Pilot Debrief

CESSNA 152 near New Smyrna Beach, FL — 2015-01-14

Final reportERA15FA099
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Date
2015-01-14
Location
New Smyrna Beach, FL, USA
Airport
EVB
Aircraft
CESSNA 152
Registration
N757ZM
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot's failure to maintain control of the airplane while operating under visual flight rules (VFR) in night, instrument meteorological conditions, likely due to spatial disorientation. Contributing to the outcome was the radar controller's failure to follow published guidance for providing assistance to VFR pilots having difficulty flying in instrument conditions.

NTSB narrative

The commercial pilot was in the process of purchasing a block of flight time with the intent of building time toward an additional rating. According to the operator, the pilot did not complete the mandatory checkout. However, she possessed the keys to the airplane since she had flown the previous day with an instructor, but he did not approve her for solo flight because he believed she required additional practice landing the airplane with an instructor onboard. On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of the operator. The accident flight was initiated at night, presumably with the intent of operating in the local airport traffic pattern. About 7 minutes into the flight, the pilot likely encountered instrument meteorological conditions (IMC) and requested assistance from air traffic control. An air traffic controller attempted to provide the pilot with radar vectors to a nearby airport; however, the pilot was unable to visually acquire that airport. The controller then observed the airplane on radar at 600 ft and descending and directed the pilot to climb and turn. A short time later, radar and radio contact were lost; the airplane had crashed. The level of damage and fragmentation of the wreckage was consistent with ground impact at a high velocity. The flight was conducted on a dark, moonless night, under an overcast ceiling, and the final portion of the flight was over the ocean. These factors would have reduced the pilot's ability to perceive the natural horizon and increased her risk of spatial disorientation. Although the pilot held an instrument rating and had recently completed an instrument proficiency check, on the night of the accident, she did not demonstrate the skills necessary to control an airplane in IMC. She also did not display the ability to adequately communicate her situation to the controller, nor did she seem to understand or comply with the assistance offered to her. Review of autopsy results and postaccident toxicological testing showed no evidence of any physiologically induced incapacitation or other impairment. During the sequence of events leading up to the accident, the pilot communicated with two air traffic controllers. The pilot described that she was operating in conditions that limited her ability to navigate and potentially affected her ability to control the airplane under visual flight rules (VFR). Although the actions of the controllers did not directly contribute to the pilot's loss of control while attempting to fly under VFR in IMC, the controllers did not act in accordance with Federal Aviation Administration (FAA) guidance that dictates how to assist pilots experiencing this type of emergency. Specifically, the controllers did not ascertain if the pilot was qualified and capable of IFR flight nor did they attempt to locate and direct the pilot toward the nearest areas reporting visual meteorological conditions. Further, a controller assisting the accident controller had the opportunity to solicit a pilot report from another pilot in a nearby airplane to ascertain if that airplane was operating above the reported IMC but did not do so. During postaccident interviews, the air traffic controllers indicated that they had not received FAA-required evidence-based simulation training on emergencies and described the computer-based emergency training that they received as poor quality.

Analysis

Primary failure mode
VFR into IMC
First missed decision gate
Pilot should not have initiated flight in IMC conditions.

NTSB coding

Evidence available

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

Docket documents16

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