NTSB Factual Report

HISTORY OF FLIGHT

On November 8, 2014, about 1822 eastern standard time, a Cessna 172S, N2152T, was substantially damaged when it impacted trees and the ground in the George Washington National Forest, near Hinton, Virginia. Night visual meteorological conditions prevailed and no flight plan was filed. The certificated flight instructor (CFI) was fatally injured and the student pilot received serious injuries. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight had departed from the Winchester Airport (OKV), Winchester, Virginia, after reportedly performing at least one touch and go landing maneuver and the intended destination was Ingalls Field Airport (HSP), Hot Springs, Virginia.

According to the student pilot, the flight was originally scheduled in a G-1000 equipped Cessna 172; however, the night before the accident flight that airplane was not available and the flight was scheduled in an instrument flight rules (IFR) equipped Cessna 172, which was the accident airplane. The CFI requested the student pilot to plan a flight from Frederick Municipal Airport (FDK), Frederick, Maryland, to OKV for pattern work, then to Charlottesville-Albemarle Airport (CHO), Charlottesville, Virginia, with a return to FDK.

On the day of the accident the student submitted the flight plan to the CFI who did not indicate any issue with or any change to the plan. The student pilot and CFI met at 1600 at FDK, at which time the CFI told the student there would be a destination change. Instead of going to CHO, the CFI changed the destination to HSP. The CFI did not require the student pilot to conduct any preflight planning specific to the new route.

The flight departed FDK about 1700. While enroute the CFI instructed the student to navigate to the Martinsburg VOR. After reaching the Martinsburg VOR the CFI gave the student a heading toward OKV where "stop and go" landings were performed. After conducting several landings at OKV the CFI, assigned the student a heading of 240 degrees and an altitude of 3,000 feet mean sea level (msl).

The student reported that while enroute he queried the CFI about terrain elevation in the area to which the CFI replied that he did not know the specific terrain elevation because "the aircraft did not have the G-1000." The student pilot further reported there were no aeronautical charts "out for immediate reference." About 68 miles from their intended destination the CFI conducted a demonstration of the autopilot to which he established an "altitude hold at 3,000" feet. Various heading changes were demonstrated as well as a climb at 200 feet per minute and then a 500 foot per minute climb. The student pilot reported that just prior to the accident, he observed the airspeed decrease from their cruise airspeed of 120 knots to 90 knots, at which point the CFI applied full-power. Subsequently, the airplane impacted terrain. The student further reported that it was "pitch black outside" and that the engine responded "normally" to the full power application.

No flight plan had been filed, nor communication established with Federal Aviation Administration (FAA) Air Traffic Control prior to or during the flight.

PERSONNEL INFORMATION

Flight Instructor

According to Federal Aviation Administration (FAA) and flight school records, the CFI, age 49, held an airline transport pilot certificate issued August 5, 2010, with a rating for airplane single-engine land, multiengine land, helicopter, and a commercial pilot certificate with ratings for airplane single-engine sea, airplane multiengine sea, and glider. He also held a flight instructor certificate for airplane single-engine, multiengine, and instrument, and glider. He held a first-class medical certificate, which was issued on December 19, 2013, and had a restriction of "must wear corrective lenses." According to a copy of his pilot logbook, the most recent recorded entry was dated October 28, 2014, at that time the pilot had 5,941.1 total flight hours with 1,182.2 hours as a flight instructor, and 410.7 total hours at night. His most recent flight review was conducted on October 9, 2014.

Student Pilot

According to Federal Aviation Administration (FAA) and student pilot's records, the student pilot, age 51, was issued a third-class medical certificate, which was also his student pilot certificate, on September 15, 2014. According to his pilot logbook, his first entry was dated August 20, 2014, and the most recent entry was dated October 27, 2014. At the time of the most recent logbook entry, the pilot had 23.8 total flight hours with 22.5 of those in the airplane accident make and model. It also indicated that the student pilot had not performed a solo flight and 4.5 total flight hours were conducted at night.

AIRPLANE INFORMATION

According to FAA records, the airplane, serial number 172S9446, was issued an airworthiness certificate on July 30, 2003, and was registered to Victor Tango LLC on May 12, 2006. It was powered by a Lycoming IO-360-L2A engine, Serial number L-30073-51A, 180-hp engine. It was driven by a McCauley IA 170E propeller. The airplane's most recent phase III inspection was completed on September 11, 2014. At the time of the inspection the airplane's total time in service was 4,263.3 hours and a recorded tachometer of 1,284.7 hours. The engine was overhauled and reinstalled in the airplane on September 11, 2014, and its most recent logbook entry was dated October 7, 2014, was recorded as a 24-hour oil change. At the time of the entry the engine had accrued 4,001.6 hours total time in service, 23.1 flight hours since overhaul, and had a record tachometer time of 1,307.8 hours. The tachometer was located at the accident site and indicated 1,328.2 hours.

METEOROLOGICAL INFORMATION

The 1815 recorded weather observation at Shenandoah Valley Regional Airport (SHD), Staunton/Waynesboro/Harrisonburg, Virginia, approximately 18 miles to the south, included wind from 190 degrees at 6 knots, 10 miles visibility, clear skies, temperature 8 degrees C, dew point minus 1 degrees C; barometric altimeter 29.93 inches of mercury.

Sun and Moon Data

According to the United States Naval Observatory, on the day of the accident sunset occurred at 1709 and the end of civil twilight occurred at 1736. Moon rise occurred at 1849 with 96% of the Moon's disc would have been illuminated.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted the side of a mountain approximately 3100 feet above msl, which was about 300 feet below the top of the ridgeline. The accident location was at 38°33.14 N and 079° 00.54 W. The debris path was oriented on a 212 degree (true) heading, began with impact to a row of trees approximately 100 feet northwest of the main wreckage, and started with a section of the right aileron located about 25 feet from the main wreckage, along the centerline. A log with a fresh cut of 45 degrees with some red paint transfer was located along the debris path. The left wingtip was located about 25 feet from the main wreckage, and about 20 feet to the right of centerline. A silver metallic groundscar, on a rock, the end of the debris path centerline and a broken section of one propeller blade was found 1 foot from the groundscar. The main wreckage was located about 20 feet downhill leaning against a tree in a near vertical attitude.

Nose Section

The nose section, including the cockpit, exhibited impact crushing and the engine remained attached to the associated airframe attach points; however, both bottom mounts and the right upper mount were impact damaged. The engine remained attached to the firewall, which remained attached to the airframe; however, the engine mounting structure was bent in the negative and aft direction and was in contact with the underside of the airplane. The propeller remained attached to the engine; however, one propeller blade was impact separated approximately mid span and located near the initial impact point. The propeller exhibited chordwise scratches and curling on the outboard section; however, the tip was impact separated and unable to be located at the accident site. The No. 1 and 3 top and bottom spark plugs were removed, appeared to be light gray in color, and were normal in wear exhibiting low in use time when compared with the Champion Check-A-Plug chart. Fluid was evident at the accident site and was visibly noted as dripping from the secured fuel cap on the left wing, the right wing was devoid of fuel; however, it had been breached due to impact damage. The fluid was similar in color and smell as 100LL aviation fuel.

Right Wing

The right wing exhibited impact crush damage, along the entire span. The flaps remained attached at their respective attach points and track rollers. The flap push rod remained attached to the bellcrank, which remained attached to the flap. The flap cable exhibited tensile overload similar in appearance to broomstrawing, however, cable continuity was confirmed with all exposed areas. The inboard section of the aileron remained attached and cable continuity was confirmed from the base of the control column through the associated fracture points out to the aileron. The outboard section of the aileron was located along the debris path and had been impact separated. The right wing's fuel caps remained attached, seated correctly, and locked in position; however, the right wing fuel tank was breached and devoid of fuel.

Tail Section

Rudder continuity was confirmed from just aft of the rudder pedals through the tail section to the rudder; however it could not be determined at the rudder pedals due to aft crush damage of the forward cockpit section. The tail was fractured about fuselage station 110. The tail section was leaning to the right side of the airplane and connected by the right side sheet metal skin. The rudder and elevator remained attached; however, continuity could not be confirmed to the elevator, due to binding of the cable in the tail section. The trim tab actuator was not accessed due to the precarious position of the vertical placement of the tail on the cliff face.

Left Wing

The left wing exhibited extensive crush and impact damage along the entire span. The fuel tank contained an undetermined amount of fuel, the fuel cap remained in place and seated. The wing remained attached to the fuselage at the attach point, aileron continuity was confirmed from the door post to the aileron and exhibited tensile overload (broomstrawing). All control surfaces remained attached to the wing structure. The flap push rod remained attached to the bellcrank; however, the control cable exhibited tensile overload.

Cockpit

The cockpit exhibited impact and crush damage in the positive and right direction. The flight control column was intact and the cables were in the as intended position, around the respective pulley.

Both front seats remained attached to the seat rails, the four locking pins remained in position for the two front seats. The left seat rails separated from the floor at the rivet points but remained attached to the seats. The right seatbelt and shoulder harness were cut by first responders. The fuel selector valve was found in the "BOTH" tank position and the fuel shutoff valve was in. The elevator trim could not be determined to the damage in the cockpit. The engine controls were found with the throttle and mixture control in the full forward position.

The flap handle was in the "UP" position and the indicator revealed zero degree position. The flap actuator was observed with no exposed threads which correlated to a flaps 0 degree setting.

In addition to on-scene examination of the wreckage, the recovered airframe and engine were examined at a recovery facility several weeks later. All damage was consistent with impact damage. The observed evidence was consistent with the flaps retracted and the engine operating normally, at impact. No evidence of any pre-impact mechanical malfunctions were noted during either examination. A detailed report of the engine examination following recovery, titled "Engine and Empennage Examination" is located in the docket associated with this accident.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the CFI on November 10, 2014, by the Department of Health Office of the Chief Medical Examiner as authorized by the Medical Examiner of Rockingham County. The cause of death was reported as "Blunt injuries" and the report listed the specific injuries.

Forensic toxicology was performed on specimens from the CFI by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no carbon monoxide detected in the blood, no ethanol was detected in Vitreous, and no drugs were detected in the urine.

SURVIVIAL ASPECTS

After the airplane had not returned to its home base airport, a search and rescue operation was initiated the following morning after being reported by the student pilot's father. The airplane was located later that day, in a remote area of the George Washington National Forest. According to FAA records, several reports of an ELT signal being audibly heard were reported to an FAA Air Traffic Control Radar facility. The reports were passed from the receiving controller to their direct supervisor; however, for unknown reasons the supervisor did not investigate the reports further nor report the signal to search and rescue personnel until the following day, after the airplane was reported as overdue. The ELT was found at the accident site connected to the antenna and the "ON" light was illuminated. The ELT was later tested and emitted an audible tone.

ADDITIONAL INFORMATION

Air Traffic Organization Policy Order JO 7110.65V

Chapter 10-2-10 "Emergency Locator Transmitter (ELT) Signals" states in part "When an ELT signal is heard or reported:

a. EN ROUTE. Notify the Rescue Coordination Center (RCC)

b. Terminal. Notify the ARTCC [Air Route Traffic Control Center] which will coordinate with the RCC.

c. Terminal. Attempt to obtain fixes or bearings on the signal

d. Solicit the assistance of other aircraft known to be operating in the signal area

e. TERMINAL. Forward fixes or bearings and any other pertinent information to the ARTCC…"

Charting and Obstructions

Review of the airplane's route of flight revealed that the pilots had selected a direct route of flight from OKV to HSP, which brought them into proximity of rising terrain and obstructions within a Designated Mountainous Area, at their selected cruise altitude of 3,000 feet msl.

Review of the Cincinnati Sectional Aeronautical Chart revealed that the quadrangle bounded by the ticked lines of latitude and longitude surround the accident site contained a maximum elevation figure of 5,100 feet msl. That figure was based on information concerning the highest known feature in the quadrangle, including terrain and obstructions. The area in the vicinity of the accident location also included an elevation mark of 3,700 feet msl.

Onboard Aeronautical Charts

During the examination of the wreckage a search for aeronautical charts revealed that the Washington Sectional chart was the only chart located and was found folded and was in the CFI's flight bag, located within the wreckage.

Controlled Flight Into Terrain (CFIT)

According to FAA information, CFIT accidents account for 17 percent of all general aviation fatalities. The FAA defines a CFIT accident as a situation that occurs when a properly functioning aircraft "is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision."

NTSB CFIT Safety Alert

In January 2008, the NTSB issued a Safety Alert (SA) entitled "Controlled Flight Into Terrain in Visual Conditions" with the subheading "Nighttime Visual Flight Operations are Resulting in Avoidable Accidents." The SA stated that recent investigations identified several accident that involved CFIT by pilots operating under visual flight conditions at night in remote areas, that the pilots appeared unaware that the aircraft were in danger, and that increased altitude awareness and better preflight planning likely would have

NTSB Probable Cause

The flight instructor’s decision to conduct a night training flight in mountainous terrain without conducting or allowing the student to conduct appropriate preflight planning and his lack of situational awareness of the surrounding terrain altitude, which resulted in controlled flight into terrain.