CHI05FA016

NTSB accident investigation · Cessna P210N · Wautoma, WI · October 26, 2004

Accident · FatalField investigationFinal report
Date
October 26, 2004, 11:25 local (16:25 UTC)
Place
Wautoma, WI
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N5485WCessna P210N
Weather
Visual (VMC) · Day
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Aero Accessories Inc., Federal Aviation Administration, Parker Hannifin Corporation, Teledyne Continental Motors
FAA report
20041026029309A
Case key
60441

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 not maintaining airplane control during cruise flight in instrument meteorological conditions after reporting a loss of gyros leading to his exceeding the design load limits of the wings. Factors were the clouds, the deteriorated vacuum manifold flapper valve, and the non-factory modification of that manifold by an unknown party.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - cloudsFactor
Airframe/component/system failure/malfunctionCruise
Maintenance,modification - performedUnknownFactor
Vacuum system - deterioratedFactor
Loss of control - in flightCruise
Aircraft control - not maintainedPilot in commandCause
Use of inappropriate medication/drugPilot in command
Inadequate substantiation process,insuff reviewFaa(organization)
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededPilot in commandCause
Wing - overloadCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane was destroyed during an in-flight break-up and subsequent impact with terrain. The pilot advised the controller that the airplane was losing its gyros and that he needed to descend. The pilot then reported that the gyros appeared to be working. The controller advised the pilot that the airplane was on a southwest heading and that the pilot could fly whatever altitude he was able to maintain. The controller was looking for an airport with visual meteorological conditions present and asked the pilot if the airplane was in the clouds. The pilot reported affirmative. The pilot's last transmission was that it was going into a spin. Radar contact was lost about that time. In a Sheriff's report, two witnesses indicated that they heard thunder or jets flying. The report showed that they heard a "high winding noise from [the] plane engine." The noise was directly above their position and they heard a loud bang. They reported seeing a plane at about 1,500 to 2,000 feet above ground level. The airplane was observed spinning straight down without its wings. The witnesses indicated that they observed something hanging from its tail section. A Meteorological Factual Report was compiled and the flight's plotted radar track showed that the airplane was in layered clouds and that there was visual flight rules weather conditions below the clouds. Recorded groundspeed varied between 130 to 160 knots. Winds aloft were headwind and quartering winds. The airplane's information manual's limitations section stated, in part, "Maneuvering Speed:4000 pounds-130 Knots Indicated Air Speed (KIAS), 3350 pounds-119 KIAS, 2700 pounds-106 KIAS Remarks: Do not make full or abrupt control movements above this speed." A flapper valve in the vacuum manifold exhibited deterioration and a crack. General observation of the manifold revealed that it had been disassembled and reassembled with non-manufacturer specified rivets. No further airframe of engine preimpact anomalies were detected with the recovered wreckage. Examination of instrument gyro rotors revealed rotational scoring.

Post-accident toxicology evaluation of specimens from the pilot was consistent with the intermittent use of fluoxetine (a prescription antidepressant often known by the trade name Prozac). The pilot did not indicate any mental conditions or the use of any psychiatric medications on applications for airman medical certificate.

Factual narrative

History of flight

On October 26, 2004, about 1125 central daylight time, a Cessna P210N, N5485W, piloted by a private pilot, was destroyed during an in-flight break-up and subsequent impact with terrain near Wautoma, Wisconsin. The personal flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. An instrument flight rules flight plan was on file and activated. The pilot and passenger were fatally injured. The flight originated from the Palwaukee Municipal Airport, near Wheeling, Illinois, at time unknown and was destined for the Pine River Regional Airport (PWC), near Pine River, Minnesota.

Federal Aviation Administration (FAA) data showed that the flight was in contact with air traffic control. During the flight, the pilot requested a heading deviation for weather and that deviation was approved. A controller asked the pilot for a ride report for his altitude and the pilot reported that the flight was "bounced" around and characterized the ride as "moderate" turbulence. The pilot reported that the ride smoothed out "considerably" after the deviation for weather. The pilot was given a frequency change and was asked to report to the next controller when he could turn back on course to his destination. The pilot was given a new transponder squawk code when he checked on with the next controller about 1113. The pilot reported that he was turning back "direct PWC" about 1117. The pilot advised the controller that the airplane was losing its gyros and that he needed to descend about 1119. The pilot then reported that the gyros appeared to be working and that he was in a "fix there a second ago" about 1120. The controller advised the pilot that the airplane was on a southwest heading and that the pilot could fly whatever altitude he was able to maintain. The controller was looking for an airport with visual meteorological conditions present and asked the pilot if the airplane was in the clouds about 1122. The pilot reported affirmative. The pilot's last transmission was that the airplane was going into a spin about 1123. Radar contact was lost about that time.

Two witnesses reported to the Waushara County Sheriff's office that they observed the flight while they were planting trees on their property. In the sheriff's report of their statements, the witnesses indicated that they heard thunder or jets flying. The report showed that they heard a "high winding noise from [the] plane engine." The noise was directly above their position and they heard a loud bang. They reported seeing a plane at about 1,500 to 2,000 feet above ground level (AGL). The airplane was observed spinning straight down without its wings. The witnesses indicated that they observed something hanging from its tail section.

Personnel information

The pilot held a private pilot certificate with single engine land, single engine sea, and instrument airplane ratings. Review of the pilot's logbook showed that the pilot had completed a flight review on June 6, 2004. The pilot had accumulated about 2,544 hours of total flight time, 607 hours of actual instrument time, 60 hours of simulated instrument time, and 12 hours in the previous 30 days.

He held a FAA third-class medical certificate issued on October 5, 2003, with a limitation to wear corrective lenses. At the time of that medical, he reported 2,500 hours total flight time and 100 hours in the six months prior to that examination. That medical application asked, "Do you currently use any medication (Prescription or Nonprescription)?" The pilot indicated, "Yes, Vioxx, Pravachol, and antacid." That application further asked, "Have you ever in your life been diagnosed with, had, or do you presently have any of the following? ... Mental disorders of any sort, depression, anxiety, etc." The pilot indicated "No"

Aircraft information

N5485W, a Cessna P210N, Centurion, serial number P21000695, was a six-place, single engine, full cantilever high-wing, all-metal airplane of semimonocoque construction. The wings were constructed with integral fuel tanks. The airplane was powered by a six-cylinder, horizontally opposed, turbocharged, air cooled, fuel injected, Teledyne Continental TSIO-520-P engine, serial number 513734. The engine was rated at 310 horsepower for five minutes and 285 horsepower continuously. Maintenance records showed that the airplane's propeller was a three-bladed McCauley D3A34C402/90DFA-10 model, hub serial number 811432. The propeller blade serial numbers were B129481, B132981, and B138862. The propeller was last overhauled on November 24, 1993. The airplane was issued a standard airworthiness certificate and was certified for normal category operations.

Maintenance records show that the airplane was equipped with an electric powered auxiliary vacuum pump, which was installed under Supplemental Type Certificate SA668GL on April 27, 1987. The airplane had accumulated 682 hours of total time at the time of the auxiliary pump installation.

Billing records show that the last annual inspection was performed on January 15, 2004, and that the airplane had accumulated 2,606 hours at the time of that inspection.

Billing records show that the engine driven vacuum pump was replaced on February 5, 2004. The airplane had accumulated 2,661.1 hours at the time of that installation. The installed engine driven vacuum pump was an Aero Accessories AA 216 CW model.

Meteorological information

A Senior Meteorologist for the National Transportation Safety Board (NTSB) compiled a Meteorological Factual Report for the investigation. Heights listed in the Surface Weather Observations are AGL. Excerpts from that report follow:

Surface Weather Observations

Surface weather observations for airports surrounding the accident

location, in part, follow:

Alexander Field South Wood County Airport (KISW), Wisconsin

Rapids, Wisconsin

field elevation 1,021 feet [mean sea level] msl, located approximately

304 degrees at 34 nautical miles from the accident location,

unaugmented Automated Surface Observing System (ASOS)

Time.1054; type.METAR; wind.060 degrees at 13 knots; visibility.

10 miles; present weather.light rain; sky condition.overcast 5,500 feet;

temperature.08 degrees Celsius; dew point.06 degrees Celsius;

altimeter setting.30.19 inches hg; remarks.rain began 1054

Time.1121; type.SPECI; wind.030 degrees at 8 knots; visibility.10

miles; present weather.none; sky condition.broken 1,300 feet overcast

5,500 feet; temperature.08 degrees Celsius; dew point.06 degrees

Celsius; altimeter setting.30.21 inches hg; remarks.lightning distant

south rain ended 1117

Time.1154; type.METAR; wind.060 degrees at 13 knots gusting 20

knots; visibility.10 miles; present weather.light rain; sky condition.

overcast 1,300 feet; temperature.08 degrees Celsius; dew point.06

degrees Celsius; altimeter setting.30.19 inches hg; remarks.lightning

distant southeast rain ended 1117 began 1144

Stevens Point Municipal Airport (KSTE), Stevens Point, Wisconsin

field elevation 1,110 feet msl, located approximately 333 degrees at 34

nautical miles from the accident location, unaugmented ASOS

Time.1055; type.METAR; wind.060 degrees at 8 knots; visibility.10

miles; present weather.light rain; sky condition.overcast 5,500 feet;

temperature.06 degrees Celsius; dew point.04 degrees Celsius;

altimeter setting.30.20 inches hg; remarks.none

Time.1155; type.METAR; wind.040 degrees at 8 knots; visibility.10

miles; present weather.light rain; sky condition.broken 1,100 feet

overcast 5,500 feet; temperature.07 degrees Celsius; dew point.05

degrees Celsius; altimeter setting.30.20 inches hg; remarks.none

Outagamie County Regional Airport (KATW), Appleton, Wisconsin

field elevation 918 feet ms

Aircraft

Registration
N5485W
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000695
Airframe hours
2,686.7
Engine
Continental TSIO-520-P, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Blue Sky Horizons Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 15, 2004 · 80.7 hours before
Departed
PWK · Chicago/Prospec, IL
Destination
PWC · Pine River, MN
Flight plan
IFR

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
57
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
June 6, 2004
Seat
Left
Toxicology
Performed
Flight hours
2,544 total · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 6 knots
Visibility
4 statute miles
Lowest ceiling
4,000 ft broken
Temperature
46 °F, dew point 43 °F
Altimeter
30.15 inHg
Observed at
VOK, 41 nm away

Docket · 39

The files NTSB released with the investigation on April 29, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 44.7 MB in all.

Meteorology 5 - Factual Report of Group ChairmanItem 1 · .PDF · 2.2 MBMedical Records InformationItem 2 · .PDF · 8 KBWreckage Diagram Provided By ContinentalItem 3 · .PDF · 196 KBWaushara County Sheriff's Report ExcerptsItem 4 · .PDF · 90 KBPlots of the Wreckage Area Supplied by the Waushara County Sheriff's OfficeItem 5 · .PDF · 240 KBMap of Wreckage Pattern and GPS Readings of Items, Supplied By a Department of Natural Resources WardenItem 6 · .PDF · 466 KBCessna Supplied Plots of Radar DataItem 7 · .PDF · 628 KBGraph of Groundspeeds From Radar DataItem 8 · .PDF · 77 KBBilling Records For Engine Driven Vacuum Pump InstallaionItem 9 · .PDF · 58 KBBilling Records for Last Annual InspectionItem 10 · .PDF · 164 KBBilling Records for Maintenance WorkItem 11 · .PDF · 89 KBFueling ReceiptsItem 12 · .PDF · 47 KBInsurance ApplicationItem 13 · .PDF · 80 KBParker Hannifin ReportItem 14 · .PDF · 13.0 MBLogbook ExcerptsItem 15 · .PDF · 997 KBToxicological ReportItem 16 · .PDF · 71 KBStatement of Party Representatives to NTSB InvestigationItem 17 · .PDF · 341 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 18 · .PDF · 79 KBPhoto 1. Accident SiteItem 19 · .PDF · 1.3 MBPhoto 2. Accident SiteItem 20 · .PDF · 1.3 MBPhoto 3. Accident SiteItem 21 · .PDF · 1.4 MBPhoto 4. Accident SiteItem 22 · .PDF · 1.4 MBPhoto 5. EngineItem 23 · .PDF · 1.4 MBPhoto 6. EmpennageItem 24 · .PDF · 1.2 MBPhoto 7. Vacuum ManifoldItem 25 · .PDF · 1.0 MBPhoto 8. Rotor HousingItem 26 · .PDF · 1.1 MBPhoto 9. RotorItem 27 · .PDF · 1.3 MBPhoto 10. Turn Coordinator RotorItem 28 · .PDF · 1.2 MBPhoto 11. Wing Tip and Empennage With Transfer MarksItem 29 · .PDF · 1.2 MBPhoto 12. Airplane LayoutItem 30 · .PDF · 1.2 MBPhoto 13. PropellerItem 31 · .PDF · 1.4 MBPhoto 14. Electric Auxilliary Vacuum Pump Motor's ArmatureItem 32 · .PDF · 1.1 MBPhoto 15. Auxilliary Pump's Compressor SectionItem 33 · .PDF · 1.2 MBPhoto 16. Manufacturer's RivetsItem 34 · .PDF · 1.2 MBPhoto 17. Non-Manufacturer's RivetsItem 35 · .PDF · 1.2 MBPhoto 18. Vacuum Manifold Flapper ValveItem 36 · .PDF · 1.2 MBPhoto 19. Vacuum Manifold Flapper ValveItem 37 · .PDF · 1.3 MBPhoto 20. Engine Driven Vacuum PumpItem 38 · .PDF · 1.2 MBPhoto 21. Witness Mark From Vane on Engine Driven Vacuum Pump's HousingItem 39 · .PDF · 1.2 MB

FAA reports on this event · 1

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