Pilot Debrief

Cessna 210 near Marathon, FL — 2019-09-08

Final reportERA19FA266
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Date
2019-09-08
Location
Marathon, FL, USA
Airport
MTH
Aircraft
Cessna 210
Registration
N9436X
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Initial climb

Probable cause

The pilot's failure to maintain a positive climb rate after takeoff due to spatial disorientation, which resulted in the airplane’s descent into water.

NTSB narrative

The pilot had planned a cross country instrument flight rules (IFR) flight but had not contacted air traffic control to receive an IFR clearance before departing. He was departing from a coastal airport during dark morning hours, prior to sunrise, and after takeoff made a right climbing turn. The airplane reached an altitude about 400 feet above the ground, about 90° through the turn, before descending in the turn and impacting the water. The airplane’s groundspeed continued to increase, from about 70 knots at liftoff, to 100 knots at the height of the right climbing turn, to 146 knots at the end of the data. Review of airport surveillance video depicted the airplane’s takeoff, initial climb, and turn toward an area of dark open water underneath a scattered cloud layer. Based on the dark night conditions and the lack of visual reference at the time of the accident, it is likely that the pilot became spatially disoriented, which led to the subsequent descent into water. Examination of the wreckage revealed a right-wing-low attitude at the time of the impact, which was consistent with the pilot maintaining the right turn seen in the surveillance video recordings. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or abnormalities that would have precluded normal operation. The pilot held an instrument rating, but no logbook information was available from which to determine his level of instrument currency or proficiency. According to medical certification files, the pilot had several eye disorders including chronic macular edema in his right eye and bilateral glaucoma; both conditions restrict visual fields. A year prior to the accident, the pilot had successfully completed a medical flight test and had been granted a statement of demonstration ability (SODA) by the Federal Aviation Administration for his right visual field defect. The medical flight test included, among other abilities, demonstrating the ability to judge distances and to recognize landmarks and the ability to read instrument panels quickly and correctly. The medical flight test is administered during daytime hours; in this accident, the pilot departed the airport under night visual conditions and then flew over the ocean which would have few visual cues. It is therefore unknown how well this pilot could respond under dark conditions. The challenge with a constricted visual field is not generally the speed to execute the visual scan, but the time to process the visual information. Given the lack of information from no nighttime vision testing as part of his SODA and insufficient information on the pilot’s instrument flight capabilities, the investigation was unable to determine what role, if any, the pilot’s vision restrictions contributed to this accident.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot did not contact ATC for IFR clearance before departure.

NTSB coding

Evidence available

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

Docket documents11

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