CEN21FA364

NTSB accident investigation · Cessna 210H · Melbourne, AR · August 9, 2021

Accident · FatalClass 3 · FieldFinal report
Date
August 9, 2021, 11:15 local (16:15 UTC)
Place
Melbourne, AR
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5940FCessna 210H
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Textron Aviation, FAA FSDO
FAA report
20210809013549A
Case key
103660

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 failure to maintain control of the airplane with full flaps during the takeoff.

Findings · 4

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 210H: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parameters: climb rateAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 210H: 1 caseAll aircraft: 265 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 210H: 2 casesAll aircraft: 1,391 casesProbable cause
Flight control systemAircraft › Aircraft systems · Incorrect use/operationCessna 210H: 1 caseAll aircraft: 65 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

The pilot was conducting a personal flight to his home airport. A witness at the departure airport reported observing the pilot conduct a preflight examination of the airplane and then taxi the airplane to the runway for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll and that the airplane lifted off near the departure end of the runway. Witnesses who were located beyond the departure end of the runway reported that the airplane was flying low and seemed to be turning just before it crashed. The airplane impacted trees and terrain. A postcrash fire ensued and destroyed the airplane. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operations. The flap actuator was found in the fully extended position (30°). The elevator trim actuator was measured at a 2-inch extension, which was consistent with a 20° nose-down position. With the flaps fully extended, the airplane’s ability to climb and maneuver was significantly degraded. As a result, the pilot was unable to maintain airplane control while making a turn at a low altitude after liftoff. Postmortem toxicology testing showed that the pilot’s hemoglobin A1C level was 7.2%, which indicated the pilot’s diabetes was uncontrolled (but not severely) during the months before the accident. His elevated glucose (sugar) level placed him at risk for fatigue, dehydration, and blurred vision. The investigation could not determine whether the pilot’s uncontrolled diabetes impaired his ability to properly monitor the airplane’s configuration and safely perform the takeoff and climb.

Factual narrative

After the accident, 42A installed radio transmission recording capability on its UNICOM frequency. According to the Cessna Turbo-System Centurion Owner’s Manual, at a gross weight of 3,400 pounds (maximum gross weight), the airplane’s stall speed at 0° of bank with the landing gear down and the flaps retracted was 74 mph. With the landing gear down and the flaps fully down (30o), the stall speed was 63 mph. With 30o of bank, the gear down, and the flaps fully down, the stall speed was 68 mph. With 60o of bank, the gear down, and the flaps fully down, the stall speed was 89 mph. The before takeoff checklist stated that flaps should be set between 0 o (flaps up) and 20o (maximum performance takeoff configuration). The takeoff discussion does not reference any flap setting greater than 20o. The owner’s manual stated that, for a balked landing (go-around) climb, the flaps should be reduced to 20o immediately after full power is applied. The manual also stated that, after all obstacles are cleared and a safe altitude and airspeed are obtained, the flaps should be retracted. The owner’s manual only cited two uses for full flaps (30o): short field landings and the emergency landing procedure with a defective nose gear. The field elevation at 42A was 734 ft. Runway 21 was 4,003 ft long. The temperature was 89.6oF (32oC), the dew point was 75oF (24oC), and the altimeter was 30.01 inches. On the basis of this information, at 3,400 pounds and with 20o of flaps and no headwind, the airplane would have a takeoff ground run of about 920 ft, and the distance needed to clear a 50 ft obstacle would be 1,708 ft. On August 9, 2021, about 1115 central daylight time, a Cessna 210H airplane, N5940F, was destroyed when it was involved in an accident near Melbourne, Arkansas. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot intended to fly the airplane from Melbourne Municipal Airport (42A), Melbourne, Arkansas, to his home airport 60 miles away in Heber Springs, Arkansas. A witness, who was at the departure airport, reported observing the pilot conduct a preflight of the airplane and taxi to runway 21 for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll, and then he observed the airplane lift off near the departure end of the runway. No radio or distress calls were heard from the pilot. At the time of the accident, the departure airport’s UNICOM radio receiver was not staffed and did not have the capability to record. An autopsy of the pilot was performed by the State Crime Lab, Medical Examiner Division, Little Rock, Arkansas. His cause of death was multiple blunt force injuries. Toxicology testing by the Federal Aviation Administration Forensic Sciences Laboratory identified no tested-for drugs. The pilot’s glucose (sugar) was 144 mg/dL in vitreous specimens and 195 mg/dl in urine specimens. The pilot’s hemoglobin A1C (HbA1c) bloodlevel was 7.2%. The FAA considers glucose levels in vitreous and urine specimens to be abnormal if above 125 and 100 mg/dL, respectively. HbA1c is an indirect measure of a person’s average blood sugar during the preceding 3 months. Generally, an HbA1c of 6.5% or higher indicates diabetes, and an HbA1c of less than 7% indicates control of diabetes. The accident site was located about 3,500 ft from the departure end of the runway on a magnetic heading of 188°, as shown in the figure below. Figure. Accident site location in relation to 42A. Examination of the wreckage showed that the airplane impacted several large 80-ft-tall trees before it came to rest on the ground. Pieces of the right elevator and right horizontal stabilizer were found embedded in tree branches about 20 ft above the ground. The fuselage, wings, and engine were laying on the ground adjacent to a large tree. Most of the airframe was consumed by the postimpact fire. The engine was found separated from the fuselage about 4 ft from the main wreckage. The engine was mostly intact and had minor fire damage. Several cut branches observed in the trees were consistent with propeller blade strikes. The propeller remained attached to the engine at the flange. All three blades showed S-bending, chordwise rubs and scratches, and leading-edge nicks. Flight control continuity was confirmed from all control surfaces to the cockpit. Further examination of the airframe showed that the flap actuator was in the fully extended position (30°). The elevator trim actuator was measured at a 2 inch extension, which was consistent with a 20° nose-down position. The engine was examined, and no pre-impact anomalies were found.

Aircraft

Registration
N5940F
Reported as
Cessna 210H
Category
Airplane
Serial number
21058940
Built
1967
Airframe hours
3,748
Engine
Cont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Langster Rodger D
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 27, 2020
Destination
HBZ · Heber Springs, AR
Airport
42A · Melbourne Muni - John E Miller Fld, runway 21, 4,003 × 75 ft, asphalt
Equipment
ADS-B

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
56
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
847 total · 658 in this make and model · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 75 °F
Altimeter
30.01 inHg
Observed at
KBVX, 22 nm away
METAR
KBVX 091556Z AUTO 21009KT 10SM FEW026 SCT034 SCT041 32/24 A3001 RMK AO2 SLP158 T03170239

Docket · 11

The files NTSB released with the investigation on September 27, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.1 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.