Wednesday, July 31, 2019

Loss of Control in Flight: Cessna 210A Centurion, N68640; fatal accident occurred April 02, 2018 in Alma, Park County, Colorado


The National Transportation Safety Board traveled to the scene of this accident.


Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama

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


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


http://registry.faa.gov/N68640 


Location: Alma, CO
Accident Number: CEN18FA266
Date & Time: 04/02/2018, MDT
Registration: N68640
Aircraft: CESSNA 210
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 2, 2018, at an unknown time, a Cessna 210A airplane, N68640, impacted mountainous terrain 5 miles west of Alma, Colorado. The pilot was fatally injured. The airplane was substantially damaged. Visual meteorological conditions prevailed at the time of the accident. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The flight departed Erie Municipal Airport (KEIK) Erie, Colorado, about 0815 mountain daylight time, and was en route to Richmond Municipal Airport (KRIF) Richmond, Utah.

The evening before the accident, one witness assisted the pilot with pushing his airplane back onto the taxiway after the left brake locked up. The pilot and witness had a short discussion about how neither the pilot nor his airplane had flown in over a year.

Also, on the evening before the accident, the pilot called a tow truck company around 1900, and requested assistance with his airplane. The pilot told the tow truck driver, who responded to the airport, that he hit the wrong lever and the nose landing gear collapsed. The tow truck driver stated that the pilot placed a soft strap around the fuselage/cowling, and the tow truck driver helped him lift the airplane. The tow truck driver did not see any visible fuselage or cowling damage. The pilot told the tow truck driver that he was going to have a mechanic look at it the next morning.

The pilot's brother dropped the pilot off at KEIK the morning of the accident. The brother planned to drive to Utah and meet the pilot at KRIF that afternoon. An Airframe and Powerplant mechanic at KRIF spoke briefly with the pilot that morning about 0815 and understood the pilot was departing at that time. The witness who had helped the pilot the night before saw the pilot conduct a long engine run up, about 15 minutes in duration. The airplane then departed.

When the pilot's brother arrived at KRIF, neither the airport manager nor the mechanic had seen the pilot or the airplane at KRIF.

The airplane was subsequently reported missing and an ALNOT was issued at 1702. Search efforts found primary radar targets and cellular telephone triangulation data, consistent with the accident flight, as late as 0932 on the day of the accident. The exact route of flight and altitudes could not be determined. Search efforts were suspended indefinitely on April 6, 2018, due to inclement weather conditions in the search area. The wreckage was found by hikers on July 13, 2018.

Pilot Information

Certificate: Private
Age: 67, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: None 
Last FAA Medical Exam: 06/27/2006
Occupational Pilot: No
Last Flight Review or Equivalent:  
Flight Time:  650 hours (Total, all aircraft), 30 hours (Total, this make and model), 1 hours (Last 24 hours, all aircraft)

The pilot's flight logbook was not located during the investigation. On the pilot's most recent medical certificate application, dated June 27, 2006, the pilot reported 650 total hours of flight time, 30 hours of which were recorded in the previous 6 months. The pilot's brother estimated that it had been at least 2 years since the pilot had flown.

According to Federal Aviation Administration (FAA) airman records, an Emergency Order of Suspension was issued on July 22, 2014, for violation of Federal Aviation Regulations including operating as pilot-in-command without a valid medical certificate, deviation from air traffic control clearances, and airspace violations. The suspension of the pilot's private pilot certificate became final on August 18, 2014; according to these records, the pilot did not surrender the certificate or respond to the FAA during their investigation. 



Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N68640
Model/Series: 210
Aircraft Category: Airplane
Year of Manufacture: 1960
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 21057627
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 02/03/2014, Annual
Certified Max Gross Wt.: 2899 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Continental Motors
ELT:
Engine Model/Series: IO-470-DcE
Registered Owner: On file
Rated Power: 260 hp
Operator: On file
Operating Certificate(s) Held: None 

Some maintenance records were located with the wreckage of the airplane, to include an airframe logbook, a current engine logbook, various FAA Form 337 records, engineering drawings, Supplemental Type Certificate documents, and invoices. All the located records were damaged by impact and exposure to moisture, and some records were saturated in fuel and oil. The airframe logbook contained entries between 1968 and 1976. The most recent maintenance entry in the engine logbook was dated February 3, 2014, and detailed the maintenance performed for a 100-hour and annual inspection. The tachometer time was recorded as 1,649.78 hours, and the time since major overhaul was recorded as 667.98 hours. No other maintenance records were located. The tachometer time at the time of the accident was not determined.

According to the airport manager at KEIK, the pilot had rented a tie-down spot at the airport in March 2014 and moved his airplane there. The airport manager was not aware of the airplane ever moving after that, although he stated it was possible that it flew at times when he was not working at the airport. About a year before to the accident the pilot's daughter contacted the airport manager regarding selling the airplane. A pre-purchase inspection was conducted at the request of one potential buyer; however, it was determined that due to the extensive repair work needed on the airplane, it would be best to sell the airplane for salvage or "as is." The details of the inspection are included in the public docket for this investigation.

The pilot's brother stated that the pilot worked on the airplane for several days before the accident flight to clean and prepare the airplane for the flight; however, he was not aware of specifics regarding the work or maintenance completed. The pilot flew the airplane the night before the accident and conducted 4 touch and go landings. The brother watched the flight from the ground and stated that the airplane sounded good and that his brother's landings were smooth. According to another family member, due to the landing gear issue on the evening before the accident, the pilot elected to fly with the landing gear down on the accident flight. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KLXV, 9924 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 0953 MDT
Direction from Accident Site: 243°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 14 knots / 25 knots
Turbulence Type Forecast/Actual: Terrain-Induced / Terrain-Induced
Wind Direction: 280°
Turbulence Severity Forecast/Actual: Moderate / Severe
Altimeter Setting: 29.79 inches Hg
Temperature/Dew Point: 6°C / -12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Erie, CO (KEIK)
Type of Flight Plan Filed: None
Destination: Richfield, UT (KRIF)
Type of Clearance: None
Departure Time: 0815 MDT
Type of Airspace: Class G

A Senior Meteorologist for the National Transportation Safety Board (NTSB) gathered relevant meteorological data for the day of the accident. This data are available in the public docket for this accident.

The National Weather Service (NWS) Surface Analysis Chart for 0900 depicted a warm front extending north to south over eastern Colorado, with a high-pressure center located over southwest Colorado. A separate low pressure system was located over the Colorado and Utah boarder. The station models depicted generally clear to scattered cloud cover over the region with temperatures around 40°Fahrenheit (F) over the higher terrain, and around 60° F over eastern Colorado and Utah. No significant weather or precipitation was reported over the route of flight.

The Denver upper air sounding wind and thermal profile indicated favorable conditions for mountain wave conditions with a primary wave at 9,000 ft capable of producing moderate-to-severe turbulence with a maximum vertical velocity of 928 ft per minute.

The Geostationary Operational Environmental Satellite (GOES)-15, taken at 0845, depicted some low to mid-level clouds in the vicinity of the accident site, with several well-defined cirrocumulus standing lenticular (CCSL) clouds surrounding the accident site. The CCSL clouds indicate orographic or mountain wave activity over that region at that time. The GOES-15 water vapor imagery, taken at 0845, depicted moisture channel darkening, which indicated descending air flow and evaporation, which were then marked by rising air, and clouds, which further defined mountain wave conditions and potential turbulence over the region.

The closest official weather observation station was Lake County Airport (KLXV), Leadville, Colorado, located 7 nautical miles west of the accident site at an elevation of 9,924 ft. The routine aviation weather report (METAR) for KLXV, issued at 0953 reported, wind 280° at 14 knots, gusting to 25 knots, visibility 10 miles, clear skies below 12,000 ft, clear, temperature 6° Celsius (C), dewpoint temperature -12° C, altimeter 29.79 inches of mercury (Hg).

The METAR taken at Copper Mountain, Red Cliff Pass (KCCU), located 12 nautical miles north of the accident site at an elevation of 12,073 ft, issued at 0936 reported, wind 260° at 25 knots, gusting to 40 knots, visibility 1 ¼ miles in light snow, sky obscured, vertical visibility 700 ft, temperature 1° C, dewpoint temperature -12° C, altimeter 29.84 inches of Hg.

A search of pilot reports (PIREPS) revealed numerous reports of moderate turbulence between the altitudes of 10,000 ft and 16,000 ft on the morning of the accident. One flight crew reported severe turbulence at 30,000 ft and another flight crew reported severe turbulence at 14,000 ft. Several flight crews reported moderate mountain wave with one that reported moderate mountain wave and the inability to hold altitude.

Airmen's Meteorological Information (AIRMET) Tango was valid for the route of flight at the time of the accident for moderate turbulence below 18,000 ft, strong sustained surface winds greater than 30 knots, and low-level wind shear.

A search of official weather briefing sources, such as contract Automated Flight Service Station (AFSS) provider Leidos weather briefings and the Direct User Access Terminal Service (DUATS), was conducted and revealed that the accident pilot did not request a weather briefing through Leidos or DUATS. 



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 39.460000, -105.663333 (est) 

The accident site was located in mountainous terrain, at an elevation of 12,700 ft msl. The rocky terrain was vegetated with short grass and wildflowers. A set of powerlines, running east/west, was located about 100 ft south of the main wreckage. The main wreckage included the engine, both wings, the fuselage, and empennage. The wreckage came to rest on its left side and the nose of the airplane was oriented on a heading of 270°.

The initial impact point was located about 33 ft west of the main wreckage. The initial impact point included fragmented plexiglass/windscreen. Debris extended from the initial impact point, east, to the main wreckage and included the portions of the left and right aileron, engine components, one propeller blade, and fragmented and torn metal from the left wing.

Landing light reflector fragments and a left-wing inspection panel were located to the north of the initial impact point. The right main landing gear separated and was located 28 ft south of the main wreckage. The left main landing gear and nose landing gear remained with the wreckage. Signatures were consistent with the landing gear being extended.

The fuselage included the cabin and instrument panel. Two seats separated from the wreckage and came to rest to the west of the main wreckage and were impact damaged. The instrument panel and engine control panel were impact damaged, fragmented, and did not provide any reliable readings.

The engine separated from the fuselage and came to rest inverted, on top of the inverted right wing. The engine was impact damaged and could not be functionally tested.

Both propeller blades separated from the engine. One blade was located in the debris field. The second blade was located 300 ft southeast of the main wreckage. Both blades displayed deep leading-edge gouges and leading-edge twisting. The blade near the initial impact area exhibited deep chordwise scrapes, with the tip torn away, and a large tear about midspan.

The right wing separated partially from the airplane. The right aileron was impact damaged and partially separated. The outboard portion of the aileron separated entirely and was located in the debris field. The right flap remained attached and signatures were consistent with the flap being up or retracted. The leading edge exhibited accordion crushing.

The left wing remained partially attached to the fuselage. The inboard portion of the left aileron was impact damaged and partially separated. The outboard portion of the aileron separated and was located in the debris field. The left flap remained attached and signatures were consistent with the flap being up or retracted. The leading edge of the left wing exhibited accordion crushing along the entire span. The outboard portion of the wing was torn and bent up and aft. The left-wing fuel tank exhibited hydraulic deformation damage along the leading edge of the wing.

The empennage included the horizontal stabilizer, vertical stabilizer, rudder, and elevator. The outboard portions of the elevators and stabilizer were impact damaged. The outboard tips of both elevators were located in the debris field. The rotating beacon separated but was adjacent to the empennage. The rudder and vertical stabilizer were bent slightly but otherwise unremarkable.

Impact damage precluded functional testing of the engine and related components. The airplane was not insured and the wreckage was not recovered from the accident site. The examination of the airframe, engine, and related systems was limited due to terrain and elevation of the accident site. Details of the examination accomplished are located in the public docket to this investigation.

Flight Recorders

A Garmin GPSMAP was located in the wreckage and subsequently sent to the NTSB recorders laboratory for further examination. No tracklog data was recovered. 

Medical And Pathological Information

The autopsy was performed by the Jefferson County Coroner's office, Golden, Colorado, on July 17, 2018, as authorized by the Park County Coroner's office. The autopsy concluded that the cause of death was "massive bodily injury secondary to blunt force trauma sustained in the airplane accident" and the report listed the specific injuries. The autopsy was limited due to injury and prolonged exposure to the elements. The autopsy documented the identified coronary arteries were widely patent with areas of calcific atherosclerosis. There was no identified evidence of heart muscle scarring in a limited specimen. The brain could not be examined.

The FAA Forensic Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Carbon monoxide and cyanide tests were not performed. Testing of the received samples detected ethanol at 0.050 g/dl in liver and at 0.070 g/dl in muscle. The primary psychoactive compound in marijuana, delta-9-tetrahydrocannibinol (THC) was detected in muscle at 0.0042 µg/mL. Its inactive metabolite 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THC-COOH) was detected in muscle at 0.001µg/ml and liver at 0.0317 µg/ml.

Ethanol the active intoxicant in beer, wine, and spirits is primarily a social drug and is a powerful central nervous system depressant. After absorption, ethanol is quickly distributed throughout the body's tissues and fluids fairly uniformly. The distribution pattern parallels the water content and blood supply of each organ. Ethanol may also be produced in the body after death by microbial activity. THC is the primary psychoactive compound in marijuana.

The 67-year-old male pilot was last medically certified in June 2006. According to the FAA medical case review, at the time of the accident flight he did not have a valid medical certificate or a pilot certificate.

About two months before the accident, the pilot was hospitalized for respiratory and renal failure with associated metabolic encephalopathy due to diabetic ketoacidosis. During the hospital stay, he experienced atrial fibrillation with rapid ventricular response. He was successfully treated with insulin, cardiovascular medications, and dialysis and was released home with a requirement for supplemental oxygen secondary to persistent oxygen desaturation during exercise. Records post-discharge were not available.

Fuel Starvation: Beechcraft 35-A33 Debonair, N9378Y; fatal accident occurred January 30, 2018 in Helenwood, Scott County, Tennessee

 Vicki and David Maxwell

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas

Aviation Accident Factual 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/N9378Y


Vicki Maxwell, Beechcraft 35-A33 Debonair (N9378Y), Dave Maxwell and Sage (Miniature Labradoodle)

Location: Helenwood, TN
Accident Number: ANC18FA022
Date & Time: 01/30/2018, 1345 EST
Registration: N9378Y
Aircraft: BEECH 35 A33
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

HISTORY OF FLIGHT

On January 30, 2018, about 1345 eastern standard time, a Beech 35-A33 airplane, N9378Y, sustained substantial damage during a forced landing following a total loss of engine power near Helenwood, Tennessee. The private pilot sustained serious injuries, and the passenger sustained fatal injuries. The airplane was registered to the pilot who was operating the airplane as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed near the accident site, and no flight plan was filed for the cross-country flight.

The airplane departed from Venice, Florida, about 0748 destined for Urbana, Ohio, with a planned intermediate fuel stop. A Garmin GPS unit was found at the wreckage location. A review of the unit's data logs revealed that, after departing Venice, the airplane landed at Barrow County Airport (WDR), Winder, Georgia, at 1146:45 (about 4 hours later), and then departed for Urbana at 1205:30. After departure, the airplane proceeded northeast before turning north at a cruising GPS altitude that varied between about 8,291 and 6,558 ft. According to the pilot, prior to departing WDR the airplane was refueled and departed with 70 gallons of fuel onboard. After departure, while in level cruise flight, the engine "sputtered," followed by a total loss of engine power. The pilot stated that the engine gauges did not indicate any sign of overheating or other mechanical problems. He followed the emergency engine restart checklist in an attempt to restart the engine to no avail. He broadcast a "mayday" call three times on the 121.5-megahertz (MHz) frequency but received no response. He then attempted to glide the airplane to the nearest airport, but he realized the airplane could not reach it, so he conducted an emergency landing to a logging road in mountainous terrain. The last fully recorded in-flight data point was at 1345:22 when the airplane was at a GPS altitude of 2,418 ft and 74 knots ground speed.

When the airplane failed to arrive at the destination airport on time, a family member contacted local law enforcement, and they initiated a search for the missing airplane. The Federal Aviation Administration (FAA) issued an alert notice at 2003, and extensive search operations were initiated. Search operations were conducted by personnel from the Tennessee Wing of the Civil Air Patrol, Scott County Sheriff's Office, Scott County Rescue Squad, the U.S. Department of Agriculture, and multiple local fire departments. A 121.5-MHz emergency locater transmitter (ELT) signal was received in the early morning hours of January 31. Initially search personnel were unable to locate the airplane due to dark night conditions; however, about 0956, search personnel located the wreckage, and found that the passenger had died.



PERSONNEL INFORMATION

The pilot held a private pilot certificate with an airplane single-engine land rating. His most recent BasicMed application was on April 27, 2017.

According to the pilot's logbook, as of January 25, 2018, he had accumulated 207.5 hours of total flight experience, including 150.6 hours as pilot-in-command and 14.1 hours of total flight experience in the accident airplane.

AIRCRAFT INFORMATION

The airplane was manufactured in 1961 and had a total time in service of 3,508.34 flight hours.

The airplane was equipped with a 225-horsepower Continental Motors IO-470-J engine. At the time of the accident, the engine had accumulated 553.86 total hours since overhaul. A review of the airplane maintenance records revealed that the most recent annual inspection of the airframe and engine was completed on July 26, 2017, 33.04 hours before the accident.

Shoulder Harnesses

The airplane was not equipped, nor was it required to be equipped, with shoulder harnesses in any of the occupant seats.

Fuel System

The airplane was equipped with an optional 63-gallon usable (70-gallon total) fuel system. The system consisted of a rubber fuel cell located in each wing leading edge, which contained 22 gallons of usable fuel (25-gallon total), and was equipped with a flush-type filler cap. The system had two auxiliary fuel cells located outboard of the wheel wells in each wing. The auxiliary cells contained 9.5 gallons of usable fuel (10-gallons total). The fuel selector valve was located on the left cockpit sidewall panel, forward of the pilot's seat. The fuel selector could be selected to "OFF," the left main tank ("LH TANK"), the auxiliary tanks ("AUX TANK"), and the right main tank ("RH TANK"). Both auxiliary fuel cells were connected to a common port at the fuel selector valve so that both fed simultaneously when the fuel selector was set to "AUX TANK."

The fuel injection system returned about 10 gallons of excess fuel per hour. Fuel lines were routed through the fuel selector valve to each main fuel cell. Except for the auxiliary cells, fuel was returned to the cell from which it was drawn. The auxiliary cells returned fuel to the left main cell only. According to the Pilot's Operating Handbook (POH), to provide space for the returned fuel, "the left main cell should be used to approximately half full before switching to auxiliary."

Fuel Quantity Indication System

Fuel quantity was measured by float-operated sensors located in each fuel cell. The sensors transmitted electrical signals to the main and auxiliary fuel quantity indicators located in the center of the instrument panel. Fuel quantity for each main or auxiliary fuel tank could be read by positioning either of the two fuel gauge selector switches which were placarded "MAIN FUEL" and "AUX FUEL", and located on the left instrument subpanel, to either right or left.



METEOROLOGICAL INFORMATION

The closest official weather observation station to the accident site was Scott Municipal Airport, Oneida, Tennessee, located about 5 miles northwest of the accident site. At 1353, a METAR was reporting, in part, wind, light and variable; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 37°F; dew point 18°F; and an altimeter setting of 30.40 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The accident site was in a steep hilly area of brush- and rock-covered terrain with sparsely populated trees at an elevation of about 1,241 ft msl. A broken 25-ft-tall tree was the initial impact point. After the initial impact, the wreckage traveled northwest along a magnetic heading of about 297° for about 143 ft before coming to rest upright, left wing low, in a rock-covered gully on an approximate 321° magnetic heading.

All the airplane's major components were located at the main wreckage site. The cockpit area exhibited impact damage. The engine, firewall, and instrument panel were displaced aft. The throttle was found in the near full-forward position, and the mixture and propeller were found in the full-forward position. The electric auxiliary fuel pump switch was found in the "ON" position. The fuel selector was found in the "AUX" position, and the fuel gauge selector switches were found in the main fuel – "LEFT", and auxiliary fuel – "LEFT" positions.

The fuel selector valve was removed and rotated through its full range of operation. Operation was smooth without excessive play, and its detents were confirmed. The fuel selector valve sump was drained, and about 2 tablespoons of light blue fluid, consistent with 100LL fuel, were recovered. The fluid was bright, free of debris, and tested negative for water.

The right auxiliary and right main fuel tank caps were on and secure. Both the right auxiliary and right main fuel tanks were breached. About 7 to 10 gallons of light blue fluid, consistent with 100LL fuel, were recovered from the right main wing tank. No fuel was present in the right auxiliary tank. Fuel was observed leaking from under the right wing.

The left auxiliary and left main fuel tank caps were on and secure. The left auxiliary fuel tank was intact. The left main fuel tank was intact, but the fuel pickup had separated at the wing root due to impact damage. About 5 to 7 gallons of light blue fluid, consistent with 100LL fuel, was recovered from the left main wing tank. No fuel was present in the left auxiliary fuel tank.

The fuel inlet line was removed from the fuel pump and the fuel return line was removed from the firewall fitting, and no fuel was present in either fuel line. About a teaspoon of light blue fluid, consistent with 100LL fuel, was recovered from the fuel line between the fuel metering unit and fuel manifold valve.

The fuselage exhibited extensive accordion-style crushing near fuselage station 151. The right wing remained attached to the fuselage but exhibited leading edge crushing damage about midspan. The right aileron and right wing flap remained attached to their respective attachment points and were relatively undamaged.

The left wing remained attached to the fuselage. An elliptical impact area was found on the leading edge at the wing root, and tree bark was present in the damaged area. The outboard portion of the left wing exhibited leading edge crushing damage from about wing station 137 outboard to the tip. The leading edge was partially separated about wing station 137. The left aileron remained attached to its respective attachment points but exhibited crushing damage about midspan. The left wing flap remained attached to its respective attachment points and was relatively undamaged.

The left and right horizontal stabilizers, elevators, vertical stabilizer and rudder, and both left and right elevator trim tabs remained attached to their respective attachment points and were relatively undamaged.

Flight control continuity was verified from all the primary flight control surfaces to the cockpit.

The examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

The engine remained attached to the airframe, and its underside exhibited impact damage. An examination of the engine, including its accessories, cylinders, pistons, valve train, crankshaft, and other internal components revealed no contamination and no evidence of any mechanical malfunctions or failures that would have precluded normal operation.

An engine test-run was conducted after replacing impact- and recovery-damaged components. The engine started normally on the first attempt without hesitation or stumbling in observed rpm. A 20-minute warm-up sequence was conducted, during which the engine rpm was advanced in steps before the engine throttle was advanced to the full-open position and held for 5 minutes to stabilize. Throughout the test phase, the engine accelerated normally and produced rated horsepower. The engine throttle was rapidly advanced multiple times from idle to full throttle without any hesitation, stumbling, or interruption in power. During the engine test-run, the magnetos were checked, and the left magneto rpm decreased 136 rpm, and the right magneto rpm dropped 100 rpm.

The propeller remained attached to the crankshaft, and both propeller blades remained attached to the propeller hub assembly. One blade was bent aft about midspan, and the other blade was bent slightly aft. The spinner remained in place and exhibited a dent on one side with no rotational scoring.

A subsequent wreckage examination revealed no additional evidence of any mechanical malfunctions or failures that would have precluded normal operation.

SURVIVAL ASPECTS

The airplane was equipped with a legacy 121.5-MHz ELT, not a digital 406-MHz ELT that transmits a distress signal to search and rescue satellites and alerts rescue personnel within minutes of the location of the crash site.

Starting on February 1, 2009, satellite monitoring of analog 121.5-MHz ELTs was terminated for several reasons, including the congestion of the 121.5-MHz frequency and numerous associated false signals, the inherent inaccuracy of the 121.5-MHz signal, and the slow receipt of a target location compared to the much faster and more accurate digital 406-MHz ELTs. According to the National Oceanic and Atmospheric Administration (NOAA) Satellite and Information Service, "NOAA, along with the U.S. Coast Guard, United States Air Force, and NASA (the four Federal Agencies who manage, operate, and use the SARSAT [Search and Rescue Satellite Aided Tracking system] are strongly advising users of 121.5/243 MHz beacons to make the switch to 406." However, the installation of a 406-MHz ELT in lieu of a 121.5-MHz ELT has not been mandated.

On September 4, 2007, the National Transportation Safety Board issued Safety Recommendation A-07-51 to the FAA, and reiterated the recommendation on January 8, 2013, which stated, in part, that the FAA:

Seek authority from Congress to require the installation of Technical Standard Order C126 [406 megahertz (MHz)] emergency locator transmitters (ELTs) in all applicable aircraft at the earliest possible opportunity. Further, the Federal Aviation Administration should strongly consider establishing a compliance date for upgrading to 406-MHz ELTs on or before the date that COSPAS-SARSAT will cease satellite processing of 121.5-MHz signals.

On April 22, 2013, the FAA responded to the NTSB's recommendation and stated in part:

The FAA will neither seek authority from Congress nor require the installation and maintenance of 406-MHz ELTs. The cost of equipping the general aviation and air taxi fixed-wing aircraft fleet is approximately $.5 billion, which is too burdensome. We continue to find that voluntary equipage and the use of other new technologies best address this recommendation. We carefully reconsidered our actions and we continue to find that our response to this recommendation reflects the best interests of aviation safety. Accordingly, we will take no further action in direct response to this recommendation.

On January 8, 2013 the NTSB classified Safety Recommendation A-07-51 CLOSED —UNACCEPTABLE ACTION.

ADDITONAL INFORMATION

POH Loss of Engine Power Emergency Procedure

The BEECHCRAFT Debonair 35-A33 and 35-B33 Pilot Operating Handbook and FAA-Approved Airplane Flight Manual, Section III, "Emergency Procedures," stated, in part, the following:

Condition: LOSS OF ENGINE POWER

1. Fuel Pressure/Flow Gage – Check

If fuel pressure is abnormally low:

a. Mixture – FULL RICH

b. Auxiliary Fuel Pump – On (Lean as required)

c. Auxiliary Fuel Pump – Off if performance does not improve in a few moments.

2. Fuel Quantity Indicator – Check for supply in tank being used.

If tank being used is empty:

Fuel Tank Selector Valve – SELECT ANOTHER FUEL TANK (feel for detent)

Air Start Procedure

a. Fuel Selector Valve – SELECT MAIN TANK MORE NEARLY FULL (check to feel detent)

b. Throttle – RETARD

c. Mixture – FULL RICH

d. Auxiliary Fuel Pump – ON until power is regained then OFF. (Leave on if engine driven pump is inoperative.)

e. Throttle – ADVANCE to desired power

f. Mixture – LEAN as required

FAA Advisory Circular 91-65

FAA Advisory Circular 91-65, "Use of Shoulder Harness in Passenger Seats," stated, in part

The [National Transportation Safety Board] found that 20 percent of the fatally injured occupants in these accidents could have survived with shoulder harnesses (assuming the seat belt fastened) and 88 percent of the seriously injured could have had significantly less severe injuries with the use of shoulder harnesses. Energy absorbing seats could have benefited 34 percent of the seriously injuries. The safety board concluded that shoulder harness use is the most effective way of reducing fatalities and serious injuries in general aviation accidents.

Additionally, the FAA issued policy statement, ACE-00-23.561-01, which addressed acceptable methods of approval for retrofitting shoulder harness installations in small airplanes. 



Pilot Information

Certificate: Private
Age: 50, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed:No 
Medical Certification: BasicMed
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 01/06/2018
Flight Time: 377.41 hours (Total, all aircraft), 14.1 hours (Total, this make and model) 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N9378Y
Model/Series: 35 A33 NO SERIES
Aircraft Category: Airplane
Year of Manufacture:1960 
Amateur Built: No
Airworthiness Certificate:Normal 
Serial Number: CD-270
Landing Gear Type: Retractable - Tricycle
Seats: 
Date/Type of Last Inspection: 07/25/2017, Annual
Certified Max Gross Wt.: 3003 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3475.3 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: C91  installed, activated, aided in locating accident
Engine Model/Series: IO-470-J
Registered Owner: On file
Rated Power: 225 hp
Operator: On file
Operating Certificate(s) Held: None



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSCX
Distance from Accident Site:
Observation Time: 1853 UTC
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Light and Variable /
Turbulence Type Forecast/Actual:
Wind Direction: Variable
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.4 inches Hg
Temperature/Dew Point: 3°C / -8°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Winder, GA (WDR)
Type of Flight Plan Filed: VFR
Destination: Urbana, OH (I74)
Type of Clearance: None
Departure Time: 
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 36.402500, -84.515278 (est)

Loss of Control in Flight: Cessna T210L Turbo Centurion, N6563D; fatal accident occurred March 25, 2017 in Hayden, Blount County, Alabama

Joseph and Jennifer Crenshaw, with their two children Jacob and Jillian.


The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Birmingham, Alabama
Continental Motors; Mobile, Alabama
Textron/ Cessna; Wichita, Kansas

Aviation Accident Factual 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/N6563D 





Location: Hayden, AL
Accident Number: ERA17FA136
Date & Time: 03/25/2017, 1433 CDT
Registration: N6563D 
Aircraft: CESSNA T210
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On March 25, 2017, about 1433 central daylight time, a Cessna T210L, N6563D, was destroyed during an uncontrolled descent and subsequent in-flight breakup near Hayden, Alabama. The private pilot and three passengers were fatally injured. The airplane was privately owned and was being operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight, which originated from Kissimmee Gateway Airport (ISM), Orlando, Florida, about 1150 and was destined for McKellar-Sipes Regional Airport (MKL), Jackson, Tennessee.

According to air traffic control (ATC) radar and voice communication data provided by the Federal Aviation Administration (FAA), after takeoff, the flight proceeded toward the destination at a cruise altitude of 10,000 ft mean sea level (msl). About 1357 and again at 1403, the pilot requested and was approved to deviate right of course due to weather. About 1420, the pilot requested and was approved to climb to 12,000 ft msl; at this time, the controller also issued a frequency change. The pilot subsequently checked in with the next controller, who described moderate to extreme precipitation ahead of the airplane and asked if the pilot needed to deviate. The pilot replied that he would go anywhere the controller thought was the quickest route across the weather. The controller replied that he did not have a better route and allowed the pilot to deviate as necessary, instructing the pilot to proceed to his destination when able. About 1429, the airplane began a series of descending right turns, and the controller instructed the pilot to maintain 12,000 ft. The airplane continued to descend, and the controller again advised the pilot that he was losing altitude; the pilot replied, "I'm doing the best I can." At 1432, the controller advised the pilot that he was descending through 5,800 ft and to check his altitude. There was no response, and radar contact was lost shortly thereafter at an altitude about 2,000 ft msl.

A witness reported that he was standing in his driveway and noticed how windy it was and that the trees were leaning over almost 90°. He said that it was not raining, but he did hear thunder in the distance. He reported hearing an airplane flying above making a "weird" sound. He said he heard a loud "boom" and saw pieces of the airplane falling out of the sky but did not see it break apart. He then saw the fuselage of the airplane, which was spinning through the air, descending toward the ground. 



Pilot Information

Certificate: Private
Age: 45, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 08/22/2016
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 288 hours (Total, all aircraft), 288 hours (Total, this make and model)

The pilot, age 45, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He reported a total flight experience of 288 hours, including 16.6 hours during the previous 6 months, on his most recent FAA third-class medical certificate application dated August 22, 2016. At that time, the pilot reported no medical conditions, and the medical certificate indicated no restrictions. The pilot's logbook was not available for review. The pilot's recent flight experience and instrument flight experience could not be determined. A review of the aircraft logbook revealed that the airplane was flown a total of 25.7 hours since the pilot's most recent flight review on July 27, 2016.



Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N6563D 
Model/Series: T210 L
Aircraft Category: Airplane
Year of Manufacture:1974 
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 21060580
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 07/18/2016, Annual
Certified Max Gross Wt.: 3800 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 4258.5 Hours as of last inspection
Engine Manufacturer: Continental
ELT: C91A installed, not activated
Engine Model/Series: TSIO-520-R
Registered Owner: RHEIORG CONSULTING LLC
Rated Power: 310 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in 1974 and was powered by a Continental TSIO-520-R engine rated at 310 horsepower equipped with a McCauley three-bladed controllable pitch propeller. The most recent annual inspection was completed on July 18, 2016, at a tachometer time of 2,220.8 hours. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: BHM, 650 ft msl
Distance from Accident Site: 22 Nautical Miles
Observation Time: 1453 CDT
Direction from Accident Site:180° 
Lowest Cloud Condition: Unknown
Visibility:  10 Miles
Lowest Ceiling: Broken / 4600 ft agl
Visibility (RVR):
Wind Speed/Gusts: 16 knots /
Turbulence Type Forecast/Actual:/ None 
Wind Direction: 260°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 21°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ORLANDO, FL (ISM)
Type of Flight Plan Filed: IFR
Destination: JACKSON, TN (MKL)
Type of Clearance: IFR
Departure Time: 1250 EDT
Type of Airspace: Class G

Synoptic Conditions

The southeast section of the National Weather Service (NWS) Surface Analysis Chart for 1300 depicted a low pressure system over Missouri at 1007-hectopascals (hPa) associated with an occluded front. Over northeast Missouri, the occluded frontal system split into a stationary front across northern Missouri eastward across Illinois, Indiana, Ohio, into Pennsylvania, and a cold front extending southward across eastern Missouri through Arkansas and into Louisiana, where the front became stationary and extended southwestward along the Texas Gulf coast. A squall line was depicted ahead of the cold front from southeastern Louisiana into southern Mississippi with an outflow boundary depicted from the end of the squall line northward across western Alabama, immediately west of the accident site at the time of the accident. The accident site was located ahead of the cold front and the outflow boundary, in the warm air sector of the front.

The station models on the surface analysis chart depicted southerly winds sustained at 5 to 15 knots and broken to overcast sky cover in the area of the accident site. One station immediately south-southwest of the accident site and behind the outflow boundary reported a thunderstorm and rain showers. East of the outflow boundary, the station models indicated temperatures in the mid-to-upper 70s°F, while west of the boundary the temperatures were in the low 60s°F. Dew point temperatures were in the 50s°F to near 60°F near the Gulf Coast.

Regional Radar Mosaic

Weather radar depicted a line of echoes in the immediate vicinity of the accident site, which is enclosed in the red circle (see figure 1), the echoes were immediately west of Birmingham, Alabama at the time. A second more defined line of intense echoes associated with the squall line extended behind the first line from southeast Mississippi, to southeastern Louisiana, and into the Gulf of Mexico. A third area was located behind the two lines west through north of Jackson, Mississippi with an area of intense echoes.


Figure 1: National Radar Mosaic

Convective Outlook

The morning convective outlook chart from the NWS Storm Prediction Center depicted a slight risk of organized severe thunderstorms over western Alabama, eastern Mississippi, and southeastern Louisiana during the period around the accident time, with a marginal area of thunderstorms through western Tennessee and the rest of Alabama. A slight risk indicated that an area of organized severe thunderstorms of scattered coverage was possible across the region, with either short-lived and/or isolated severe storms possible. A marginal risk indicated more isolated severe storm coverage. The convective outlook is typically used in preflight weather briefings to highlight areas where thunderstorms and severe thunderstorms can be expected.

Surface Observations

The closest weather reporting station was Birmingham-Shuttlesworth International Airport (BHM), located 25 miles south of the accident site at an elevation of 650 ft.

The 1353 observation included wind from 160° at 14 knots gusting to 19 knots, 10 miles visibility, a few clouds at 4,700 ft above ground level (agl), broken ceiling at 6,000 ft agl, temperature 26°C, dew point temperature 13°C, altimeter 30.10 inches of mercury. Remarks included peak wind from 200° at 28 knots at 1307, and distant lightning to the northwest.

The 1453 observation included wind from 260° at 16 knots, 10 miles visibility, broken ceiling at 5,500 feet agl, temperature 21°C, dew point temperature 12°C, altimeter 30.09 inches of mercury.

A special weather observation issued at 1502 included wind from 260° at 17 knots gusting to 22 knots, 10 miles visibility, overcast ceiling at 4,600 ft agl, temperature 20°C, dew point temperature 12°C, altimeter 30.09 inches of mercury. Remarks included wind shift occurred at 1442, and distant lightning to the south and southwest.

Preflight Weather Briefing

The pilot accessed an online weather briefing through ForeFlight and filed an IFR flight plan. He obtained a low-altitude route briefing between Kissimmee, Florida, and Jackson, Tennessee, at 0606 and again at 1134, about 20 minutes before departure. The briefing included all relevant reports and forecasts, advisories, and NOTAMs for the route.

The terminal forecast for BHM, which was along the route of flight, predicted marginal visual flight rules conditions with southeasterly wind at 20 knots gusting to 30 knots, with visibility 4 miles in moderate rain, overcast cumulonimbus clouds at 2,000 ft agl, and thunderstorms. At the time of the briefing, other than the AIRMETs Tango for turbulence, there were no hazardous weather advisories current for the route. A review of the briefing indicated that the convective outlook documented above was included in the information accessed by the pilot.

Although there were no hazardous weather advisories or convective SIGMETs active at the time the pilot received his preflight weather information, two of the air traffic controllers who worked the flight broadcast convective SIGMETs while the pilot was on frequency that affected the pilot's intended route of flight and called for thunderstorms with tops exceeding 40,000 ft. One of these SIGMETs was broadcast about 1 hour into the flight, and the second about 2 hours into the flight (about 40 minutes before the accident occurred).

In-Flight Weather Information

Convective SIGMET

Convective SIGMETs 60C and 61C were issued at 1255 for two areas of thunderstorms over western Alabama, Mississippi, southeastern Louisiana, and for the immediate coastal waters. Convective 60C impacted the route of flight but did not extend over the location of the accident. The advisory was current until 1455.

Three sperate convective SIGMETs were issues at 1355 for portions of southwestern Alabama, southern Mississippi, and Louisiana, which were valid until 1555. In the hour prior to the accident, no Convective SIGMENTS were current for the route of flight, although the outlook area warned of potential issuance of advisories over the region.

Reflectivity

Figure 2 depicts the airplane's flight track overlaid on the Birmingham WSR-88D base reflectivity image for 1432 with reflectively elevation angle scans at 0.44°, 1.23° and 2.35°; respectively. Echoes of 5 to 35 dBZ or light to moderate intensity echoes along the flight track were present at all elevation scans with echoes of 45dBZ or heavy intensity echoes present within 5 miles northwest of the flight track. A strong intensity echo with reflectivity of 55dBZ or extreme intensity echoes south-southwest of the accident site was beginning to develop or surge upwards and move to the north-northeast.


Figure 2: Birmingham WSR-88D Base Reflectivity Images

[For additional weather information, see the NTSB Meteorology Factual Report located in the public docket for this investigation.]

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 4 Fatal
Latitude, Longitude: 33.909167, -86.732778

The wreckage field was about 4,550 ft long, oriented on a true heading about 247°. The left elevator was located at the beginning of the debris field. Continuing along the wreckage path was the inboard right wing and the left wing assembly, including the aileron and flap. Various parts of the airplane continued along the debris path that led to the main wreckage, which was located at the end of the debris path. The main wreckage comprised the engine, fuselage, and empennage. The engine mounts were broken; however, the engine remained attached to the airframe through hoses, wires, and cables. The cockpit and cabin were destroyed; the flight instruments were impact damaged. The empennage remained attached by the rudder and elevator control cables. The horizontal stabilizers were bent upward toward the vertical stabilizer. The rudder remained attached to the vertical stabilizer.

The left wing and center wing section separated from the fuselage and remained intact. The right wing separated outboard of the top and bottom spars. The right wing was separated into 3 large pieces with the aileron still attached to the outboard portion of the wing. An approximate 6-ft section of the middle portion of the right wing, which included the entire right flap, was removed from the accident site before the site could be secured.

Control cable continuity was established from the rudder, elevator, and elevator trim tab to the forward floor assembly area. Control cable continuity was established from the right aileron bellcrank to the wing root area. Control cable continuity was established from the left aileron bellcrank to the wing root area for the drive cable. The left aileron carry-through cable was fractured in tensile overload from the bellcrank. Examination of the airframe did not reveal any pre-accident anomalies that would have precluded normal operation.

Examination of the engine established continuity between the crankshaft, camshaft, connecting rods, and associated components by rotating the crankshaft with a hand tool. All six cylinders displayed thumb compression and suction. The No. 5 cylinder displayed significantly less compression and suction than the other cylinders; a borescope inspection revealed a small piece of wood between the intake valve and the valve seat. All the cylinders were inspected using a lighted borescope; the internal components displayed normal operating and combustion signatures.

The fuel pump remained attached to its installation point and displayed minor impact damage signatures. The fuel pump was removed; the drive coupling was intact and the driveshaft was capable of rotation. The throttle and fuel metering assembly had broken free from its installation point and displayed impact damage. The throttle and mixture control arms remained secured to their shafts and the fuel inlet screen was clear of any contaminants. The manifold valve was undamaged and disassembled. The internal components displayed normal operation signatures; there were no anomalies noted within the valve housing. The fuel injectors were removed and were clear of obstructions.

Examination of the magnetos revealed that the right magneto had broken free from its mounting pad and the left magneto remained partially attached to its mounting pad. The magnetos were removed and the driveshafts were rotated by hand as well as using an electric drill. Both magnetos produced a spark to each of the posts in the correct order. The ignition harness displayed impact damage signatures to several of the ignition leads.

The top spark plugs were removed and visually inspected; the electrodes displayed normal operating and wear signatures. The bottom spark plug electrodes were inspected using a lighted borescope and displayed normal operating signatures.

The turbocharger remained attached to the exhaust system and displayed impact damage. Continuity was established between the compressor and turbine section and both the compressor and tubing were capable of normal rotation. The compressor and turbine blades displayed normal operating signatures. Examination of the engine revealed no pre-impact anomalies that would have prevented normal operation or production of rated horsepower.

Examination of the propeller revealed that blades No. 1 and No. 2 displayed minor forward-bending deformation and blade No. 3 displayed a significant amount of aft-bending deformation. All blades displayed chordwise scoring and impact damage. No pre-impact anomalies were noted during the examination that would have prevented normal operation. 



Medical And Pathological Information

An autopsy was performed on the pilot by the University of Alabama, Birmingham, Department of Pathology; the cause of death was multiple blunt force injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified N-propanol and ethanol at 0.046 gm/dl in muscle, but no ethanol in liver, and amphetamine in lung and heart tissue (0.114 µg/g).

Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. Because ingested alcohol is distributed throughout the body, levels from different postmortem tissues are usually similar. Ethanol may also be produced in body tissues by microbial activity after death; in this case levels may vary widely.

Amphetamine is a Schedule II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorders and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. 

Additional Information

According to the FAA's General Aviation Joint Steering Committee, a pilot's sight, supported by other senses, allows a pilot to maintain orientation while flying. However, when visibility is restricted (i.e., no visual reference to the horizon or surface detected), the body's supporting senses can conflict with what is seen. When this spatial disorientation occurs, sensory conflicts and optical illusions often make it difficult for a pilot to tell which way is up.

The FAA Airplane Flying Handbook (FAA-H-8083-3) describes some hazards associated with flying when visual references, such as the ground or horizon, are obscured. The handbook states,

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.

FAA Advisory Circular (AC) 60-22, Aeronautical Decision Making, states, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff'." One of the common behavioral traps that the AC describes is "Get-There-Itis." The text states, "Common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action."

FAA AC-00-6B, Aviation Weather, describes thunderstorms and the turbulence that is associated with them. The AC stated, in part:

Turbulence is present in all thunderstorms. Severe or extreme turbulence is common. Gust loads can be severe enough to stall an aircraft at maneuvering speed or to cause structural damage at cruising speed. The strongest turbulence occurs with shear between updrafts and downdrafts. Outside the cumulonimbus cloud, turbulence has been encountered several thousand feet above, and 20 miles laterally from, a severe storm.

The Turbulence Reporting Criteria Table in the FAA Aeronautical Information Manual provides the following definitions:

Severe: Turbulence that causes large, abrupt changes in altitude and/or attitude. It usually causes large variations in indicated airspeed. Aircraft may be momentarily out of control.

Extreme: Turbulence in which the aircraft is violently tossed about and is practically impossible to control. It may cause structural damage.