Pilot Debrief

CESSNA 172 near Charlotte Amalie, CB — 2023-08-04

Final reportERA23LA328
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Date
2023-08-04
Location
Charlotte Amalie, CB, USA
Airport
STT
Aircraft
CESSNA 172
Registration
N13384
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

Probable cause

The pilots’ loss of airplane control due to spatial disorientation. Contributing to the accident was both pilots’ lack of experience in operating in actual instrument meteorological conditions.

Contributing factors

Contributing to the accident was both pilots’ lack of experience in operating in actual instrument meteorological conditions.

NTSB narrative

The purpose of the night, cross-country flight over open water was for the one of the pilots, who was a certificated private pilot, to accumulate hours of flight experience for an instrument rating. The other pilot held a commercial pilot certificate with an instrument rating, but had only accrued 4.9 hours of actual instrument flight experience. The airplane flew uneventfully on an instrument flight rules (IFR) flight plan for 1 hour, 34 minutes, from the departure airport to another island airport where the flight crew performed a practice instrument approach and missed approach. During the return flight leg back to the departure airport, about 7 minutes after the missed approach, the airplane diverged from its on-course heading while climbing to its assigned altitude of 6,000 ft mean sea level (msl). The airplane began turning to the right as it entered an area of light to heavy precipitation. The airplane turned through 540° and climbed to an altitude of 6,450 ft msl before it entered a right-turning spiral descent. Radar contact with the airplane was lost as it descended through 4,700 ft, and the pilots made no transmissions to air traffic control indicating any distress or abnormalities. The airplane occupants and wreckage were not located or recovered, and the airplane was presumed to have impacted the water shortly after radar contact was lost. Given that the airplane was operating over open water at night, and in an area of precipitation, the pilots’ ability to determine the airplane’s attitude using outside visual references would have been greatly diminished. While the pilots were operating on an IFR flight plan, one of the pilots was not instrument rated and the other had logged less than 5 hours of flight experience in actual instrument meteorological conditions. It could not be determined which of the pilots was flying the airplane at the time of the accident, though their combined lack of total instrument flight experience would have increased the potential for a loss of control in flight given the restricted visibility environment they were operating in. The airplane’s final moments of maneuvering flight, particularly the turning spiral descent that occurred during the final 25 seconds of its flight track, was consistent with a loss of control due to spatial disorientation. Based on the available information, it is likely that the pilots lost control of the airplane while flying in reduced visibility conditions as a result of their spatial disorientation.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Flight crew could have chosen to avoid the area of precipitation during climb.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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