Pilot Debrief

CESSNA 172 near Pembroke Pines, FL — 2023-10-31

Final reportERA24LA030
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Date
2023-10-31
Location
Pembroke Pines, FL, USA
Aircraft
CESSNA 172
Registration
N140FS
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Climb

Probable cause

The pilot’s loss of airplane control and descent into terrain due to spatial disorientation during a solo night cross country flight. Contributing to the accident was the pilot’s self-reported fatigue.

Contributing factors

Contributing to the accident was the pilot’s self-reported fatigue.

NTSB narrative

The non-instrument-rated private pilot had previously scheduled a night flight with a safety pilot in another airplane, but the safety pilot was unable to go. The pilot departed on the first leg of the night flight and landed at the destination airport uneventfully. He then departed for the return flight. The pilot reported that, while flying over a non-populated area with no ground reference lights, he experienced altitude deviations that he attributed to spatial disorientation, which was exacerbated by self-reported fatigue. After entering a cloud, the airplane began a right turn while descending, completing multiple right turns with a decreasing turn radius. The airplane subsequently impacted the marshy terrain below. The pilot was able to self-extricate from the wreckage and was rescued more than 6 hours later. Following the accident, the pilot confirmed there was no mechanical failure or malfunction of the airplane’s flight controls. Given this information, during cruise flight at night, over an area with no ground reference lights and after encountering a cloud, the pilot experienced spatial disorientation that was exacerbated by the effects of fatigue. The airplane then entered a right descending turn that was unarrested by the pilot, and that continued to ground contact. Had a safety pilot been present, it is possible that the pilot’s spatial disorientation could have been recognized before it developed into the terminal descent. Personnel from flight school who operated the airplane stated that they were not aware that the pilot was flying the airplane at the time of the accident flight, so it was not immediately apparent to them that the airplane was overdue. Additionally, the pilot did not request flight following services from air traffic control, contrary to the flight school’s recommendation. In addition, the airplane’s 406 MHz emergency locator transmitter (ELT) signal was not detected by the applicable monitoring satellite after the accident, likely due to radio signal attenuation as a result of the ELT’s antenna being partially submerged in water. All of these factors likely contributed to the considerable delay in initiating search and rescue efforts following the accident.

Analysis

Primary failure mode
Spatial disorientation
First missed decision gate
Pilot could have opted for a safety pilot or avoided night flight due to fatigue.

NTSB coding

Evidence available

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

Docket documents19

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