CEN12FA311

NTSB accident investigation · Cessna T210L · Boyd, TX · May 21, 2012

Accident · FatalField investigationFinal report
Date
May 20, 2012, 19:30 local (May 21, 2012, 00:30 UTC)
Place
Boyd, TX
Injuries
1 fatal, 3 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N29112Cessna T210L
Defining event
Approach-VFR go-around: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed · report September 24, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO Fort Worth, Cessna
FAA report
20120520009179A
Case key
83719

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s delayed initiation of a go-around and early retraction of the flaps during the maneuver, which resulted in a collision with trees.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: delayed actionPersonnel issues › Action/decision · PilotCessna T210L: 1 caseAll aircraft: 894 casesProbable cause
Use of equip/infoPersonnel issues › Task performance · PilotCessna T210L: 1 caseAll aircraft: 111 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

A witness reported observing the airplane on what seemed to be a normal approach toward the 1,800-foot-long grass airstrip before the airplane was no longer visible behind treelines. A pilot-rated passenger stated that the wind was calm during the straight-in approach and that the airplane had not touched down by about midfield, at which time, the pilot initiated a go-around. During the climbout, the pilot retracted the flaps. The airplane subsequently collided with the top of a treeline located perpendicular to the departure end of the runway, rolled left, struck more trees, and then impacted the ground. A postimpact fire ensued. Visual meteorological conditions with light wind prevailed at the time of the accident. Examination of the airframe and engine did not reveal any preexisting anomalies that would have contributed to the accident. Estimated weight and balance calculations showed that the airplane was within limits for takeoff and landing. Airplane performance calculations indicated that the airplane should have had positive climb performance during the go-around; however, the pilot retracted the flaps when the airplane was about 900 feet down the runway, which left only 900 feet to clear the 30-foot-high treeline. Therefore, although the airplane had positive climb performance, the delayed go-around and early retraction of the flaps left the airplane in a position with insufficient distance to clear the treeline, which resulted in a collision with the trees.

Factual narrative

The wreckage was released to the owner's representative. The airplane, a 1973 model Cessna T210 was purchased by the pilot on April 2, 2012. The airplane's most recent annual inspection was completed on April 21, 2011. A review of the airplane's logbooks showed that it had about 3,698 hours total time. The engine, a Continental TSIO-520-H4B, had about 1,441 hours since it's most recent major overhaul. No uncorrected mechanical anomalies were found in the airframe or engine records. On May 20, 2012, at 1930 central daylight time a Cessna T210L, N29112, registered to and owned by the pilot, was substantially damaged when it impacted trees and the ground during a go-around maneuver at a private grass airstrip near Boyd, Texas. There were 4 occupants onboard. The private pilot sustained fatal injuries and 3 passengers sustained serious injuries. Visual meteorological conditions prevailed in the vicinity and no flight plan was filed for the 14 Code of Federal Regulations Part 91 flight. The personal cross-country flight originated at 1800 from the Shreveport Downtown Airport (DTN), Shreveport, Louisiana, and the private airstrip was its final destination. Several residents of the area located in the vicinity of the airstrip saw the airplane on what seemed to be a normal approach toward the airstrip before the airplane was no longer visible behind tree lines. One passenger who survived, who occupied the right front seat, stated that the wind was calm during the approach and that the airplane had not touched by about mid-field, at which time the pilot decided to initiate a go-around. The passenger stated that during the go-around climb out, the pilot retracted the flaps.The airplane collided with the top of a tree line located perpendicular to the departure end of the runway. After the collision, the airplane rolled to the left, struck more trees and impacted the ground. A post-impact fire ensued. The three passengers were able to exit the airplane and were transported to a local hospital. The seat belt restrained pilot succumbed to injuries at the accident site. The nearest weather reporting station was located at Decatur, Texas, about 10 miles north of the accident site. Visual meteorological conditions prevailed throughout the area. Winds were reported as light from 130 degrees at 3 knots. Skies were clear and visibility was 10 miles. The pilot had recently transitioned from a 1960 Cessna 210 to the 1973 Cessna T210 accident airplane. He held a private pilot certificate (Airplane Single Engine Land), and had a valid FAA third class medical certificate dated November 2, 2010. At the time of the November 2nd medical application, the pilot reported 335 total hours of flight time. A review of the pilot's logbooks and interviews with his associates showed that he had a total of about 416 hours of flight time at the time of the accident. Family and friends of the pilot reported that he was a conscientious and meticulous pilot and was proficient in flyingthe T210. The pilot had recently purchased the 1973 Cessna T210L. He had previously flown a 1960 Cessna 210. The passenger reported that the pilot had retracted the flaps after he initiated the go-around, about midfield of the 1,800 foot long runway. The 1960 Cessna 210 hydraulic flaps may be stopped in any intermediate position between retracted and extended. This is done by releasing the flap control handle which is spring-loaded to return to its center (off) position. The 'After Takeoff' (or go-around) procedure in the 1960 Cessna 210 is: Retract the wings flaps at a safe altitude and airspeed. The 1973 Cessna T210L electric flap control lever detent determines the stopping position of the flaps. 1973 Cessna T210L Go-Around procedure is: The wing flap setting should be reduced to 20 degrees immediately after full power is applied. After all obstacles are cleared and a safe altitude and airspeed are obtained, the wing flaps should be retracted. Estimated weight and balance calculations showed that the airplane was within limits for takeoff from Shreveport and landing at Boyd. Several broken/damaged tree branches atop two 30-foot tall trees were found beyond the departure end of the 1,800-foot grass runway near the extended runway centerline, consistent with the airplane's flight path. The airplane wreckage was found beyond the damaged trees and appeared to impact the ground inverted. Evidence at the accident site showed that the airplane had contacted three separate trees before coming to rest inverted on top of a small wooden well house structure. The left outboard balance weight and fiberglass tip fairing were found near the second tree along the right side of the energy path. The post-impact fire consumed a majority of the cabin, fuselage and inboard wing sections. Primary flight control continuity was established from the cockpit to the flight control surfaces. The elevator trim cable continuity was established from the cabin floor area to the actuator. The elevator trim tab was observed approximately 5degrees tab down (nose up) position. The flaps and flap actuator were in the retracted position. The ailerons, elevators, and rudder were attached to their respective fixed attachment points. The fuel tanks were compromised and the fuel selector valve was found in the right tank position. The right tank finger screen was found not obstructed. The post-impact fire damage prevented investigators from documenting cockpit switch positions. No pre-impact anomalies were discovered during the airframe examinations. The engine and propeller assemblies were transported to a secured facility for examination. The engine was intact with severe fire damage. All of the accessories were separated during the impact with the exception of the propeller governor, fuel pump, starter, and alternator. The vacuum pump was also still attached to the engine. The number two cylinder head was separated and the number four and six rocker covers were burned away. Partof the oil sump was burned away and a hole was burned in the crankcase halves below the magneto attachment points. The top spark plugs and rocker arms were removed, but the crankshaft could not be rotated due to thermal and impact damage. The cylinders were examined using a lighted borescope. With the exception of the number two cylinder, normal combustion deposits were observed on the heads and the cylinder domes. The valves were in place and not damaged. Other than the severe thermal and impact damage, no pre-impact anomalies were discovered during the engine examination. The three bladed propeller assembly and propeller spinner showed evidence of rotation at impact.

Aircraft

Registration
N29112
Reported as
Cessna T210L
Category
Airplane
Serial number
21059805
Airframe hours
3,698.7
Engine
Cont Motor TSIO-520 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Steven Dauenhauer
Registered owner
Steven Dauenhauer
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 21, 2011
Departed
DTN · Shreveport, LA
Destination
0000 · Boyd, TX
Airport
0000 · Dauenhauer Field (Private), runway 35, 1,800 × 50 ft, grass/turf

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
September 18, 2011
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
417 total · 60 in this make and model · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 50 °F
Altimeter
30.07 inHg
Observed at
LUD, 18 nm away

Docket · 9

The files NTSB released with the investigation on September 9, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.