Aviation Accident Summaries

Aviation Accident Summary DFW08FA080

Abbeville, LA, USA

Aircraft #1

N732RR

Cessna T210M

Analysis

The commercial pilot was being vectored for an instrument approach to his destination airport when the pilot continued a right turn past his assigned heading and began to descend. The pilot did not respond to further instructions, lost control of the airplane and the airplane subsequently impacted terrain. No distress call was transmitted. The airplane, engine and systems were examined. No anomalies were discovered. The vacuum pump coupling drive and the attitude direction indicator gyro both displayed scoring consistent with proper operation at the time of impact. A passenger who had gotten off the airplane before the accident flight stated that the only malfunction he witnessed that day was a problem with the airplane's right brake. The passenger also recalled that the last time he saw the pilot, the pilot appeared to be well and alert. An assessment of the weather and airplane flight path showed that the airplane flew through instrument meteorological conditions to include dark skies, light to moderate rain, and light to moderate turbulence.

Factual Information

HISTORY OF FLIGHT On March 10, 2008, at approximately 2023 central daylight time, a Cessna T210M, N732RR, was destroyed following a collision with terrain near Abbeville, Louisiana. The instrument rated commercial pilot and passenger were fatally injured. The airplane was owned and operated by Gulf States Financial Services Incorporated. Instrument meteorological conditions prevailed and an instrument flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 48-nautical mile personal flight that originated from Baton Rouge Metropolitan Airport (BTR) at approximately 1948 and was destined to Lafayette Regional Airport (LFT). The pilot had transported two passengers from Louisiana to Mississippi for a business meeting. After the meeting was concluded, the pilot transported and deplaned one passenger at BTR and was en route to LFT for the final landing of the day. Air traffic control (ATC) was had first vectored the airplane for a visual approach to runway 29, but the pilot did not visually acquire the runway and subsequently accepted an Instrument Landing System (ILS) approach to runway 04R. The last radio transmission from the pilot was his acknowledgement for a heading of 335 degrees. Radar plots displayed the airplane turning through the assigned heading of 335 degrees while in a clockwise turn. The pilot did not respond to subsequent ATC directions. The last radar plot at 2023 shows the airplane heading approximately 046 degrees at an altitude of 1,600 feet and a ground speed of 207 knots. Local law enforcement responded to a 911 call of a crashed airplane. The wreckage was located near house and a sugar cane field. PERSONNEL INFORMATION The pilot, age 60, held a commercial pilot certificate with single-engine land, multi-engine land and instrument airplane ratings. In addition, the pilot held a flight instructor certificate with airplane single-engine land, airplane multi-engine land, and instrument airplane ratings. An instrument proficiency check was accomplished in according with 14 CFR Part 61.57(d) on June 20, 2007. A valid second-class medical certificate was issued on March 1, 2007. On that date, the pilot reported having accumulated 11,800 hours total time and 130 hour in the previous 6 months. AIRCRAFT INFORMATION The six-seat, retractable gear airplane, serial number 21061718, was manufactured in 1977. It was powered by a single, turbo-charged, 310-hp Teledyne Continental Motors (TCM) TSIO-520-R engine driving a three bladed McCauley propeller. Review of the maintenance records revealed that the last annual was accomplished on September 10, 2007, at a recorded tachometer of 1,826.4 hours and an airframe time of 4,286.9 hours. The factory remanufactured engine was installed during the annual inspection. METEOROLOGICAL INFORMATION At 1226, a LFT terminal area (TAF) was released valid from 1300 on March 10 to 1300 on March 11. The TAF forecasted weather from 1800 to be winds from 080 degrees at 8 knots, visibility greater than 6 miles, light rain showers, thunderstorms in the vicinity, and ceiling overcast at 2,500 feet with associated cumulonimbus clouds. Temporary conditions were forecast between 1800 and 2300 for a visibility of 2 miles, rain showers, mist, and ceiling overcast at 2,500 with associated cumulonimbus clouds. At 1821, a LFT TAF was released valid from 1900 on March 10 to 1900 on March 11. The TAF forecasted weather from 2000 to be winds from 360 degrees at 8 knots, visibility greater than 6 miles, rain showers, ceiling broken at 600 feet, broken at 1,500 feet and broken at 3,000 feet. Temporary conditions were forecast between 2000 and 2300 for a visibility of 4 miles, mist, few clouds at 600 feet, ceiling broken at 1,500 feet and overcast at 3,000 feet. At 2031, an automated weather reporting facility at LFT, approximately 11 nautical miles northeast of the accident site, reported winds from 330 degrees at 11 knots, visibility 2.5 miles, heavy rain showers, mist, few clouds at 600 feet, ceiling broken at 2,200 feet, overcast at 2,700 feet, temperature 59 degrees Fahrenheit, dew point 55 degrees Fahrenheit, and a barometric pressure of 30.20 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a sugar cane field consisting of soft, irrigated soil with raised berms for sugar cane. The initial point of impact was a ground scar consistent with the right wing striking the ground. At the beginning of this ground scar green lens fragments, consistent with the right wing tip navigation light, were discovered. The fuselage impact point was approximately 6 feet wide, 10 feet long, and 3 feet deep near the sugar cane field fence line. From this impact point, wreckage was scattered in a 45 degree wedge with components discovered as far as 360 feet away. The main wreckage consisted of a portion of the cabin, empennage, rudder, and horizontal stabilizer located on a magnetic heading of 160 degrees, 114 feet from the fuselage impact point. The engine was found at the fuselage impact point buried in the soft soil at an approximate depth of 4 feet. The engine was buried at an angle of approximately 20 degrees nose down with an undetermined amount of right bank. MEDICAL AND PATHOLOGICAL INFORMATION Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in muscle. The drug trimethoprim was detected in the muscle, which is consistent with the antibiotics that were prescribed to the pilot on March 4, 2008 for a sinus infection. According to the spouse, the pilot had been taking the medication for several days prior to the accident with no reported side effects. TESTS AND RESEARCH A field examination of the airframe and engine was conducted by the NTSB, FAA, and representatives from Cessna Aircraft and TCM. All major airplane components were discovered at the accident scene. Flight control continuity was established to the ailerons, rudder, and elevator. The flaps were found in the retracted position. The fuel selector was found in the left tank position which was consistent with the detailed fuel log that the pilot maintained during the flight. No anomalies were discovered which would preclude the safe operation of the airplane. Engine continuity was established to number 1 through 4 cylinders, however, cylinders 5 and 6 had been impact damaged and continuity could not be established to those cylinders. Thumb compressions was confirmed on all six cylinders. Trace amounts of fuel was discovered during examination of the fuel pump. No evidence of hard particle passage was discovered in the oil system. Two blades had separated from the propeller hub and all three blades exhibited evidence of S-bending, chord wise scratches and gouging consistent with power at the time of impact. No anomalies were discovered which would preclude the production of engine power. The vacuum pump case had impact damage. Pieces of the drive coupling displayed evidence of rotational scoring. The attitude direction indicator (ADI) displayed an approximate level attitude and 25 degrees of right bank. When the ADI was disassembled the internal gyro displayed rotational scoring. No warning flags were present on the ADI. A horizontal situation indicator (HSI) displayed a heading of approximately 270 degrees with a selected course of approximately 036 degrees, consistent with the desired inbound course for the ILS 04R approach. No warning flags were present on the HSI. The internal components of the HSI sustained heavy damage. ADDITIONAL INFORMATION A telephone interview was conducted with the passenger who deplaned at BTR. He stated that he had flown with the pilot numerous times and would describe the pilot as a cautious pilot. On the day of the accident the passenger reported that the pilot behavior was normal and the pilot did not mention any health or fatigue concerns. The passenger recalled a single malfunction that had occurred on the second flight of day involving the airplane's right brake. The pilot ensured that the airplane was serviced properly and no other malfunctions were encountered. When last observed by the passenger, the pilot appeared to be alert. A telephone interview was conducted with the certified flight instructor (CFI) who had signed off the pilot's instrument flight rules proficiency check on June 20, 2007. The CFI reported that in his opinion the pilot was a very conservative pilot who was very knowledgeable concerning instrument procedures. The CFI added that he had flown into LFT near the time of the accident, and recalled the weather consisted of heavy rain showers and turbulence. The CFI commented that he would categorize the turbulence as "not severe." According to the pilot's spouse, the pilot normally went to bed between the hours of 2030 and 2130. The pilot worked at a hospital and normally worked 12 hour shifts. According to flight tracking information, the pilot's first flight of the day departed LFT at 0754 and radar data places the time of the accident at approximately 2023, which puts the pilot's "time-on-duty" at over 12 hours and 29 minutes. It is unknown when the pilot ate and how long he rested during the day of the accident.

Probable Cause and Findings

The pilot's failure to maintain aircraft control for undetermined reasons. Contributing to the accident were the prevailing clouds, rain, and turbulence.

 

Source: NTSB Aviation Accident Database

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