# NTSB CEN21FA364: Cessna 210H, N5940F, Melbourne, AR, August 9, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 9, 2021, 11:15 local (16:15 UTC) - Place: Melbourne, AR - Coordinates: 36.056675, -91.835556 - Nearby events: https://openairdocs.org/map.md?lat=36.0567&lon=-91.8356&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Aviation, FAA FSDO - NTSB case key (mKey): 103660 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA364 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103660/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103660 - Page: https://openairdocs.org/ntsb/CEN21FA364 ## Probable cause The pilot’s failure to maintain control of the airplane with full flaps during the takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 210H, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073436), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 210H, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=2073436), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 210H, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073436), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Flight control system](https://openairdocs.org/ntsb-findings/01022700): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 210H, 1 case](https://openairdocs.org/ntsb-findings/01022700/cases.md?model=2073436), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/01022700/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 210H, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=2073436), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/deregistered/N5940F-2023-10-01), registration cancelled 2023-10-01, S/N 21058940, built 1967 (OpenAirDocs) - Reported make and model: CESSNA 210H - Registry model: [Cessna 210H](https://openairdocs.org/model/cessna-210h) (registry code 2073436) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21058940 - Year built: 1967 - Airframe hours: 3748 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210809013549A](https://openairdocs.org/incident/20210809013549A), Aug 9, 2021: Cessna 210H, Melbourne, AR, Destroyed, 1 fatal. On August 09, 2021 at approximately 1117 hours, in Melbourne, AR. A 1967 Cessna 210 aircraft registration number N5940F, serial number MM21058940 impacted… ## Docket (11 files) The files NTSB released with the investigation on September 27, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103660. 11.1 MB in all. - Field examination report (item 1, PDF, 6 pages, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15926791&FileExtension=pdf&FileName=Field%20Exam%20Report-Rel.pdf - Memorandum of record, izard county sheriff (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15904841&FileExtension=pdf&FileName=Sheriff%20Melton,%20Izard%20Co.%20AR%20MOR-Rel.pdf - Memorandum of record, j. chmura (item 3, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15927804&FileExtension=pdf&FileName=John%20Chmura%20MOR-Rel.pdf - Memorandum of record, r. dawe (item 4, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15928230&FileExtension=pdf&FileName=Dr.%20Dawe%20MOR-Rel.pdf - Witness statement (item 5, PDF, 1 page, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15905434&FileExtension=pdf&FileName=Witness%20Statement-Rel.pdf - Accident site location (item 6, PDF, 1 page, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15905696&FileExtension=pdf&FileName=Accident%20Site%20Location-Rel.pdf - Statement of party representatives to NTSB investigation, Textron aviation (item 7, PDF, 1 page, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15905157&FileExtension=pdf&FileName=Party%20Form,%20Textron_Redacted-Rel.pdf - Photographs (item 8, PDF, 6 pages, 9.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15905571&FileExtension=pdf&FileName=Photo%20Array,%20Melbourne,%20AR-Rel.pdf - Toxicological report (item 9, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15906792&FileExtension=pdf&FileName=Toxicology%20Report_Redacted-Rel.pdf - Memorandum, recording capability (item 10, PDF, 1 page, 390 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15905886&FileExtension=pdf&FileName=NTSB%20Memo_Redacted-Rel.pdf - Medical factual report (item 11, PDF, 5 pages, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16012120&FileExtension=pdf&FileName=CEN21FA364_MedicalFactualReport-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.