Savannah, GA, USA
N78304
CESSNA 172K
The pilot was attempting an instrument landing system approach to a northbound runway in night, instrument meteorological conditions. The air traffic controller issued a series of radar vectors to the pilot to guide him to the localizer course. However, after the controller cleared the pilot to intercept the localizer, the airplane instead continued across the localizer course. The pilot initiated a 270-degree turn to the south, crossed the localizer course, and then turned back toward the localizer course again. The controller observed that the airplane was in a descent and queried the pilot on his altitude. The pilot replied that he was "…trying to recover." Radio and radar contact were then lost and search and rescue operations were initiated. The airplane was located in a salt marsh south of the destination airport and appeared to have been in a right, descending spiral when it impacted the marshy terrain. The wreckage was extremely fragmented. An examination of the wreckage revealed no evidence of a preimpact mechanical anomaly or failure that would have precluded normal operation. Propeller signatures indicated high engine power at impact. The pilot received his instrument rating about 6 months before the accident, at which time he reported about 189 hours of total flight time, including about 43 hours of instrument and 21 hours of night pilot-in-command flight time. Based on the night, instrument meteorological conditions, the pilot's actions and responses during the flight, and examination of the wreckage, it is likely that the pilot experienced spatial disorientation and lost control of the airplane.
HISTORY OF FLIGHT On November 18, 2012, about 1855 eastern standard time, a Cessna 172K, N78304, was substantially damaged following a loss of aircraft control and collision with terrain during approach to Savannah/Hilton Head International Airport (SAV), Savannah, Georgia. The private pilot was fatally injured. The airplane was registered to a private individual and was operated by the pilot under the provisions of 14 CFR Part 91 as a personal flight. Night, instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The local flight originated at Causey Airport (2A5), Liberty, North Carolina, about 1642. Prior to the flight, the pilot filed an IFR flight plan and obtained a weather briefing through the Direct User Access Terminal Service (DUATS). The flight departed 2A5 and the pilot checked in with Greensboro South Radar (SR) controller at 1643. At 1646, the pilot was issued an IFR clearance to SAV. About 1718, the Florence, South Carolina approach controller issued a heading of 180 degrees after noticing the pilot executing a turn of about 90 degrees. The pilot later stated that the turn was due to weather conditions. About 1827, the pilot contacted the Savannah approach controller at 4,000 feet above mean sea level (msl) and was told to expect the instrument landing system (ILS) approach to runway 1. From 1833 until 1851, the pilot was issued seven vectors. They were, in chronological order, 180, 200, 210, 230, 250, 260, and 270 degrees. At 1852, the controller informed the pilot that he was four miles from MIZLU, was issued a right turn to heading 340, was instructed to maintain 2,000 feet until established on the localizer and was cleared for the ILS runway 1 approach. The pilot acknowledged. Recorded radar data revealed that, after being cleared for the approach, the airplane continued on a southwesterly heading for about 90 seconds, and then a right turn to an easterly heading was observed. At 1853, the controller directed the pilot to turn left to a heading of 320, that he was five miles from MIZLU intersection, and re-cleared the pilot for the ILS approach to runway 1. At that time, the control advised the pilot that it appeared that the wind was pushing the aircraft off course. The pilot acknowledged. Radar data indicated that the pilot completed a left turn to the west, roughly perpendicular to the localizer course. After crossing through the localizer, the airplane was observed in a right turn of about 270 degrees until it was on a southerly heading. The airplane then continued the right turn back toward the localizer. At 1855:15 (HHMM:SS), the controller directed the pilot to maintain 2,000 feet until established on the localizer. He then asked the pilot to "say your altitude." The last return with altitude readout was at 1855:11 (1,600 feet). At 1855:26, the last transmission was received from the pilot, "three zero four we’re trying to recover." The last radar return was observed at 1855:30. The wreckage was located about 0005 on November 19, 2012, about 1/4 nautical mile west-southwest of the last radar return. There were no known witnesses to the accident. PERSONNEL INFORMATION The private pilot held airplane single engine land and instrument airplane ratings. He was issued a temporary airman certificate for an instrument airplane rating on May 27, 2012. On his additional rating application, he reported a total flying experience of 188.5 hours, including 111.4 hours as pilot in command (PIC). On the same application, he reported 65.8 hours of cross country time, 42.6 hours of instrument time, and 20.5 hours of night PIC time. The pilot's personal logbooks were not recovered or located after the accident. A friend of the pilot, who was also his flight instructor during instrument training, reported that the accident pilot had logged about 234 hours total time about a week prior to the accident, and all but about 5 hours were flown in Cessna 172 airplanes. He also reported that the pilot used an iPad to fly approaches, as well as a Garmin 155XL GPS. He and the accident pilot accomplished a majority of their training at night, and the accident pilot was comfortable flying at night. AIRCRAFT INFORMATION The airplane was a single-engine, high-wing, fixed tricycle gear airplane, serial number 17257561. It was powered by a Lycoming O-320-E2D engine rated at 150 horsepower. A review of the aircraft maintenance records indicated that an annual inspection of the airframe and engine was performed on June 29, 2012. The aircraft total time at the time of the annual inspection was 8,340.04 hours. The most recent maintenance logbook entry was recorded on November 14, 2012, at 8,373.12 hours total time (transponder inspection). METEOROLOGICAL INFORMATION The 1853 surface weather observation for SAV included scattered clouds at 600 feet, broken clouds at 1,300 feet, an overcast layer at 2,000 feet, wind from 350 degrees at 11 knots, 3 miles visibility with light rain and mist, temperature 12 degrees C, dew point 11 degrees C, and altimeter 30.24 inches of mercury. Sunset occurred about 1723 and evening civil twilight ended about 1749. The phase of the moon on November 18 consisted of a waxing crescent with 28 percent of the moon's visible disk illuminated. WRECKAGE AND IMPACT INFORMATION The wreckage was found in a salt marsh, about 12 miles south of SAV. The airframe was fragmented, and several sections were submerged in mud and salt water. There were no indications of fire. The wreckage was recovered on November 19 and 20, and was transported to a storage facility for subsequent examination by the investigation team. The accident site conditions prevented the investigation team from performing an on-scene examination of the wreckage. On December 3 and 10, 2012, the wreckage was examined under the direction of the NTSB investigator-in-charge (IIC) at a storage facility in Griffin, Georgia. All primary flight control surfaces were accounted for in the wreckage. The right wing was fragmented into multiple sections. The left wing remained generally intact with leading edge crushing in an aft direction throughout its entire length. The cockpit connections for the aileron control cables were damaged by impact forces. The cables remained attached to the aileron bell cranks in the wings. The wing flap actuator was found in the retracted (flaps up) position. The empennage was generally intact aft of the baggage compartment. The cockpit and cabin were fragmented into multiple sections. The instrument panel was crushed and separated from the fuselage. No scoring was observed on the vacuum or electric gyro rotors or housings. The airspeed indicator needle was observed at the "188 knots" position. No engine instruments were observed in the recovered wreckage. The right horizontal stabilizer separated from the right elevator during ground impact. The left horizontal stabilizer and left elevator remained attached to each other and were separated from the empennage. The vertical stabilizer was separated from the empennage. The rudder was separated from the vertical stabilizer and was fragmented by impact forces. The rudder and elevator control cables were attached at the control surfaces and at the cockpit controls. All cable separations exhibited tension overload signatures or were cut by recovery personnel. The elevator trim actuator was found in the "10-degree tab up" position. The fuel strainer bowl was found separated from the fuel strainer. The strainer screen was clogged with mud that was similar in appearance to the mud found at the accident site. The fuel tank selector valve was disassembled and found in the "both tanks" position. The emergency locator transmitter (ELT) was found generally intact and the power switch was found in the "OFF" position. The ELT, a model EBC-102A, was affixed with a decal stating that the battery replacement date was May, 2011. An entry was found in the aircraft logbook stating that the ELT battery was replaced during the annual inspection on May 20, 2011. The propeller assembly remained attached to the crankshaft flange. Both blades exhibited aft bending and blade twisting. The tip of one blade was missing and was not recovered; however, there was a witness mark on the number three cylinder rocker cover that mated with the end of the fractured blade. The engine was attached to a hoist to facilitate its examination. The carburetor was broken free from the oil sump and was not recovered. There was a puncture hole in the oil sump and the sump contained mud. The vacuum pump was disassembled. The pump drive coupling and internal vanes were intact. All rocker covers and spark plugs were removed. The spark plugs that were not impacted with mud displayed color and wear consistent with normal combustion when compared to a Champion Spark Plug wear guide. The engine was manually rotated using the propeller; suction and compression were observed on all cylinders. The valve rocker arms were observed moving in a normal manner. The accessory gears were observed rotating. All cylinders were examined using a lighted bore scope; no defects were observed. The oil filter was opened for examination; the paper element was free of particulates. Nothing was observed during the course of the examination that would have precluded the engine from making rated power prior to impact. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was performed at the Georgia Bureau of Investigation Coastal Regional Medical Examiner’s Office, Savannah, Georgia, on November 20, 2012. The autopsy report noted the cause of death as "Blunt force injury" and the manner of death was "Accident." Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated negative for ethanol and drugs. Testing for carbon monoxide and cyanide was not performed. ADDITIONAL INFORMATION At approximately 1910, the Savannah Tower air traffic manager (ATM) received a phone call at home from the supervisor on duty. He was told that the facility may have lost an aircraft and that Savannah Police had been notified. The ATM told the supervisor to call the Bryan County Sheriff's Office and the Chatham County Sheriff's Office if it had not already been done. The supervisor stated that she would call Bryan County as the aircraft was on final to runway 1 and could be close to the Bryan County/Chatham county line. When the ATM arrived at the facility, search and rescue operations were underway. The ATM reviewed the radar replay and looked at the coordinates of the aircraft's last known position. The helicopters were already flying to the vicinity. There were three helicopters actively conducting the search: two helicopters from the Chatham County Sheriff and one helicopter from the US Coast Guard. The ATM continued to review the replay and voice recordings looking for new information to aid in the search. Chatham County and Bryan County called on the phone looking for updates. The ATM explained the areas of concern were near Coffee Bluff marina, or possibly near Keller in Bryan County. The ATM also advised to them to look near Highway 204 and Highway 17 near the river.
The pilot's failure to maintain airplane control while operating in night, instrument meteorological conditions, due to spatial disorientation.
Source: NTSB Aviation Accident Database
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