NTSB CAROL · Event
Event ERA23LA328
Registry · N13384
FAA Aircraft Registry record.
Make / Model
CESSNA 172M
Year of manufacture
1973 · 50 years old at event
Engine
LYCOMING 0-320 SERIES (180 hp)
Seats / Engines
4 seats · 1 engine
Last airworthiness date
19731215
ADS-B equipped
Yes — Mode-S A089E3
Registrant of record
PREMIER VACATIONS LLC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The pilots’ loss of airplane control due to spatial disorientation. Contributing to the accident was both pilots’ lack of experience in operating in actual instrument meteorological conditions.
Factual narrative
On August 4, 2023, at 2117 Atlantic standard time, a Cessna 172M, N13384, was presumed destroyed when it was involved in an accident near Charlotte Amalie, St. Thomas, United States Virgin Islands (USVI). The commercial pilot and the private pilot were not located and were presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to an FAA inspector, the purpose of the flight was for the private pilot to accumulate additional hours of flight experience toward an instrument rating. Review of ADS-B and air traffic control data revealed that the airplane departed Rafael Hernandez Airport (BQN), Aguadilla, Puerto Rico, about 1933. The airplane was en route to Cyril E. King Airport (STT), Charlotte Amalie, USVI, on an instrument flight rules flight plan at 5,000 ft msl. At 2043:25, the flight crew requested the ILS Runway 10 approach at STT, followed by the missed approach procedure, and a return to BQN. The San Juan approach controller issued missed approach instructions to turn right to a 250° heading and climb and maintain 3,000 ft msl. The flight crew acknowledged this with a correct readback and no further transmissions were received from the flight crew. After the missed approach, at 2109:31, the controller instructed the flight crew to climb and maintain 6,000 ft msl and proceed directly to BQN. At 2114:30, ADS-B track data depicted the airplane deviating from its on-course heading in the climb, turning to the right as it entered an area of isolated, light to heavy precipitation (the airplane had flown through the same area on the inbound flight leg to STT, 13 minutes before, at 2101:19). The airplane turned through 540° and reached 6,450 ft msl before it entered a right-turning spiral descent (see figure). At 2117:25, track data for the airplane ended at 4,700 ft msl. The approach controller attempted to contact the flight crew at 2119:30, and six additional times over the subsequent 5 minutes. Figure 1 - Overhead view of the final segment of the accident flight track overlaid onto aerial image (note that clouds depicted are not representative of the conditions at the time of the accident). The airplane’s position and altitude are annotated with numbered dots and a corresponding table. The United States Coast Guard searched about 6,400 square miles by ship and helicopter for a combined total of 45 hours before suspending its search on August 7, 2023. Neither the airplane nor its occupants were recovered. The pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, rotorcraft-helicopter, and instrument airplane and helicopter. The pilot’s FAA first-class medical certificate was issued on May 24, 2023, and he declared 327 total hours of flight experience on that date. A review of his pilot logbook revealed an estimated 437 total hours of flight experience, of which 4.9 hours were in actual instrument meteorological conditions. On the copilot’s FAA airman certificate application dated April 19, 2023, he declared 94.5 total hours of flight experience. The copilot’s logbook was not recovered. According to FAA and maintenance records, the FAA performed a ramp inspection of the airplane on June 15, 2023. On June 29, 2023, at 4,235,6 total aircraft hours, maintenance personnel corrected the discrepancies noted during the ramp inspection and completed an annual inspection of the airplane. The purpose of the night, cross-country flight over open water was for the one of the pilots, who was a certificated private pilot, to accumulate hours of flight experience for an instrument rating. The other pilot held a commercial pilot certificate with an instrument rating, but had only accrued 4.9 hours of actual instrument flight experience. The airplane flew uneventfully on an instrument flight rules (IFR) flight plan for 1 hour, 34 minutes, from the departure airport to another island airport where the flight crew performed a practice instrument approach and missed approach. During the return flight leg back to the departure airport, about 7 minutes after the missed approach, the airplane diverged from its on-course heading while climbing to its assigned altitude of 6,000 ft mean sea level (msl). The airplane began turning to the right as it entered an area of light to heavy precipitation. The airplane turned through 540° and climbed to an altitude of 6,450 ft msl before it entered a right-turning spiral descent. Radar contact with the airplane was lost as it descended through 4,700 ft, and the pilots made no transmissions to air traffic control indicating any distress or abnormalities. The airplane occupants and wreckage were not located or recovered, and the airplane was presumed to have impacted the water shortly after radar contact was lost. Given that the airplane was operating over open water at night, and in an area of precipitation, the pilots’ ability to determine the airplane’s attitude using outside visual references would have been greatly diminished. While the pilots were operating on an IFR flight plan, one of the pilots was not instrument rated and the other had logged less than 5 hours of flight experience in actual instrument meteorological conditions. It could not be determined which of the pilots was flying the airplane at the time of the accident, though their combined lack of total instrument flight experience would have increased the potential for a loss of control in flight given the restricted visibility environment they were operating in. The airplane’s final moments of maneuvering flight, particularly the turning spiral descent that occurred during the final 25 seconds of its flight track, was consistent with a loss of control due to spatial disorientation. Based on the available information, it is likely that the pilots lost control of the airplane while flying in reduced visibility conditions as a result of their spatial disorientation. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Psychological-Perception/orientation/illusion-Spatial disorientation-Flight crew
- — Personnel issues-Experience/knowledge-Experience/qualifications-Total instrument experience-Flight crew
- — Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on personnel
- — Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low visibility-Effect on personnel
Verbatim from NTSB's published report. Source file
NTSB_2023_ERA23LA328.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (loss of control, spatial disorientation, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NASA NTRS 2019 · Conference Paper
Crash Testing and Simulation of a Cessna 172 Aircraft: Pitch Down Impact Onto Soft Soil
During the summer of 2015, NASA Langley Research Center conducted three full-scale crash tests of Cessna 172 (C-172) aircraft at the NASA Langley Landing and Impact Research (LandIR) Facility.
- NASA NTRS 2019 · Technical Memorandum (TM)
Simulating the Impact Response of Three Full-Scale Crash Tests of Cessna 172 Aircraft
During the summer of 2015, a series of three full-scale crash tests were performed at the Landing and Impact Research Facility located at NASA Langley Research Center of Cessna 172 aircraft.
- Embry-Riddle Scholarly Commons 2025 · Journal article (IJAAA)
Design, Implementation, and Testing of Spatial Disorientation Scenarios in a Modified Hexapod Motion Simulator
Abstract Investigations into aviation accidents aim to identify root causes and enhance safety. Despite advancements in safety measures, technology, and education, general aviation accident rates rema…
- NTSB Aircraft Accident Reports 2002 · Accident report
Loss of Control and Impact with Pacific Ocean — Alaska 261
Alaska Airlines Flight 261 (MD-83) Pacific Ocean, January 31, 2000 — 88 fatalities. Definitive investigation of the Alaska 261 pitch-runaway-and-loss-of-control crash.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
A Scoping Review of Aviation Loss of Control Inflight Research
Loss of control – inflight (LOC-I) contributes to aircraft accidents at unacceptably high rates. Significant industry efforts and research have aimed to improve LOC-I prevention, detection, and recove…
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