NTSB Factual Report

HISTORY OF FLIGHT

On December 7, 2009, at 2223 eastern standard time (EST), a Cessna 172, N5269X, was destroyed by impacting the water on Lake Russell near Kissimmee, Florida. The certificated, non-instrument rated, private pilot and three passengers were fatally injured. Instrument meteorological conditions prevailed and no flight plan was filed for the personal flight, which departed from Florida Gateway Airport (ISM), Kissimmee, Florida, with an intended destination of Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, Florida. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

Security camera recordings revealed that the pilot and three passengers arrived at the fixed base operator (FBO) facility at 2126. Another camera showed the pilot standing at a weather computer for approximately 8 minutes, but the computer screen contents were not discernible. The video image data showed that at approximately 2140, the pilot and three passengers walked to the airplane, and from 2140 until approximately 2153 someone appeared to conduct a preflight inspection of the airplane with a flashlight, however due to the lack of lighting the person’s identity was unable to be confirmed. About 2153, the airplane engine was started, and for approximately the next 10 minutes, the airplane remained stationary, with the engine running. At 2208, the airplane began to taxi out of the parking spot with its taxi light illuminated.

Several witnesses employed by the FBO provided written statements to the NTSB. Their accounts were similar to what was observed on the security tape and none of the reports mentioned any problems with the pilot, passengers or the airplane.

Recordings of voice and radar tracking data was obtained from the Federal Aviation Administration (FAA) Air Traffic Control (ATC) facility located in Orlando, Florida. About 2206, the pilot requested a "special VFR [visual flight rules]" clearance from ISM to FXE. About 2208, ATC issued the clearance and instructed the pilot to "maintain VFR at or below one thousand five hundred" and provided the pilot with a release time of 2208 and a clearance void time of 2215. The aircraft departed ISM about 2213. About 2222, ATC issued a clearance of "on course." This clearance was acknowledged by the pilot, and was the last transmission received from the flight. Radar tracking data indicated that the airplane made a slight left turn for an on-course heading to FXE, and subsequently made a right turn of approximately 100 degrees away from the direct track towards FXE. At 2223 radar data showed the airplane at an altitude of 2,400 feet above mean sea level (msl). Approximately 12 seconds after the final 2,400 foot radar return, another radar return showed an airplane altitude of 0 feet.

PERSONNEL INFORMATION

According to FAA records, the pilot held a private pilot certificate with an airplane single-engine land rating. The date of issuance was October 13, 2009. His most recent FAA first-class medical certificate was issued on July 3, 2009. The pilot's logbook was recovered from the lake, and the last entry, dated December 6, 2009, indicated that he had 150.7 total hours of flight experience and 4.9 total hours of simulated instrument flight experience. No record of actual logged instrument flight time was found. The logbook also indicated that he had previously flown into and out of ISM on several occasions.

In a review of the pilot's training records and interviewing the certificated flight instructor (CFI) that did most of his training the pilot had the FAA minimum instrument training requirements for a private pilot certificate. In an interview with the NTSB investigator, the CFI stated that he would fly the students he instructed, including the accident pilot, "out towards the everglades at night with the hood on and then have them remove the hood and demonstrate how a dark, unlit terrain with little horizon reference could cause spatial disorientation." The vice president and operations manager of the flight school told the NTSB investigator that the accident pilot was taught the "basics of the autopilot" which included how to utilize the autopilot for heading and altitude hold. He further stated that they taught all students enrolled in the private pilot training stage in order for them to utilize all the equipment available especially if they were to be "heads down adjusting the radio." He also reported to the NTSB that "special VFR is as required for certification but it is not approved" at the school.

AIRCRAFT INFORMATION

According to maintenance records obtained from the flight school that utilized the accident airplane for training and rental, as of December 2, 2009, the airplane had 4,815 total hours of service. The most recent annual/100 hour inspection was completed on October 29, 2009. At the time of that inspection, the airplane had a total time in service of 4,760.0 hours, and the engine had 400.1 total hours since its most recent major overhaul.

According to FAA records, the four-seat, high-wing, fixed-gear airplane, was manufactured in 2002 and was issued an airworthiness certificate on October 15, 2002. It was powered by a four cylinder, normally aspirated Lycoming IO-360-L2A engine, and equipped with a two blade McCauley constant-speed propeller.

METEROLOGICAL

The 2153 recorded weather observation at ISM, located approximately 10 miles north of the accident site, included winds from 060 degrees at 8 knots, a broken cloud layer at 800 feet above ground level (agl), an overcast cloud layer at 2,700 feet agl, temperature 21 degrees C, dew point 19 degrees C, and an altimeter setting of 30.13 inches of mercury.

According to the Astronomical Applications Department at the United States Naval Observatory located in Washington D.C. official sunset for Kissimmee, Florida was at 1730 EST. The moon rise was not until 2329 and was to have a 65% visible disk on a waning moon.

WRECKAGE AND IMPACT

The wreckage was located in water of approximately 6 feet depth, about 500 feet from the shore on a circular shaped lake that had a diameter of approximately 6,500 feet, and was confined to an area approximately 60 feet by 60 feet. The majority of the airplane was recovered from the water. Recovery divers estimated that the engine was embedded approximately four feet into the floor of the lake, and that the rest of the airplane was positioned above it, consistent with the airplane being in a nose down attitude at impact. The right wing exhibited leading edge crush damage in the aft direction, with increased damage toward the wingtip. The left wing exhibited uniform leading edge crush damage, with the exception of the outboard 13 inches, which sustained more damage. The right wing strut was fracture-separated from the fuselage, and the wing strut was bent approximately 45 degrees in the aft direction. The leading edge of the left wing flap had damage consistent with impact with the main landing gear.

The right main landing gear was bent in the up and aft direction. The aft area of the fuselage was fragmented and exhibited damage similar to impact damage. The left main landing gear tire was separated from the rim. The rudder, left horizontal stabilizer, elevator, and right horizontal stabilizer counterweight were recovered. The right horizontal stabilizer was not recovered. The left horizontal stabilizer leading edge damage was consistent with being struck by the left main landing gear. The upper 11 inches of the rudder exhibited impact damage in the down and aft directions. One flight control cable was cut during the recovery process; however all other flight control cables exhibited fracture separations consistent with tensile overload. Cable continuity was established to all flight control surfaces.

The passenger compartment exhibited compression and fracture damage. All four seats were recovered and the right passenger seat and seat track were fracture-separated from the floor. The shoulder harnesses were still attached to the buckle, the inertial reels were attached to the cockpit ceiling support structure and the belt webbing was stretched similar to an overstress indication. The two sets of rudder pedal brackets were fracture–separated from the cross tube that connected the two sets of rudder pedals and also from the attach point within the cockpit. Several small bags, including the pilot's flight case, were recovered. An accurate weight for these items was not determined, but they were estimated to weigh a total of approximately 50 pounds. A wrist watch was also recovered; it was stopped at a time of 2224.

The engine was examined and the right frontal area of the engine including cylinder No. 1 exhibited heavy impact damage. Cylinder No. 1 cooling fins exhibited extensive fracture damage. Scoring on the forward left side of the engine was similar in size and the same distance from the propeller shaft as the radius of the propeller gear. The propeller shaft revealed damage consistence with tensile overload. The propeller was impact separated from the engine and was not recovered.

Both vacuum pumps were examined. The upper vacuum pump remained attached to the engine and was removed for examination. The pump did not turn however the drive coupling was intact. The casing was opened and the rotor was fractured consistent with rotation at the time of impact. The lower vacuum pump was impact separated from the engine, had no rotation, and the coupling was found intact. The case was opened and the rotor was fractured consistent with rotation at the time of impact.

The magnetos were examined and produced spark on all towers. The oil system suction screen and oil filter element were examined and were free of contamination.

The fuel servo was fracture separated; the suction screen was clean and no fuel was present in the fuel system.

The spark plugs were removed and the bottom set of spark plugs were mud caked, the upper spark plugs appeared normal to worn when compared to the Champion spark plug guide. A lighted borescope examination was conducted on all cylinders and revealed mud throughout all cylinders. All of the cylinders were washed and re-examined utilizing a lighted borescope. The examination revealed the inside of all cylinders appeared to be normal. Crankshaft, camshaft and gear train continuity was confirmed; however a full rotation was unable to be obtained due to a binding. After all four cylinders were removed, full crankshaft rotation was obtained. The source of the binding was unable to be determined.

Several flight instruments were recovered; the attitude indicator was disassembled and exhibited rotational scoring on the inside of the gyro case. The airspeed indicator had numerous impact marks on the face between 140 and 155 knots; however the rest of the case had been fractured. The electronic turn coordinator gyro exhibited rotational scoring.

MEDICAL AND PATHOLOGICAL INFORMATION

Post mortem examination of the pilot was performed by the Office of the Medical Examiner, District Nine, Kissimmee, Florida. The cause of death was attributed to multiple trauma.

The FAA's Civil Aerospace Medical Institute performed toxicology testing on specimens obtained from the pilot. The tests were negative for carbon monoxide, cyanide, ethanol, and drugs..

ADDITIONAL INFORMATION

Fuel records obtained from the FBO at ISM indicated that a total of 7 gallons of fuel was provided to the airplane before the accident flight, with 3 1/2 gallons dispensed into each of the wing tanks.

Airplane Rental Agreement

According to the rental agreement signed by the accident pilot on August 4, 2009, under "Flight Operations Safety Rules," there were seven rules that the renter pilot was to comply with. One of the rules was "Weather – Renter shall plan to operate the aircraft only when the present and forecasted weather indicates VFR conditions local and en route (Ceiling of at least 3,000 feet and visibility 5 miles or greater) unless renter is instrument rated, current for IFR and specifically approved by the Operator for IFR flight."

Airplane Flying Handbook

According to the FAA Airplane Flying Handbook, FAA-H-8083-3A (Chapter 16, Emergency Procedures), "A VFR pilot is in IMC conditions anytime he or she is unable to maintain airplane attitude control by reference to the natural horizon, regardless of the circumstances or the prevailing weather conditions."

The handbook additionally stated, "The pilot must believe what the flight instruments show about the airplane's attitude regardless of what the natural senses tell. The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately send the attitude changes which occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

FAA Advisory Circular 60-4A

"The attitude of an aircraft is generally determined by reference to the natural horizon or other visual reference 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 sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of orientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.'…Surface references and the natural horizon may at times become obscured, although visibility may be above flight rule minimums. Lack of natural horizon or such reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions…. The disoriented pilot may place the aircraft in a dangerous attitude… therefore, the use of flight instruments is essential to maintain proper attitude when encountering any of the elements which may result in spatial disorientation."

FAA Advisory Circular 61-134

"According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continue VFR flight into IMC… The importance of complete weather information, understanding, the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities and operating environment with an accurate forecast cannot be emphasized enough… VFR pilots in reduced visual conditions may develop spatial disorientation and lose control, possibly going into a graveyard spiral…"

Special Visual Flight Rules (VFR)

The FAA describes Special VFR as "meteorological conditions that are less than those required for basic VFR flight in controlled airspace and in which some aircraft are permitted flight under visual flight rules." It further states in part that "Special VFR operations may only be conducted…except for helicopters, between sunrise and sunset unless the person being granted the ATC clearance meets the applicable requirements for instrument flight…"

Private Pilot Certification

According to the FAA, the minimum requirement for private pilot certification was in part "…3 hours of flight training in a single-engine airplane on the control and maneuvering of an airplane solely by reference to instruments, including straight and level flight, constant airspeed climbs and descents, turns to a heading, recovery from unusual attitudes, radio communications, and the use of navigation systems/facilities and radar services appropriate to instrument flight…".

NTSB Probable Cause

The pilot's decision to depart under special VFR flight at night when instrument meteorological conditions prevailed at the departure airport and along the route of flight and his continued VFR flight into instrument meteorological conditions, which resulted in his spatial disorientation and subsequent loss of aircraft control.