Pilot Debrief

CESSNA 172R near Key West, FL — 2010-08-14

Final reportERA10LA421
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Date
2010-08-14
Location
Key West, FL, USA
Aircraft
CESSNA 172R
Registration
N2435X
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Maneuvering

Probable cause

The non-instrument-rated pilot's spatial disorientation during night, over-water, low-ambient-light conditions, which resulted in the airplane impacting the ocean.

NTSB narrative

The non-instrument rated pilot performed a touch-and-go practice takeoff and landing at an airport located on an island at night. Thereafter, the flight continued over water at a low altitude. A pilot of a commercial flight inbound to the island observed the accident airplane on his traffic collision and avoidance system (TCAS) and additionally noticed the reflection of its landing light on the water. When the reflection disappeared, the TCAS contact also disappeared, likely due to the airplane impacting the water. After rescue, the pilot could not recall much of the event, but did remark that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident, the moon's phase was waxing crescent with 18 percent of the disk illuminated. Federal Aviation Administration Advisory 60-4A states that, "The attitude of an aircraft is generally determined by reference to the natural horizon or other references on the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. ...Spatial disorientation to a pilot means simply the inability to tell which way is up....Lack of natural horizon or surface reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions."

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have avoided the turn without visual references over water.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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