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 Fatal 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/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.

7 comments:

Anonymous said...

YEP..... Sometimes things just sneak up and bite ya in the rear end....... I see a long chain of bad events .... and then he got bit.
NEVER like to read things like this but it sure has opened my eyes to what can and does happen if we stop and NOT THINK !
R.I.P. Sir GOD BLESS.

Anonymous said...

A lot of information to unpack on this one. I'm curious if they will be able to determine if he was using oxygen during the flight giving that glimpse of medical history laid out at the end of the report. Too many red flags to bother typing out and frankly if the guy was on dialysis maybe a plane crash was better then slowly wasting away. My guess was the intent was to take the plane to where it could be repaired and sold. Couldn't get any sane ferry pilot to fly it for him in its unairworthy condition. Ignoring all the rule violations my only critique is that he really needed oxygen in his condition, and shouldn't have flown in those winds in flat country let alone mountains.

Kell490 said...

FAA took his medical he kept flying if he wanted to sell could have found an A&P drive to his aircraft and fix it. My buddy has a mobile A&P guy all he does it drive to airports all his tools are on his truck. At least didn't take a passenger with him.

Anonymous said...

Surprised the accident chain held together long enough for this guy to get off the ground.


In Re: the kidney failure, it sounds like he was acutely ill and temporarily needed dialysis, not someone who needed it regularly. The illness he suffered (diabetic ketoacidosis) usually occurs in individuals with long-neglected diabetes who have another health crisis that coincides (pneumonia or similar) that throws them into the ICU. Really, kind of this guy's MO. Pretend everything's OK despite abundant evidence to the contrary, then finally suffer a completely foreseeable catastrophe.

In my experience, these folks are often quite smart, capable (I couldn't have flown a plane with that many handicaps), and decent individuals who just muddle along in denial. as a doctor, I just puzzle at why these experiences never seem to change the person's behavior and am saddened by my inability to help them avoid these traumas.

Anonymous said...

"My guess was the intent was to take the plane to where it could be repaired and sold. Couldn't get any sane ferry pilot to fly it for him in its unairworthy condition."

Well the story says a pre-purchase inspection rep for a potential buyer advised the owner's daughter who wanted to sell it said she'd have better luck selling it for scrap. Clearly the daughter knew her father had no business trying to get back in that thing.

All that said, so many things here: definite health issue, possible substance impairment issue, definite airworthiness issue, definite flight proficiency issue, and potential flight weather condition issue based on nearest METAR and PIREPS.

It's never one event. It's always a long chain of events that ultimately lead to a crash from leaving the ground to impact.

Anonymous said...

After reading this I'd say this guy was determined to kill himself in his airplane rather than die a slow death in a hospital or nursing home. He knew his flying days were over and he went out on his own terms. You have to respect that. At least he didn't hurt anyone else or damage anyone's property.

Anonymous said...

The plane was junk(deregistered by FAA in 2014), his health was gone....the man had a plan and carried it out. Rest In Peace, Pilot.