NTSB Factual Report

HISTORY OF FLIGHT

On March 28, 2001, at 1858 Pacific standard time, a Cessna 172N, N2838E, descended into an area of the Pacific Ocean known as the Santa Monica Bay, near Santa Monica, California. The private pilot had rented the airplane from Justice Aviation, a Santa Monica based flight school, which operated it. The airplane was destroyed upon impacting the ocean. The pilot and two passengers were fatally injured. The flight was performed under the provisions of 14 CFR Part 91, and no flight plan had been filed. Visual meteorological conditions existed at the Santa Monica Municipal Airport, about 7 nautical miles (nm) east of the crash site, from where the flight originated at 1852.

According to Justice Aviation personnel, the pilot had rented the airplane for a 1- to 2-hour-long personal flight over the local Los Angeles area. Prior to taking off, at 1851:40, the pilot advised the Santa Monica control tower's local controller that he intended to perform a flight under visual flight rules. Regarding the pilot's planned route, he advised the controller that he intended to fly "up and down the shoreline."

Federal Aviation Administration (FAA) recorded radar data indicates that at the commencement of the airplane's takeoff roll, the airplane's Mode C transponder altitude was indicating the approximate 175-foot mean sea level (msl) airport elevation. During the initial climb, upon passing the end of runway 21, the airplane's altitude was approximately 500 feet. The airplane continued tracking in southwesterly and westerly directions until reaching the shoreline whereupon it turned to a northwesterly course, which paralleled the coastline.

The FAA radar data further indicates that the airplane cruised about 1/2 mile offshore while maintaining between 900 and 1,100 feet. After passing the Pacific Palisades area, while cruising west of Pacific Coast Highway 1, the airplane turned away from the city lights and began flying along a southerly course, nearly perpendicular to the shoreline. Seconds later, between 1857:07 and 1857:21, the airplane descended from about 1,000 to 500 feet while in a right turn, and the radar track ended. During this period, the airplane's rate of descent was over 2,100 feet per minute. At the time of the last recorded radar hit, the airplane was about 1 mile south of the Topanga State Beach, at the following coordinates: 34 degrees 01 minute 26 seconds north latitude by 118 degrees 34 minutes 40 seconds west longitude.

A witness, located near the Topanga State Beach, reported observing red and white lights descending rapidly from the air toward the water about the time of the accident. The witness indicated that the aircraft flew nose first into the water. The witness described the descent profile to be like a falling rock. Because of his vantage point, he did not observe it contact the water. Thereafter, the witness called 911 to report an airplane accident.

U.S. Coast Guard personnel and Los Angeles County lifeguards subsequently observed fragmented portions of airplane wreckage near this vicinity. The main wreckage was found about 0.24 miles from its last recorded radar position.

PERSONNEL INFORMATION

Pilot Qualifications.

The pilot's logbook was not located and/or provided to the National Transportation Safety Board for examination. A review of records maintained by the FAA indicated that the pilot was issued a private pilot certificate with an airplane single engine land rating on July 27, 2000. The pilot was not instrument rated. On the application for his airman's certificate the pilot reported that his total flight time was 99.1 hours. Additionally, he reported that his pilot-in-command time was 24.4 hours, his instrument time was 3 hours, and he had received 4.7 hours of instruction while flying at night. The pilot obtained his flight training at airports located near Dallas, Texas.

A review of the pilot's medical records on file with the FAA indicated that on November 28, 2000, when he applied for his most recent third-class aviation medical certificate, he reported that his total flight time experience was 135 hours. Also during the preceding 6 months he had flown 48 hours.

According to the airplane operator, at the time of the accident the pilot had a total of approximately 150 hours of flight time. About 50 hours were in the accident make and model airplane.

Flight Training.

Three days before the accident flight, on March 25, the pilot received a daytime check out in the accident model of airplane by a certified flight instructor (CFI) who worked at Justice Aviation. The Safety Board investigator interviewed the CFI. According to the CFI, the pilot satisfactorily completed the 1.5-hour-long checkout in the Cessna, and thereafter was authorized to rent Cessna 172s for both day and night flights. The CFI did not indicate that during the checkout flight he had assessed the pilot's instrument flying skill. Also, the CFI reported that he had discussed typical weather patterns along the coast and had noted the presence of the marine layer of clouds. The pilot indicated that, having received his flight training in Texas, he had no experience flying in coastal weather conditions.

AIRPLANE INFORMATION

A CFI, who worked for Justice Aviation, reported that she had flown N2838E the day before it crashed. The CFI reported that during her flight "all instruments were working, especially the attitude indicator. There were no squawks for the airplane...."

METEOROLOGICAL INFORMATION

Visual meteorological conditions existed at the time of the accident pilot's takeoff from the Santa Monica Municipal Airport. The airport is located about 6.5 nautical miles east (080 degrees, magnetic) of the crash site.

About 7 minutes before the accident, Santa Monica Airport's weather was reported, in part, as follows: Overcast sky condition with the cloud base at 1,200 feet above ground level; 7 miles visibility; wind from 240 degrees at 4 knots; and temperature/dew point of 15/13 degrees Celsius.

According to U.S. Naval Observatory data, the end of civil twilight on March 28 was at 1837. The moon was a waxing crescent with 14 percent of the visible disk illuminated.

A pilot, who was flying in the vicinity and who possessed an instrument rating, reported to the Safety Board investigator that about 1830, when he departed from the Santa Monica airport, the cloud bases were about 1,100 feet msl, and the top of the cloud layer was about 1,700 feet msl. Visibility below the cloud layer was about 5 to 6 miles. It was a dark night, and no moon was visible.

Another pilot, who was flying over the Los Angeles basin between Hawthorne and Torrance between 1900 and 2000, reported that a marine layer extended over the airports. The cloud base was between 1,400 to 1,600 feet, and the top of the layer was between 2,200 and 2,400 feet. What he particularly noticed was that it was a very dark night. No moon was visible. Also the cloud layer was so dense that you could not see city lights through the clouds. It was a "horizonless" night.

Hawthorne Automated Flight Service Station reported that no services were provided to the accident pilot/airplane from 1500 to 1800 on the night of the accident.

WRECKAGE AND IMPACT INFORMATION

Airplane recovery personnel reported to the Safety Board investigator that the main wreckage was located at the following global positioning satellite coordinates: 34 degrees 01 minute 18.8 seconds north latitude by 118 degrees 34 minutes 55.4 seconds west longitude.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot possessed a third-class aviation medical certificate that was issued on November 28, 2000. No restrictions or limitations were indicated on the certificate.

On March 28, 2001, at 1700, an employee of Justice Aviation spoke with the pilot at the airport. The employee reported that the pilot sounded coherent and was understandable. Thereafter, the pilot and passengers boarded the airplane and departed.

The wreckage and the pilot's body were recovered nearly 2 weeks after the accident. An autopsy was performed on the pilot by the Los Angeles County Coroner's Office.

The FAA's manager, Toxicology and Accident Research Laboratory, performed toxicological tests on specimens from the pilot. The manager reported finding no evidence of amphetamines, marihuana, or any illegal drugs. There was a finding of 2 mg/dL acetaldehyde in urine and heart, and 1 mg/dL N-Propanol in urine. Also, 13 (mg/dL) ethanol was detected in the pilot's urine, and 20 mg/dL of ethanol was found in his heart. No ethanol was found in muscle. The manager noted that the volatile concentrations are determined by headspace chromatography at a cut off of 10 mg/dL, and there was evidence of putrefaction.

TESTS AND RESEARCH

Under the supervision of the Safety Board investigator, the salt water emersion and impact damaged airplane was initially examined on the deck of a salvage vessel upon its April 10, 2001, recovery. The airframe and engine were additionally examined on June 20.

Airframe and Propeller Examination.

In pertinent part, the fuselage was destroyed from the rear cabin floor area upward and from the aft fuselage forward. The majority of the left and right wing skin was either missing or fragmented. Compressive buckling of the remaining skin was noted in an aft direction.

The cockpit and instrument panel were completely fragmented and destroyed. Evidence of all flight control surfaces was found with the wreckage. The vertical stabilizer, rudder, and elevator control surfaces were partially attached to the empennage.

The propeller was attached to the crankshaft. The blades were predominantly deformed in an aft direction, were torsionally twisted, and exhibited an "S" bend.

Engine and Accessory Examination.

During the engine examination, no evidence of preimpact contamination was found in the oil suction screen. The spark plugs exhibited signatures consistent with their having been subjected to the corrosive effects of the salt water environment. No evidence of preimpact case rupture or puncture was noted. The valve and gear train continuity was confirmed. The engine participant indicated that no evidence was found of any preimpact mechanical malfunctions.

The vacuum pump was secured to its mounting pad. The pump was removed, and its drive gear was intact. There was no visible evidence of damage. The rotor/vane assembly was also intact and undamaged.

Maintenance Records.

An FAA airworthiness inspector reviewed the airplane's maintenance records. The inspector reported that all applicable airworthiness directives and inspections had been complied with. All of the maintenance records were current and no irregularities were noted.

WRECKAGE RELEASE

On June 20, 2001, all recovered wreckage was released to the insurance representative of the airplane's owner.

NTSB Probable Cause

the pilot's loss of airplane control while maneuvering due to spatial disorientation. Contributing factors were the dark night, the marine cloud layer that restricted the pilot's cruising altitude, and the pilot's lack of familiarity with nighttime flight over the ocean.