Aviation Accident Summaries

Aviation Accident Summary NYC97FA103

ELLISTON, VA, USA

Aircraft #1

N9162M

Cessna 210M

Analysis

The pilot/owner filed an instrument flight plan, listed himself as the pilot-in-command (PIC), and departed on an instrument proficiency flight with two passengers, who were both certified flight instructors (CFIs). The airplane was vectored for an LDA Runway 6 Approach in instrument meteorological conditions (IMC), and all radio communications were normal. The airplane was observed on radar turning away from the final approach course. No further communications were received from the airplane, and it descended below radar coverage. A witness on the ground observed the airplane exit and reenter the clouds, then heard a reduction in engine power. The airplane descended from the base of the clouds, in a nose down vertical descent, with the wings intact. Engine noise was heard to increase, followed by a 'swoosh' and bang. The 70-year old PIC had neither scheduled the flight with the employer of the CFIs nor was he listed on the their schedule. The 22-year old CFI rated passenger (seated in the front) had been a full-time college student until the previous month. His total flight experience was 340 hours, of which, 24 hours were as a CFI; and he had no experience in the make and model of airplane or with the PIC.

Factual Information

HISTORY OF FLIGHT On June 3, 1997, about 1658 eastern daylight time, a Cessna 210M, N9162M, was destroyed when it collided with terrain near Elliston, Virginia, while on an instrument approach to the Roanoke Regional/Woodrum Field (ROA), Roanoke, Virginia. The private pilot/owner and two flight instructor rated passengers were fatally injured. Instrument meteorological conditions prevailed at the accident site for the flight that departed ROA, about 1640. An instrument flight rules (IFR) flight plan had been filed for the personal flight conducted under 14 CFR Part 91. The pilot/owner contacted the Leesburg Automated Flight Service Station, at 1509, and obtained a standard weather briefing for an IFR flight in the Roanoke, Virginia area. At 1538, the pilot again contacted the Leesburg AFSS and obtained a preflight weather briefing for the local Roanoke, Virginia area, and filed an IFR flight plan. In the flight plan information provided to the AFSS, the pilot listed himself as the pilot-in-command. According to the pilot/owner's wife, the pilot was to receive refresher instrument training from a flight instructor. However, the private pilot had not scheduled to fly with any employees of the local flight school, which included the two certificated flight instructor (CFI) rated passengers. Also, he was not on either of the CFIs work schedules for the day. Neither CFI had any previous experience in the pilot's make and model airplane. The three pilots entered the airplane, where the pilot/owner was seated in the front left seat. One of the CFIs was seated in the front right seat, and the other was seated in a rear seat. The engine was then started, and the airplane was taxied to a run-up area. Witnesses reported hearing the engine run at a high power setting in the run-up area for over 15 minutes, and one witness stated that the engine appeared to be "running OK." According to statements provided by Air Traffic Control (ATC) personnel, and transcripts of ATC communications, N9162M was issued an instrument flight rules clearance, from ROA to ROA, and for practice instrument approaches, at 1628. A review of the voice tape of the communications revealed that the pilot/owner was making the radio transmissions. The airplane was cleared to taxi to runway 15, at 1630, and was cleared to takeoff, about 1640. After takeoff, N9162M was issued a frequency change to Roanoke approach control. The ROA approach controller issued N9162M headings to fly, and vectored the airplane to the LDA Runway 6 final approach course. At 1654:00, the controller issued an approach clearance to N9162M, which stated, "Centurion six two mike, three miles from clamm, turn right heading zero four zero, maintain five thousand until established on the localizer, cleared LDA runway six approach." This was acknowledged by the pilot, at 1654:11. The controller then asked at 1655:15, if the landing was going to be a full stop, and the pilot responded at 1655:21, "Six two mike, no, the first approach will be a missed approach, and the second will be a full stop." The controller asked for a clarification at 1655:27, and the pilot responded at 1655:31, "vectors back for, repeat ahhhh ILS for runway six." At 1655:36, the controller stated, "six two mike, uhmmmm, this approach, and then vectors out for a LDA to runway six." The pilot responded at 1655:41, "That's affirmative." This was the last transmission from the airplane. At 1655:49, the controller stated, "centurion six two mike, appears your southeastbound of, I don't know what heading, turn to the left heading zero two zero." With no response from N9162M, at 1656:01, the controller stated, " centurion six two mike, alright it looks like your back on the localizer there, ahhh, say heading." According to the controller's statement, he stated: "...N9162M had been vectored onto the localizer for the LDA Runway 6 approach. He tracked the approach course inbound level at 5,000 feet for about 2 miles. Just prior to the CNQ NDB it appeared the aircraft turned abruptly southeast bound. I informed the pilot of this and instructed him to turn left heading 020 in an attempt to re-intercept the localizer. He never responded to this or any further transmissions. The aircraft appeared to turn back northbound toward the localizer. I informed him of this and then lost the target..." A witness on the ground stated he had just arrived home, and was outside of his house, when he heard the sounds of an airplane engine. When he looked up, he observed an airplane appear from the clouds. The airplane was level, about 250 to 300 feet above the ground, heading in a southerly direction. The direction of flight was across a valley. The engine sounds were "normal," and he watched as the airplane reentered the clouds. A few seconds after the airplane entered the clouds, the engine sounds decreased, followed by a backfire. Another few seconds later, the witness observed the airplane as it descended out of the bottom of the clouds, on the other side of the valley. The witness stated that the airplane appeared from the clouds with it's nose straight down, in a near vertical descent. He was looking at the top of the fuselage, and could not see the landing gear, which was on the bottom of the airplane. The airplane was intact, with the wings straight out. As the airplane descended, his view was blocked by a tree on his property, about 20 feet in front of him. When the airplane went below his line of sight, he heard the engine power up, followed by a "swoosh" sound and a "bang." These sounds were heard one right after the other. When he looked around the tree, he observed what appeared to be smoke and debris in the vicinity of the impact area. The witness reported that the cloud level was just below the top of the ridgeline near the accident site. The accident occurred during the hours of daylight approximately 37 degrees, 14 minutes north latitude, and 80 degrees, 12 minutes west longitude. PERSONNEL INFORMATION The pilot/owner held a private pilot certificate with ratings for airplane single engine land, and instrument airplane. His most recent FAA Third Class Medical Certificate was issued on September 9, 1995. The 70 year old pilot's personal flight log books revealed that he had accumulated about 2,911 hours of total flight experience, of which approximately 1,190 hours were in make and model. He had logged 57 total flight hours, and 25 hours of actual weather experience during the previous 12 months, all in make and model. During the previous 6 months, the pilot had logged 4 instrument approaches in his log book, and 11 hours of actual weather. His last flight review was conducted on July 19, 1995, and his last instrument competency check was conducted on July 5, 1996. The last entry in the pilot's log book was dated May 11, 1997. The 22 year old CFI rated passenger seated in the front right seat, held a commercial pilot certificate with ratings for airplane single engine land, and instrument airplane. He also held a flight instructor certificate for airplane single engine land that was issued on June 26, 1996. He further obtained his instrument instructor rating on May 7, 1997. His pilot log book revealed that he had accumulated 340 hours of total flight experience, all in single engine airplanes. Most of his flying was accomplished in Cessna 150 and 172 airplanes. He had accumulated a total of 6.5 hours of actual weather experience, and his last actual weather experience was logged prior to June 1996. His log book revealed no previous experience in Cessna 210's, or with the pilot/owner. The CFI rated passenger was a full-time student at college during the Fall 1996, and the Spring 1997, semesters. He resumed flight instructing at ROA, on May 20, 1997. His total flight instructor experience was 23.8 hours. The 25 year old CFI rated passenger seated in the rear seat, held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. He also held a flight instructor certificate for airplane single engine land that was issued on December 19, 1996. His pilot log book revealed his total flight experience was about 450 hours, of which 5 hours were actual weather experience. His log book revealed no previous experience in Cessna 210's, or with the pilot/owner. METEOROLOGICAL INFORMATION Weather Observations taken at Roanoke were as follows: 1554: Winds 050 degrees at 8 knots, 9 miles visibility, ceiling 1,200 feet overcast, temperature 13 C, dewpoint 12 C, altimeter 29.92 1654: Winds 040 degrees at 10 knots, 10 miles visibility, ceiling 1,600 feet overcast, temperature 13 C, dewpoint 11 C, altimeter 29.92 1713: Winds 040 degrees at 9 knots, 9 miles visibility, ceiling 1,400 overcast, temperature 13 C, dewpoint 12 C, altimeter 29.93 Pilot reports and radar summaries were reviewed. There were no reports or indications of moderate to severe turbulence, or thunderstorm activity in the vicinity of the accident airplane. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on June 4 and 5, 1997. The examination revealed that all major components of the airplane were accounted for at the accident scene, except for the left wing which was separated from the fuselage, and located in several pieces about 600 feet west of the main impact hole. The main wreckage came to rest on the north slope of a 1,667 foot ridgeline, at an elevation of approximately 1,400 feet above mean sea level. The main impact hole was about 10 feet across, and airplane wreckage was scattered in a northeasterly direction across a sloped area. The impact hole contained small pieces of airplane debris, which included a door frame and one of the three propeller blades. The fuselage of the airplane was about 57 feet northeast of the main impact hole. The fuselage and associated components were destroyed. Two lap belts were found, and remained buckled. The engine remained attached to the fuselage. Separated from the engine were the left and right magnetos, vacuum pump, fuel pump, starter, propeller governor, and the number six cylinder. The three propeller blades were separated from the propeller hub. All three blades displayed chordwise twisting and scratches, and "S" bending. The leading edges of all the blades also contained nicks and gouges. Flight control continuity was not established due to impact damage; however, the ends of all control cables displayed "splaying." The left wing was separated from the main wreckage. It was located in four major section and several smaller pieces, about 600 feet southwest of the main impact hole. When the pieces of the wing were laid out together, they presented the appearance of upward bowing. The separated end of the wing sections displayed upward bending. The wing spar at the fuselage wing attach point also displayed upward bending. TESTS AND RESEARCH The pilot's attitude indicator was shipped to the NTSB Office in Parsippany, New Jersey, and examined by the NTSB Investigator on July 21, 1997. Examination of the gyro revealed rotational scoring on the gyro and the inside of the gyro case. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on the pilot/owner and the front seat pilot rated passenger on June 4, 1997, by Dr. William Massello, Office of the Chief Medical Examiner, Roanoke, Virginia. The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, revealed negative for drugs and alcohol for the pilot and the front seat pilot rated passenger. ADDITIONAL INFORMATION The airplane wreckage was released on August 4, 1997, to John W. Cooley, a representative of the owner's insurance company.

Probable Cause and Findings

failure of the PIC to maintain control of the airplane, due to spatial disorientation.

 

Source: NTSB Aviation Accident Database

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