# NTSB CEN22FA042: Cessna T310R, N310JA, Chadron, NE, November 22, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 21, 2021, 19:20 local (Nov 22, 2021, 02:20 UTC) - Place: Chadron, NE - Coordinates: 42.84705, -103.11431 - Nearby events: https://openairdocs.org/map.md?lat=42.8471&lon=-103.1143&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Medical event](https://openairdocs.org/ntsb-events/850) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron, FAA FSDO - NTSB case key (mKey): 104284 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104284/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104284 - Page: https://openairdocs.org/ntsb/CEN22FA042 ## Probable cause The incapacitating effects of a myocardial infarction (heart attack), which resulted in the pilot's loss of airplane control and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot; cases with it: [Cessna T310R, 2 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=2074246), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Cessna T310R, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2074246), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Medical event](https://openairdocs.org/ntsb-events/850) (defining event); cases with it: [Cessna T310R, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=2074246), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna T310R, 4 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2074246), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T310R, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2074246), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed on a personal flight in dark night visual meteorological conditions. The airplane impacted terrain northwest of the airport about 30 seconds after departure. The distribution of the debris was consistent with a wings-level, slightly nose-down impact. The airplane was destroyed by impact forces and a postimpact fire. Postaccident examination of the airframe and engines revealed no mechanical anomalies that would have precluded normal operation. Although toxicology results revealed that the pilot was taking at least two medications (chlorpheniramine and dextromethorphan) that may have impaired his performance, the fact that the medication levels were unquantifiable indicated that their levels were too low for them to have had significantly impairing effects at the time of the accident. According to the autopsy findings, the pilot was actively having a heart attack in the hours before the accident. This placed him at severely increased risk for acute impairment/incapacitation from chest pain, shortness of breath, feeling faint, or becoming unconscious. Any of these symptoms would have likely led to the low altitude loss of control identified in this crash. Therefore, the pilot’s ongoing myocardial infarction (heart attack) is the most likely cause of this accident. ## Factual narrative On November 21, 2021, about 1920 mountain standard time, a Cessna T310R, N310JA, was destroyed when it was involved in an accident near Chadron, Nebraska. The pilot and two passengers sustained fatal injuries. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The airplane landed at the Chadron Municipal Airport (CDR), Chadron, Nebraska, dropped off a passenger, and refueled. About 40 minutes later, the airplane departed from runway 30 at CDR in dark night visual meteorological conditions. Airport security video showed the airplane takeoff roll and liftoff. Automatic dependent surveillance – broadcast (ADS-B) data showed the airplane climbed to about 200 ft, turned to the right, and descended into rising terrain (Figure 1). According to a Federal Aviation Administration (FAA) inspector, the pilot had flown two legs the day before the accident flight. On November 20, 2021, the pilot departed his home airport about 1134 and returned to his home airport about 0023. The pilot departed about 6 hours later and arrived at CDR about 0630 on November 21, 2021, then proceeded to Flying Cloud Municipal Airport (FCM), Eden Prairie, Minnesota. The pilot departed FCM about 1704 central standard time and arrived at CDR about 1843. About 1920, the pilot departed CDR on the accident flight. Figure 1 – ADS-B flight path. An autopsy of the pilot was performed by Western Pathology Consultants. According to the autopsy report, the cause of death was blunt force injuries due to acute coronary thrombosis and the manner of death was accident. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the pilot. Chlorpheniramine was detected. Chlorpheniramine is an antihistamine used to treat allergies and can cause drowsiness. Chlorpheniramine is acceptable for flying if it is used no more than 1-2 times per week and 5 days have elapsed before flying. Dextromethorphan and its metabolite dextrorphan were detected. This medication is used as a cough suppressant and can cause drowsiness and nausea. Dextromethorphan is disqualifying for flying and requires at least 48 hours before performing pilot duties. Loratadine and the metabolite desloratadine was detected. Loratadine (Claritin) is a nonprescription nonsedating antihistamine used to treat allergies. It is acceptable for FAA medical certification. Losartan was detected. Losartan (Cozaar) is an ACE-II inhibitor-type antihypertensive used to treat high blood pressure and is acceptable for FAA medical certification. This medication was reported on the most recent medical exam. Local airport personnel stated that the night was dark with no visible horizon at the departure end of the runway. The pilot held a private pilot certificate with a rating for airplane multi-engine land and airplane single-engine land. The pilot’s most recent FAA medical examination was on July 27, 2020. At that time, the pilot reported civilflight experience of 445 total hours. He had reported hay fever and high blood pressure to the FAA and used losartan to treat his blood pressure. No significant abnormalities were identified during the exam, and he was issued a third-class medical certificate limited by a requirement to wear corrective lenses. A review of the pilot’s logbook revealed that the pilot had accumulated 502.3 total hours of flight experience as of November 20, 2021, the day before the accident. He had about 83 hours of flight experience in the accident airplane make and model. In the 30 days before the accident, he had accumulated about 10 hours, with about 7 hours in the 24 hours before the accident. The initial ground impact was about 3,347 ft above mean sea level (msl), on an approximate heading of 350°. The wreckage debris was dispersed over 600 ft past the initial ground impact point. See Figure 2. Figure 2. Wreckage Distribution. A postcrash fire consumed most of the airplane. The distribution of the debris was consistent with a nearly-wings-level, slightly nose-down, high-speed impact. Ground scars from the propeller blades of both engines were present and consistent with rotation at the time of impact. Although most of the airplane wreckage was consumed by fire, examinations of the flight controls did not reveal any preimpact anomalies. Both engines were examined and did not reveal any preimpact anomalies. Fuel was present in each engine’s fuel distribution system. The damage to the propeller blade assemblies from both left and right engines were symmetrical, consistent with the engines producing similar power at the time of impact. ## Aircraft - Registration: [N310JA](https://openairdocs.org/aircraft/N310JA), registered now, S/N 310R-1319, built 1978 (OpenAirDocs) - Reported make and model: CESSNA T310R - Registry model: [Cessna T310R](https://openairdocs.org/model/cessna-t310r) (registry code 2074246) (OpenAirDocs) - Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 310R-1319 - Year built: 1978 - Airframe hours: 5410 - Engines: Continental TSIO-520-EB 300 horsepower reciprocating; Continental TSIO-520-EB 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 25, 2021, 36 hours before - Departed: KCDR, Chadron, NE - Destination: FNL, Fort Collins, CO - Airport: CDR, Chadron Municipal, runway 30, 4,400 × 75 ft, asphalt - Equipment: ADS-B, Auto-pilot, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review July 2, 2020; seat: left; restraint: 3-point; flight hours: 502.3 total, 88 in this make and model, 20 in the last 90 days, 10 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 28 °F, dew point 18 °F - Altimeter: 30.24 inHg - Observed at: KCDR, 1 nm away - METAR: KCDR 220153Z AUTO 00000KT 10SM CLR M02/M08 A3024 RMK AO2 SLP281 T10221083 ## 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 20211121019749A](https://openairdocs.org/incident/20211121019749A), Nov 21, 2021: Cessna T310R, Chadron, NE, Destroyed, 3 fatal. On Sunday November 21, 2021 at 1919 MST, N310JA, a Cessna T310R, departed Chadron municipal airport (kcdr) runway 30, in Chadron, Nebraska with one pilot and… ## Docket (9 files) The files NTSB released with the investigation on January 30, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104284. 54.1 MB in all. - Memorandum for record (item 1, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16395150&FileExtension=pdf&FileName=MFR%208020-23-Rel.pdf - Wreckage diagram (item 2, PDF, 1 page, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16393326&FileExtension=pdf&FileName=Wreckage%20diagram-Rel.pdf - Memorandum for the record site airframe and engines examination findings CEN22FA042 (item 3, PDF, 3 pages, 539 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16449908&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Site%20Airframe%20and%20Engines%20Examination%20Findings%20CEN22FA042_Redacted-Rel.pdf - Video file (item 4, MP4, 52.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16363190&FileExtension=mp4&FileName=551417793_1_20211121T191805Z_20211121T192123Z-Rel.mp4 - ADS-B data (item 5, CSV, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16362810&FileExtension=csv&FileName=20211122_A3479A_470119319_ADSB-Rel.csv - Medical factual report (item 6, PDF, 3 pages, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16362936&FileExtension=pdf&FileName=CEN22FA042_Medical%20Factual%20Report-Rel.pdf - Toxicological report (item 7, PDF, 2 pages, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16389880&FileExtension=pdf&FileName=2021_207_002%20-%20Pilot%20Tox_Redacted-Rel.pdf - Certificate of party representative Textron CEN22FA042 (item 8, PDF, 1 page, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16451269&FileExtension=pdf&FileName=Certificate%20of%20Party%20Representative%20Textron%20CEN22FA042_%20Redacted-Rel.pdf - Wreckage release CEN22FA042 (item 9, PDF, 2 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16451801&FileExtension=pdf&FileName=Wreckage%20Release%20CEN22FA042-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.