ERA10FA091

The pilot's decision to depart under special VFR flight at night when instrument meteorological conditions prevailed at the departure airport and along the route of flight and his continued VFR flight into instrument meteorological conditions, which resulted in his spatial disorientation and subsequent loss of aircraft control.

The non-instrument-rated pilot departed for a night cross-country flight while instrument meteorological conditions existed at the departure airport. The pilot requested and received from air traffic control a special visual flight rules (VFR) clearance. After departure, the airplane was observed on radar climbing to an altitude of 2,400 feet above mean sea level (msl). Approximately 1 minute prior to the last radar return, air traffic control cleared the accident flight "on course" and the clearance was acknowledged by the pilot. Subsequently, radar data indicated that the airplane began a 180-degree right turn and its altitude decreased from 2,400 feet msl to 0 feet msl in about 12 seconds. The last radar return was located in the immediate vicinity of the accident location. The dark surface of the water in a relatively unlit area would have provided the pilot limited external visual reference and could have resulted in him becoming spatially disoriented or affected by a visual illusion. The pilot's logbook revealed that he had visited the departure airport several times prior to the accident. A postaccident examination of the airplane, structure, flight controls, engine, aircraft systems, and flight instruments revealed no preimpact mechanical malfunctions.

HISTORY OF FLIGHT On December 7, 2009, at 2223 eastern standard time (EST), a Cessna 172, N5269X, was destroyed by impacting the water on Lake Russell near Kissimmee, Florida. The certificated, non-instrument rated, private pilot and three passengers were fatally injured. Instrument meteorological conditions prevailed and no flight plan was filed for the personal flight, which departed from Florida Gateway Airport (ISM), Kissimmee, Florida, with an intended destination of Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, Florida. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Security camera recordings revealed that the pilot and three passengers arrived at the fixed base operator (FBO) facility at 2126. Another camera showed the pilot standing at a weather computer for approximately 8 minutes, but the computer screen contents were not discernible. The video image data showed that at approximately 2140, the pilot and three passengers walked to the airplane, and from 2140 until approximately 2153 someone appeared to conduct a preflight inspection of the airplane with a flashlight, however due to the lack of lighting the person’s identity was unable to be confirmed. About 2153, the airplane engine was started, and for approximately the next 10 minutes, the airplane remained stationary, with the engine running. At 2208, the airplane began to taxi out of the parking spot with its taxi light illuminated. Several witnesses employed by the FBO provided written statements to the NTSB. Their accounts were similar to what was observed on the security tape and none of the reports mentioned any problems with the pilot, passengers or the airplane. Recordings of voice and radar tracking data was obtained from the Federal Aviation Administration (FAA) Air Traffic Control (ATC) facility located in Orlando, Florida. About 2206, the pilot requested a "special VFR [visual flight rules]" clearance from ISM to FXE. About 2208, ATC issued the clearance and instructed the pilot to "maintain VFR at or below one thousand five hundred" and provided the pilot with a release time of 2208 and a clearance void time of 2215. The aircraft departed ISM about 2213. About 2222, ATC issued a clearance of "on course." This clearance was acknowledged by the pilot, and was the last transmission received from the flight. Radar tracking data indicated that the airplane made a slight left turn for an on-course heading to FXE, and subsequently made a right turn of approximately 100 degrees away from the direct track towards FXE. At 2223 radar data showed the airplane at an altitude of 2,400 feet above mean sea level (msl). Approximately 12 seconds after the final 2,400 foot radar return, another radar return showed an airplane altitude of 0 feet. PERSONNEL INFORMATION According to FAA records, the pilot held a private pilot certificate with an airplane single-engine land rating. The date of issuance was October 13, 2009. His most recent FAA first-class medical certificate was issued on July 3, 2009. The pilot's logbook was recovered from the lake, and the last entry, dated December 6, 2009, indicated that he had 150.7 total hours of flight experience and 4.9 total hours of simulated instrument flight experience. No record of actual logged instrument flight time was found. The logbook also indicated that he had previously flown into and out of ISM on several occasions. In a review of the pilot's training records and interviewing the certificated flight instructor (CFI) that did most of his training the pilot had the FAA minimum instrument training requirements for a private pilot certificate. In an interview with the NTSB investigator, the CFI stated that he would fly the students he instructed, including the accident pilot, "out towards the everglades at night with the hood on and then have them remove the hood and demonstrate how a dark, unlit terrain with little horizon reference could cause spatial disorientation." The vice president and operations manager of the flight school told the NTSB investigator that the accident pilot was taught the "basics of the autopilot" which included how to utilize the autopilot for heading and altitude hold. He further stated that they taught all students enrolled in the private pilot training stage in order for them to utilize all the equipment available especially if they were to be "heads down adjusting the radio." He also reported to the NTSB that "special VFR is as required for certification but it is not approved" at the school. AIRCRAFT INFORMATION According to maintenance records obtained from the flight school that utilized the accident airplane for training and rental, as of December 2, 2009, the airplane had 4,815 total hours of service. The most recent annual/100 hour inspection was completed on October 29, 2009. At the time of that inspection, the airplane had a total time in service of 4,760.0 hours, and the engine had 400.1 total hours since its most recent major overhaul. According to FAA records, the four-seat, high-wing, fixed-gear airplane, was manufactured in 2002 and was issued an airworthiness certificate on October 15, 2002. It was powered by a four cylinder, normally aspirated Lycoming IO-360-L2A engine, and equipped with a two blade McCauley constant-speed propeller. METEROLOGICAL The 2153 recorded weather observation at ISM, located approximately 10 miles north of the accident site, included winds from 060 degrees at 8 knots, a broken cloud layer at 800 feet above ground level (agl), an overcast cloud layer at 2,700 feet agl, temperature 21 degrees C, dew point 19 degrees C, and an altimeter setting of 30.13 inches of mercury. According to the Astronomical Applications Department at the United States Naval Observatory located in Washington D.C. official sunset for Kissimmee, Florida was at 1730 EST. The moon rise was not until 2329 and was to have a 65% visible disk on a waning moon. WRECKAGE AND IMPACT The wreckage was located in water of approximately 6 feet depth, about 500 feet from the shore on a circular shaped lake that had a diameter of approximately 6,500 feet, and was confined to an area approximately 60 feet by 60 feet. The majority of the airplane was recovered from the water. Recovery divers estimated that the engine was embedded approximately four feet into the floor of the lake, and that the rest of the airplane was positioned above it, consistent with the airplane being in a nose down attitude at impact. The right wing exhibited leading edge crush damage in the aft direction, with increased damage toward the wingtip. The left wing exhibited uniform leading edge crush damage, with the exception of the outboard 13 inches, which sustained more damage. The right wing strut was fracture-separated from the fuselage, and the wing strut was bent approximately 45 degrees in the aft direction. The leading edge of the left wing flap had damage consistent with impact with the main landing gear. The right main landing gear was bent in the up and aft direction. The aft area of the fuselage was fragmented and exhibited damage similar to impact damage. The left main landing gear tire was separated from the rim. The rudder, left horizontal stabilizer, elevator, and right horizontal stabilizer counterweight were recovered. The right horizontal stabilizer was not recovered. The left horizontal stabilizer leading edge damage was consistent with being struck by the left main landing gear. The upper 11 inches of the rudder exhibited impact damage in the down and aft directions. One flight control cable was cut during the recovery process; however all other flight control cables exhibited fracture separations consistent with tensile overload. Cable continuity was established to all flight control surfaces. The passenger compartment exhibited compression and fracture damage. All four seats were recovered and the right passeng