna Beach, Florida, located about 2 nm inland, at 1818, included wind from 070 degrees true at 7 knots, visibility 5 statute miles in light mist, scattered clouds at 800 feet above ground level (agl), a broken cloud layer at 1,900 feet agl, temperature 15 degrees C, dew point 15 degrees C, altimeter setting 30.23 inches of mercury. According to U.S. Naval Observatory astronomical data, sunset occurred at 1814, and the end of civil twilight occurred at 1838. Moonrise occurred at 1640, and moonset occurred at 2330. Moon phase was waxing gibbous with 96 percent of the visible disk illuminated. At 1830, the moon was 21 degrees above the horizon, about 85 degrees true, east of north. PERSONNEL INFORMATION The CFI, age 28, held a commercial pilot certificate for airplane single engine land, multi-engine land, instrument airplane. He was also a certificated flight instructor for single engine and multiengine airplanes, and instrument-airplane. His latest FAA first class medical certificate was issued on March 18, 2010, with no restrictions. The CFI's logbook was not recovered. According to the operator, the CFI had accumulated 603.7 hours of total flight time and 378.7 hours as a CFI. As a previous student at the flight school, he flew his CFI-instrument check ride on March 12, 2010. The CFI was then hired as an instructor on March 29, 2010, and at that time, his resume indicated 6.3 hours of actual instrument time and 37.6 hours of simulated instrument time. Computer records indicated that as of the accident flight, the CFI had accumulated 18.0 hours of actual instrument time, while the 37.6 hours of simulated instrument time remained the same. On February 4, 2011, the CFI flew 1.4 hours solo in a flight training device, but the extent/type of instrument practice is unknown. The pilot under instruction, age 21, held a private pilot certificate with an airplane single engine land rating, which was issued on December 28, 2010. His FAA first class medical certificate was issued on June 8, 2010, with no restrictions. The private pilot's logbook was not recovered. According to flight school records, the private pilot had accumulated 72.9 hours of total flight time, 0.8 hour of actual instrument time, and 20.6 hours of simulated instrument time. AIRCRAFT INFORMATION The four-seat, high-wing, fixed gear single engine airplane, serial number 172S10839, was manufactured in 2008. It was powered by a Lycoming IO-360-L2A, 180-horsepower engine. According to maintenance records, the most recent 100-hour inspection occurred on February 4, 2011, at an airframe/engine total time of 1,694.2 hours. For primary flight instrumentation, the airplane was equipped with an electronic multifunction display and for 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, abeam Mary McLeod Bethune Beach Park. During initial recovery operations, the engine, firewall, instrument panel and pedestal, cabin floor assembly, vertical stabilizer with rudder, and right horizontal stabilizer with elevator were recovered. Components not recovered included the left and right wing, the center wing forward spar, the left and right cabin doors, cargo door, left horizontal stabilizer and left elevator. Fragments of the left and right wing tips, tail cone assembly, interior plastic, cargo area structure, cowling, and left outboard aileron were also recovered from the water and beach in the days following the accident. The left and right main wheel and brake assemblies were also recovered. The left landing gear strut exhibited aft bending, and the left wheel and the brake assembly were missing from the strut. The right landing gear strut was not bent aft, and although the right wheel was missing, the brake assembly remained attached to the strut. The nose wheel assembly was not recovered. The engine appeared impact-separated from the airframe. The top tubular mounts were fractured at the top cluster and the bottom tubular mounts were torn out of the riveted firewall attachment brackets. The engine was damaged on all sides with greater damage on the lower front and left side. The No. 2 cylinder front baffle was crushed aft. The No. 2 cylinder intake and exhaust pipes were dislodged and the valve covers on the left side of the engine (Nos. 2 & 4) were dented. The muffler was crushed upward and aft. The vacuum pump drive coupling, internal rotor and pump vanes were all intact. The airspeed indicator indicated 91 knots. The propeller remained attached to the crankshaft flange, and the spinner exhibited rotational crush signatures. Both propeller blades were slightly bent aft, with one having abraded paint on the outboard trailing edge. The outboard left side of the instrument panel was bent aft and the left pilot seat exhibited aft damage on the upper, outboard side. The left wing was subsequently recovered, and exhibited accordion crushing of the leading edge, with the greater crush toward the wingtip and the crush toward the wing tip rolled under the wing. There was no evidence of an in-flight fire. MEDICAL AND TOXICOLOGICAL INFORMATION Autopsies were performed on both pilots at the Florida Office of the Medical Examiner, Daytona Beach, Florida. Cause of death for both pilots was "multiple blunt traumatic injuries." Toxicological testing was performed for both pilots by the FAA Toxicology Research Team, Oklahoma City, Oklahoma, with no anomalies noted for either pilot. ADDITIONAL INFORMATION FAA publication FAA-H-8083-25A, "Pilot's Handbook of Aeronautical Knowledge," Chapter 4, Aerodynamics of Flight, notes that, "The wing on the outside of [a] turning moment travels forward faster than the inside wing and, as a consequence, its lift becomes greater. This produces an overbanking tendency which, if not corrected by the pilot, results in the bank angle becoming steeper and steeper. At the same time, the strong directional stability that yaws the aircraft into the relative wind is actually forcing the nose to a lower pitch attitude. A slow downward spiral begins which, if not counteracted by the pilot, gradually increases into a steep spiral dive. It also notes that, "Since the airspeed in the spiral condition builds up rapidly, the application of back elevator force to reduce this speed and to pull the nose up only 'tightens the turn,' increasing the load factor. The results of the prolonged uncontrolled spiral are inflight structural failure or crashing into the ground, or both. The most common recorded causes for pilots who get into this situation are: loss of horizon reference, inability to control the aircraft by reference to instruments." FAA publication AC 60-4A, "Pilot's Spatial Disorientation," dated February 9, 1983, states, "The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometime conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.' Tests conducted with qualified instrument pilots indicate that it can take as much as 35 seconds to establish full control by instruments after the loss of visual reference with the surface. When another large group of pilots were asked to identify what types of spatial disorientation incidents they had personally experienced, the five most common illusions reported were: 60 percent had a sensation that one wing was low although wings were level; 45 percent had, on leveling after banking, tended to bank in opposite direction; 39 percent had felt as if straight and level when in a turn; 34 percent had become confused in attempting to mix 'contact' and instrument cues; and 29 percent had, on recovery from steep climbing turn, felt to be turning in opposite direction. Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common on overwater flights…or in low visibility conditions… The disoriented pilot may place the aircraft in a dangerous attitude." FAA Publication AM-400-03/1, Medical Facts for Pilots, "Spatial Disorientation" notes, "A 'Graveyard Spiral' is more associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter. If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground."
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.
Source: NTSB Aviation Accident Database
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