Tuesday, March 13, 2018

Cessna 172F Skyhawk, N7870U: Fatal accident occurred July 04, 2016 in Brookings, Oregon

John Luke Belnap

Ryan Merker and Maxel Jed Belnap


The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entity: 
Federal Aviation Administration / Flight Standards District Office; Hillsboro, Oregon

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/aN7870U 

Location: Brookings, OR
Accident Number: WPR16LA138
Date & Time: 07/04/2016, 2300 PDT
Registration: N7870U
Aircraft: CESSNA 172
Aircraft Damage: Destroyed
Defining Event: Collision during takeoff/land
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The non-instrument-rated pilot departed for the third leg of a cross-country flight in the airplane during dark (moonless) night conditions. The departure path was toward the ocean and over an area with few ground-based light sources to provide visual cues. A witness heard an airplane flying nearby and assumed that it was taking off from the airport. As the airplane continued, he heard a reduction in engine power, like a pilot throttling back while landing. According to the witness, the engine did not sputter. Review of the recorded radar data showed that the airplane turned left shortly after takeoff and climbed to about 700 ft above ground level as it passed near the witness's location. The airplane did not arrive at its destination, and a search was initiated. The wreckage of the airplane was found in ocean waters about 2 miles west of the departure airport. Although visual meteorological conditions prevailed, no natural horizon and few external visual references were available during the departure. This required the pilot to monitor the flight instruments to maintain awareness of the airplane's attitude and altitude. Given the lack of external visual cues and the the pilot's lack of recent night flight experience and his lack of an instrument rating, it is likely that the pilot became spatially disorientated during the departing left turn.

The main wreckage was not recovered. Therefore, it could not be determined whether any preimpact mechanical malfunctions or anomalies were present.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's spatial disorientation and loss of situational awareness during the departure turn in dark night conditions, which resulted in an in-flight collision with water.

Findings

Personnel issues
Spatial disorientation - Pilot (Cause)
Situational awareness - Pilot (Cause)

Environmental issues
Dark - Effect on personnel (Cause)

Factual Information

History of Flight

Initial climb
Collision during takeoff/land (Defining event)

On July 4, 2016, about 2300 Pacific daylight time, a Cessna 172F, N7870U, impacted the Pacific Ocean shortly after takeoff from Brookings Airport (BOK), Brookings, Oregon. The private pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was registered to Cessna 7870U, LLC, and was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the third leg of the cross-country flight, and no flight plan was filed. The destination was Grants Pass Airport, Grants Pass, Oregon.

According to the co-owner of the airplane, on the morning of the accident, the pilot departed from Hollister Municipal Airport (CVH), Hollister, California. According to airport documentation and a fuel receipt, he refueled at Rohnerville Airport (FOT), Fortuna, California, that afternoon before continuing to BOK, where he landed about 1430. The pilot did not report to the co-owner any problems with the airplane during that flight.

A witness located about 1.5 miles west of BOK and near the ocean shoreline, reported that around the time of the accident, he heard an airplane flying nearby and assumed that it was taking off from BOK. As the airplane continued, he heard a reduction in engine power, like a pilot throttling back while landing, but he could not remember whether it stopped before it went out of hearing range. He further stated that the engine did not sputter.

Review of the recorded radar data depicted that the airplane turned left to a west heading shortly after takeoff and then climbed to about 700 ft above the ground as it neared the ocean shoreline. The area was sparsely populated. The last recorded radar target was near the witness's location, west of BOK, and about 1.5 miles southeast of where personal effects from the occupants of the airplane were found washed ashore.

Information provided by the Federal Aviation Administration (FAA) revealed that the pilot's family contacted local authorities after they became concerned when the pilot did not arrive at his intended destination. The FAA subsequently issued an alert notification that was then cancelled on July 7 after personal effects from the occupants of the airplane were found washed ashore on the beach about 3 miles northwest of BOK. 

Pilot Information

Certificate: Private
Age: 46, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 01/13/2014
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:   207 hours (Total, all aircraft), 207 hours (Total, this make and model) 

The pilot held a private pilot certificate with an airplane single-engine land rating. He did not hold an instrument rating. He was issued an FAA third-class airman medical certificate on January 13, 2014, with the limitation that he must wear corrective lenses. According to the pilot's logbook, he had accumulated 207 total flight hours, all of which were in the accident airplane. The last entry recorded in the pilot's logbook was dated March 7, 2016, and was for a cross-country trip with a total duration of 13.87 flight hours of which 3 hours were at night. No other night flight time was recorded in the 6 months before the accident. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N7870U
Model/Series: 172 F
Aircraft Category: Airplane
Year of Manufacture: 1964
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17251870
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 11/11/2015, Annual
Certified Max Gross Wt.: 2299 lbs
Time Since Last Inspection:
Engines:  1 Reciprocating
Airframe Total Time: 4372 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: Installed, not activated
Engine Model/Series: O-300 SER
Registered Owner: On file
Rated Power: 145 hp
Operator: On file
Operating Certificate(s) Held: None
Operator Does Business As:
Operator Designator Code: 

The four-seat, high-wing airplane, serial number (S/N) 17251870, was manufactured in France in 1964 as a flight training airplane for the United States Air Force. It was powered by a Continental Motors O-300 engine. Review of the maintenance records showed that the engine was overhauled on November 15, 2013, at a total operating time of 4,372 hours. The last annual inspection was completed on November 11, 2015, at which time the engine had accumulated a total of 279 hours since the overhaul. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: KBOK, 459 ft msl
Observation Time: 0556 UTC
Distance from Accident Site: 3 Nautical Miles
Direction from Accident Site: 114°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 13°C / 9°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 30.06 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: BROOKINGS, OR (BOK)
Type of Flight Plan Filed: None
Destination: GRANTS PASS, OR (3S8)
Type of Clearance: None
Departure Time: 1100 PDT
Type of Airspace: Unknown 

The nearest weather reporting station was BOK. According to recorded information, at 2256, the weather conditions were winds calm, visibility 10 statute miles or greater, sky clear, temperature 13°C, dew point 09°C, and an altimeter setting of 30.06 inches of mercury.

According to the Astronomical Applications Department of the United States Naval Observatory, the official sunset was at 2056; the official end of civil twilight was at 2130; and the official moonset was 2104.

Airport Information

Airport: BROOKINGS (BOK)
Runway Surface Type: Asphalt
Airport Elevation: 462 ft
Runway Surface Condition: Dry
Runway Used: 30
IFR Approach: None
Runway Length/Width: 2900 ft / 60 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude:  42.078889, -124.333333

The main wreckage was identified in high current waters about 2 miles west of BOK and was not recovered. The search and rescue efforts continued for over 30 days until the occupants were recovered. The nose landing gear assembly and seat foam were the only airplane parts recovered. 

Medical And Pathological Information

The Oregon State Police Morgue, Oregon State Police Headquarters, Central Point, Oregon, performed an autopsy of the pilot. The cause of death was reported as severe blunt trauma.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing that identified ethanol at 0.041 gm/dl in cavity blood and 0.017 gm/dl in urine. In addition, N-propanol was identified in cavity blood and urine. Ethanol is the intoxicant found in beer, wine, and liquor. Ethanol may also be produced in postmortem tissues by microbial action; when this occurs other alcohols such as N-propanol may also be formed. 

Additional Information

Spatial Disorientation

According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under [visual flight rules] VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured. The handbook states that, "the vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."



NTSB Identification: WPR16LA138
14 CFR Part 91: General Aviation
Accident occurred Monday, July 04, 2016 in Brookings, OR
Aircraft: CESSNA 172, registration: N7870U
Injuries: 3 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On July 4, 2016, about 2300 Pacific daylight time, a Cessna 172F, N7870U, impacted the Pacific Ocean shortly after takeoff from Brookings Airport (BOK), Brookings, Oregon. The private pilot and two passengers were presumed to have been fatally injured; the search for the airplane continues. The airplane was registered to Cessna 7870U, LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed for the local flight, and no flight plan was filed. The flight originated from BOK about 2300, with a destination of Grants Pass Airport, Grants Pass, Oregon.

Information provided by the Federal Aviation Administration (FAA), revealed that the family of the pilot contacted local authorities after they became concerned when the pilot had not arrived at his intended destination. The FAA subsequently issued an Alert Notification, which was then cancelled on July 7, after airplane wreckage was found washed up on shore 3 miles northwest of BOK.

Review of the recorded radar data depicted that the airplane turned left shortly after takeoff, and then climbed westward to about 700 feet above the ground. The last recorded radar target was about 1 mile west of BOK, and less than 2 miles southeast from where the airplane wreckage was found.

A witness located 1 1/2 miles west of BOK reported that during the time of the accident, he heard an airplane flying nearby and assumed that it was taking off from the airport. He thought it was unusual for an airplane to be flying that late in the evening. As the airplane continued, he heard the engine slowdown in speed but couldn't remember whether it stopped or went out of hearing range.

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