Aviation Accident Summaries

Aviation Accident Summary FTW98FA344

CREEDE, CO, USA

Aircraft #1

N2WF

Cessna T210N

Analysis

The airplane was on a flight to distribute the cremation ashes of the pilot's mother. Witnesses observed the airplane fly around the high altitude valley (elevation 10,400 feet, density altitude 11,864 feet) once and then spin to the ground. One witness observed a 'cloud of something' pass behind the airplane moments before it 'spun to the ground.' Records indicate that the pilot had accumulated a total of 441 hours of flight experience, with approximately 30 hours in the last 12 months. Toxicology tests on the pilot revealed that sertraline (trade name Zoloft, a non-approved drug for flight status) was present in his brain in levels several times higher than what would normally be expected from the maximum recommended dosage. A powder, which was light tan in color and gritty to the touch (similar to cremation ashes), was found throughout the cabin area.

Factual Information

HISTORY OF FLIGHT On August 6, 1998, approximately 0750 mountain daylight time, a Cessna T210N, N2WF, was destroyed when it impacted the ground while maneuvering at approximately 300 feet agl near Creede, Colorado. The private pilot and his three passengers were fatally injured. The airplane was owned/operated by Ford Farms, Inc., under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the local flight which originated from Center, Colorado, approximately 25 minutes before the accident. No flight plan had been filed. According to family members, the pilot, his son, and the pilot's two brothers departed Center, Colorado, en route to the Pearl Lakes Trout Club (elevation 10,400 feet), where several of the family members owned fishing cabins. They stated that they believed the intention of the flight was to spread the cremation ashes of their mother/grandmother who had been killed six weeks earlier in an automobile accident. Family members reported that the brothers, in June, 1995, had scattered the cremation ashes of their father over the same location near the family's cabins. According to one witness, the airplane entered the north to south oriented valley of Pearl Lakes from the south on the east side of the valley at approximately 1,000 feet above the ground. He stated that the aircraft turned left, then flew south along the west side of the valley. It then turned east along the south side of the Pearl Lakes property line, then turned north/northeast, at which time he temporarily lost sight of the aircraft. When it came into view again, the aircraft "was nose down about 20 degrees and went into [a] spin (counter-clockwise) 2 1/4 turns - banked to [the] left plus or minus 10 degrees [and] crashed into trees." He stated that the aircraft appeared to be 400 to 500 feet above the ground when it began to spin, and the spin lasted approximately 4 to 5 seconds. He further stated that a "fuel vapor cloud appeared below the [impact] site 40 to 50 yards to the west [of his location]." He said that there was a "strong odor of gasoline in the air." Another witness was walking near the northern end of Pearl Lakes and observed the aircraft pass overhead. She watched the aircraft head west, then heard it down at the south end of the valley. When she made contact with the airplane the second time, it was heading north adjacent to the house owned by Douglas Ford, one of the pilot's brothers (the front seat passenger in the airplane), as it was "nose diving in spirals with the spruce trees as a background." Another witness who was observing the aircraft from her family's cabin approximately 600 feet north of the accident site stated that she saw a "cloud of something" pass behind the airplane moments before it "spun to the ground." The airplane came to rest in heavily wooded terrain which slopped approximately 20 to 30 degrees down towards the west. PERSONNEL INFORMATION The pilot began flying in 1975, received his private single-engine land license on May 3, 1976, and had accumulated approximately 441 hours of flight experience by the time of the accident. The pilot's most recent FAA Part 61 required flight review was dated July 29, 1997. Records found in the airplane indicate that the pilot had flown approximately 30 hours during the last 12 months and approximately 4 hours during the last 3 months. A pilot-rated passenger, Douglas W. Ford (a brother of the pilot), was seated in the right front seat. FAA records indicate that he started flying in 1974, received his private single-engine land license on April 12, 1975, and had a current third class medical dated March 4, 1997. The records further indicate that, as of his last medical, he had accumulated approximately 600 hours of flight experience. AIRCRAFT INFORMATION The airplane was a propeller-driven, four seat airplane (plus a two-place bench seat), manufactured in 1979, and was powered with a reciprocating, turbocharged, fuel-injected engine rated at 300 horsepower. The airplane was equipped with a Robinson STOL kit. According to the aircraft maintenance records, the engine was overhauled on February 22, 1996, and reinstalled in the aircraft on March 10, 1996, at a tachometer time of 521.2 hours. The last annual inspection was performed on July 23, 1997, at a tachometer time of 616.0 hours. The aircraft had accumulated 65 hours since the last inspection. METEOROLOGICAL INFORMATION At 0756, weather conditions at Gunnison, Colorado (elevation 6,602 feet, 018 degrees for 43 miles for the closest weather station) were as follows: wind calm; visibility 10 statute miles; sky condition clear; altimeter 30.50 inches of mercury; temperature 46 degrees F.; dew point 39 degrees F. A witness at the accident site reported that the temperature was approximately 50 degrees F. at the time of the accident; the density altitude would have been approximately 11,864 feet. WRECKAGE AND IMPACT INFORMATION The wreckage was located in forested mountainous terrain (elevation 10,520 feet) at N37 degrees 50.219 minutes, W107 degrees 15.092 minutes. The airplane was found upright and vertically crushed in an approximate 30 degrees nose down attitude with no horizontal ground scar. The fuselage exhibited slight left torsional bending. The cabin area had been cut open by rescue personnel and the seats had been removed. Both fuel tanks were found compromised; the right wing fuel tank exhibited signs of hydraulic expansion towards the underside of the wing; and the cockpit had a strong odor of fuel. The numerous 40 to 60 foot trees surrounding the impact site were not damaged. All the airplane's flight control components were accounted for; aileron continuity was congruent to each wing. Control continuity was established for the rudder and elevator components to the aft cabin area. The tricycle retractable landing gear was found in the extended position. Examination of the flap's actuator screw drive indicated that the flaps were deployed approximately 20 degrees. The engine was found displaced aft into the firewall with all four of its engine mounts broken, but the engine control cables, hoses, and wires remained attached to the fuselage. The engine exhibited continuity by rotating the propeller; thumb compression was obtained on all cylinders and both magnetos produced spark. The throttle control was out and bent down; the mixture control was out approximately one inch; and the propeller control was full forward. The 3-bladed propeller was still attached to the engine crankshaft flange. Blade A exhibited chordwise scuffling and some leading edge damage; Blade B exhibited S bending and chordwise scoring; and Blade C was bent forward 45 degrees, twisted, and exhibited heavy chordwise scoring with heavy leading edge damage/gouges (see photographs). Two distinct types of powder were found throughout the cabin area and on the empennage. The first powder was as white as a movie screen and felt soft between one's fingers. This powder matched the powder extracted from the airplane's broken fire extinguisher bottle which is normally located under the pilot's seat. The second powder was light tan in color, and felt coarse and gritty between one's fingers. All major components of the airplane were accounted for at the accident scene. There was no evidence of pre or post impact fire. No preimpact engine or airframe anomalies, which might have affected the airplanes performance, were identified. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies on the pilot and the pilot-rated passenger were performed by Dr. Thomas M. Canfield, forensic pathologist, at the Hinsdale County Coroner's Office, on August 7 and 8, 1998, in Montrose, Colorado. Toxicology screens were performed on Gene A. Ford (the pilot) and Douglas W. Ford (right seat pilot-rated passenger) by FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. According to CAMI's report on Gene A. Ford (#9800249001), carbon monoxide and cyanide tests were not performed due to lack of suitable specimens, and no ethanol was detected in the muscle and kidney fluid. The NTSB's Medical Officer, Dr. Mitchell A. Garber, stated that the toxicology report "indicates high levels (several times higher than what would normally be expected from the maximum recommended dosage) of sertraline (Zoloft), a prescription antidepressant, and its metabolite were present in the blood and brain of the pilot." He further stated that "the high levels of medication [present in the pilot] suggest the possibility of self-medication in excess of recommended doses or of an unusual metabolism in this individual (see attached medical statement)." CAMI's report on Douglas W. Ford (#9800249002) indicated that no carbon monoxide, cyanide, or drugs were detected in the blood; and no ethanol was detected in the vitreous. ADDITIONAL INFORMATION The airplane, including all components and logbooks, were released to a representative of the owner's insurance company on September 10, 1998.

Probable Cause and Findings

The pilot's failure to maintain flying airspeed and the subsequent stall/spin. A contributing factor was high density altitude.

 

Source: NTSB Aviation Accident Database

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