NTSB Factual Report

HISTORY OF FLIGHT

On March 15, 2002, about 1935 eastern standard time, a Cessna 172P, N96811, was destroyed when it impacted the Atlantic Ocean while on approach to Ocean City Municipal Airport (OXB), Ocean City, Maryland. Two passengers were fatally injured, and the certificated private pilot/owner and a third passenger were presumed lost at sea. Night visual meteorological conditions prevailed for the flight that originated at Bay Bridge Airport (W29), Stevensville, Maryland. No flight plan was filed for the personal flight conducted under 14 CFR Part 91.

According to a witness, a certificated airline transport pilot, he was approaching the Ocean City Airport in a twin-engine turbo-prop airplane at the same time as the accident airplane. He became aware of the accident airplane when the accident pilot transmitted on the Ocean City Airport UNICOM frequency.

The accident pilot's first radio call was about 10 miles from Ocean City to the north, when he called for a taxicab. The witness answered the radio call, and told the accident pilot that the airport closed at sunset, and that he would have to wait to get on the ground to call for a cab. The accident pilot acknowledged the radio call.

When the witness was within 4 miles of the Ocean City beacon, he heard the pilot announce a left downwind for landing on runway 20, then transmit, "Is that right?" The witness watched the accident airplane as it passed abeam the departure end of runway 14, and suddenly transitioned from "horizontal flight to vertical flight." The airplane went out over a "black hole," then disappeared.

The witness wasn't close enough to see if the airplane was spinning during its descent. Immediately before the descent, the witness saw both wing tip strobe lights flash at the same time, one over top of the other, as if the airplane were in a 90-degree bank.

The witness was asked to describe the weather and the light levels around the Ocean City Airport at the time of the accident. He stated that it was a clear, but dark night and that there was no moon; it was a "black hole."

The witness further stated: "They probably were spatially disoriented, because when you get on downwind and head out over the ocean like that, you may as well get on the instruments, and stay on the instruments, until you turn final."

A second witness said she was in her home on the shore, when she saw the airplane's strobe lights through the window. The position of the airplane seemed unusual, as she was familiar with the usual positions of airplanes and helicopters when they flew around the airport traffic pattern. At first, she thought it was a helicopter because of its low altitude. The airplane traveled south to north along the coast, then turned east, out to sea. The airplane completed a "half turn," then descended straight down into the water.

The airplane was not yet abeam the airport when it turned out to sea, and the witness thought the pilot was lost, disoriented, or just unfamiliar with the area. According to the witness:

"It just seemed unusual to me because, if it was a plane, it was low. And if it was a helicopter, that was unusual because of the time of night. It was clear, but it was dark. You couldn't see a horizon. He made that half turn out over the ocean, and then he went straight down."

PILOT INFORMATION

The pilot held a private pilot certificate with an airplane single-engine land rating. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued on November 19, 2000. He reported 300 hours of flight experience on that date.

During an interview, a friend of the pilot who was also a certified flight instructor, stated that he had been acquainted with the pilot for a number of years. The flight instructor had provided instrument flight instruction to the pilot since October 2001. Instruction included academics, and instrument flight maneuvers, navigation, holding, precision and non-precision approaches, unusual attitude recoveries, and emergency procedures. All training was conducted under a training hood, in VFR conditions.

Examination of the flight instructor's notes revealed that he and the accident pilot flew together on eight training flights for a total of 17.4 hours. Three training flights were conducted between October 9 and October 18, 2001. Training resumed on February 25, 2002, after the pilot completed a tour at sea as a merchant marine. The latest training flight occurred on March 8, 2002.

When questioned about the pilot's technique for traffic-pattern flight, the flight instructor said that he was a "pretty sharp guy," but one time, at Bay Bridge Airport, on the downwind leg, at traffic pattern altitude, and he flew out to mid-span of the Chesapeake Bay Bridge before turning base. It made the flight instructor nervous, so they went to another airport and worked on traffic patterns. Once at the other airport, the flight instructor gave the pilot detailed instruction on the geometry of traffic patterns, and techniques that would provide consistent results.

AIRCRAFT INFORMATION

The airplane was a 1984 Cessna 172P. Examination of the airplane's maintenance records revealed that the most recent annual inspection was completed on September 10, 2001, at 10,868.4 aircraft hours. According to the pilot's flight instructor, the airplane was equipped with wingtip-mounted position strobes.

METEOROLOGICAL INFORMATION

The weather reported at Ocean City Municipal Airport at 1753, included clear skies with winds from 210 degrees at 15, gusting to 19 knots. Official sunset was at 1808, and the end of civil twilight was at 1834. Only 3 percent of the moon's visible disk was illuminated, and the moon set at 1941.

WRECKAGE INFORMATION

Airplane tires, cowlings, fairings, upholstery, and paperwork associated with the accident airplane were recovered along the shore in the days following the accident.

The main wreckage was located in mid-April 2002, at 38 degrees, 17.62 minutes north latitude, 75 degrees, 6.04 minutes west longitude.

The airplane wreckage was subsequently examined at the United States Coast Guard Station, Ocean City, Maryland, on April 19, 2002. All major components of the airplane were accounted for.

The right wing and spar, main spar, and the left wing spar were all connected. The left wing and the left wing spar outboard the wing strut mount were separated from the wing spar assembly. The leading edge of the left wing was crushed aft in compression, and flattened against the spar. The left wing fuel cell was not located. Approximately 2 feet of the outboard left wing was torn away, and not located. Control cable continuity was established from the left aileron to the point of wing separation, where the cable ends were broomstrawed.

The right wing was largely intact, and exhibited only slight leading-edge deformation. The bottom wing skin in the area of the fuel cell was not installed, and the fuel cell was absent from the wing. The bottom wing skin remained from about the wing strut attach point out to the wing tip. The skin exhibited hydraulic deformation upwards, towards the top of the wing. Control cable continuity was established from the aileron out to the point of wing separation, where the cable ends were broomstrawed.

The engine, firewall, and instrument panel were connected when recovered. Salvage operators separated the engine from the firewall and instrument panel during recovery. The instrument panel was completely destroyed by impact. The cockpit and cabin area were completely destroyed, with only the cabin roof, and approximately 2 square feet of cabin floor recovered.

The landing gear box structure, with both left and right landing gear attached, was separated from the cabin and the empennage. The empennage skin was separated from the landing gear box structure and the tail section. The left and right horizontal stabilizers were attached, with the vertical fin separated, and the rudder horn torn from its mount. The vertical fin was recovered, and was largely intact.

Control cables connected all the horizontal stabilizers, elevators, rudder horn, landing gear box structure, cabin floor segment, and the flight control quadrants. Control cable continuity was established from the rudder pedals to the rudder horn, and from the elevator bell crank to the elevators. Both elevators pivoted in their mounts and the rudder pivoted in its mounts.

Examination of the engine revealed that the left magneto, starter ring bulkhead, air/oil sump, and the #2 push rod assembly were no longer installed. The starter ring was separated from the starter ring bulkhead. The starter housing exhibited deep rotational scoring on its face.

The engine was rotated by hand. Continuity was established through the powertrain, and valve train to the accessory section. Compression was confirmed using the thumb method. Rocker arm movement was observed at cylinders 1, 3, and 4. Lifter action was observed at cylinder #2.

The propeller was still attached to the engine. The propeller spinner was crushed aft, over the forward spinner bulkhead support, and revealed torsional twisting. The aft spinner bulkhead support was crushed aft, over the propeller bulkhead, and revealed torsional twisting and tearing.

The propeller blades were marked "A" and "B" for identification purposes. Both blades displayed twisting and S-bending. The B blade was blocked against the #1 cylinder and displayed deep, chordwise scoring. The exhaust stacks on both sides of the engine displayed severe malleable bending.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Baltimore, Maryland, performed post-mortem examinations and testing. Toxicological testing was performed at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.

ADDITIONAL INFORMATION

The maximum allowable gross weight of the airplane was 2,400 pounds.

Interpolation of weight and balance charts based on the airplane's delivery documents, the estimated fuel on board, and the weights of the occupants, revealed the aircraft weight was 2,494 pounds, and loaded outside the center of gravity moment envelope.

According to the FAA Airplane Flying Handbook, FAA-H-8083-3, chapter 10:

"Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning....Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane....Crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, not only from the standpoint of landing (ditching) in the water, but also because with little or no lighting the horizon blends with the water, in which case, depth perception and orientation become difficult. During poor visibility conditions over water, the horizon will become obscure, and may result in a loss of orientation. Even on clear nights, the stars may be reflected on the water surface, which could appear as a continuous array of lights, thus making the horizon difficult to identify."

According to AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further stated that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

According to the book, "Night Flying," by Richard Haines and Courtney Flatau:

"Vestibular disorientation refers to the general feeling that one's flight path isn't correct in some way. By calling this effect vestibular, it emphasizes the role played by the middle ear's balance organ. Flying an uncoordinated turn produces this effect, as does excessive head turning during a turn in flight. Vestibular disorientation is often subtle in its onset, yet it is the most disabling and dangerous of all disorientation."

On April 19, 2002, the wreckage was released to a representative of the owner's insurance company.

NTSB Probable Cause

The pilot's spatial disorientation, which resulted in his subsequent loss of control of the airplane. A factor was the dark night, over water visual conditions.