Pilot Debrief

CESSNA 172S near Key West, FL — 2012-02-24

Final reportERA12FA193
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Date
2012-02-24
Location
Key West, FL, USA
Airport
EYW
Aircraft
CESSNA 172S
Registration
N53589
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The non-night-qualified pilot's improper decision to depart in dark night visual meteorological conditions, which resulted in his subsequent spatial disorientation, loss of control, and impact with water.

NTSB narrative

Earlier on the day of the accident, the private pilot and his pilot-rated passenger had departed an airport in the Bahamas to return the airplane to an airport near Miami, Florida, where they had rented the airplane; it was due back at the fixed base operator's facility the following day. While enroute, they diverted to Key West, Florida, as a visit to the Miami area by the President of the United States was occurring and a temporary flight restriction (TFR) was in effect. Later that evening, when the TFR was cancelled, they departed on a night visual flight rules (VFR) flight to their original destination. Witness statements and a review of radar data revealed that after departure, the airplane's flight path became erratic before it entered a descent and impacted the water. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. Dark night visual conditions existed at the time of the accident. Because the airport was surrounded by water, the moon had already set, and no ground lighting existed in the area of the accident, it is unlikely that a discernable horizon was present. Examination of the airplane's maneuvers immediately after it departed were consistent with the pilot experiencing spatial disorientation, which Federal Aviation Administration guidance indicates can occur when there is no natural horizon or surface reference, such as a night flight in sparsely populated areas similar to that of the accident area. Further, spatial disorientation is more likely to occur if a pilot lacks proficiency in instrument flying. The pilot's private pilot certificate was issued on the basis of his Polish private pilot license, which did not authorize VFR night flights (his FAA certificate required him to comply with all restrictions and limitations of his Polish private pilot license). A review of his rental checkout form indicated that he had not received a checkout for night operations. The pilot-rated passenger's certificate did authorize him for night VFR flights, but the lack of a discernable horizon would have required him to reference the airplane's flight instruments to maintain attitude. Since he was not instrument-rated, was seated in the right front seat of the airplane, and did not have flight instruments mounted in the panel in front of him, it is unlikely that he could have positively influenced the outcome of the flight.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot should not have attempted night flight without proper authorization.

NTSB coding

Evidence available

  • CVR
  • ADS-B / radar
  • Photos
  • 29 docket documents
View NTSB final reportView NTSB docket

Docket documents29

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