# NTSB CHI05FA016: Cessna P210N, N5485W, Wautoma, WI, October 26, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 26, 2004, 11:25 local (16:25 UTC) - Place: Wautoma, WI - Coordinates: 44.043334, -89.172225 - Nearby events: https://openairdocs.org/map.md?lat=44.0433&lon=-89.1722&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - 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 - NTSB case key (mKey): 60441 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60441/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60441 - Page: https://openairdocs.org/ntsb/CHI05FA016 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, cruise - weather condition - clouds (contributing factor) - Airframe/component/system failure/malfunction, cruise - maintenance,modification - performed, unknown (contributing factor) - vacuum system - deteriorated (contributing factor) - Loss of control - in flight, cruise - aircraft control - not maintained, pilot in command (cause) - use of inappropriate medication/drug, pilot in command - inadequate substantiation process,insuff review, faa(organization) - Airframe/component/system failure/malfunction, descent - uncontrolled - design stress limits of aircraft - exceeded, pilot in command (cause) - wing - overload (cause) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N5485W-2013-04-24), registration cancelled 2013-04-24, S/N P21000695, built 1981 (OpenAirDocs) - Reported make and model: Cessna P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P21000695 - Airframe hours: 2686.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; 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 ## 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 20041026029309A](https://openairdocs.org/incident/20041026029309A), Oct 26, 2004: Cessna P210N, Wautoma, WI, Destroyed, 2 fatal. (-23) At 1620 UTC, while at FL200, the instrument rated private pilot of N5485W advised minneapolis air route traffic control center (zau-artcc) "losing my… ## Docket (39 files) The files NTSB released with the investigation on April 29, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60441. 44.7 MB in all. - Meteorology 5 - Factual Report of Group Chairman (item 1, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223891&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Medical Records Information (item 2, .PDF, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40225111&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Wreckage Diagram Provided By Continental (item 3, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229928&FileExtension=.PDF&FileName=Wreckage%20Diagram%20Provided%20By%20Continental-Master.PDF - Waushara County Sheriff's Report Excerpts (item 4, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40229973&FileExtension=.PDF&FileName=Waushara%20County%20Sheriff%27s%20Report%20Excerpts-Master.PDF - Plots of the Wreckage Area Supplied by the Waushara County Sheriff's Office (item 5, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230036&FileExtension=.PDF&FileName=Plots%20of%20the%20Wreckage%20Area%20Supplied%20by%20the%20Waushara%20County%20Sheriff%27s%20Office-Master.PDF - Map of Wreckage Pattern and GPS Readings of Items, Supplied By a Department of Natural Resources Warden (item 6, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230045&FileExtension=.PDF&FileName=Map%20of%20Wreckage%20Pattern%20and%20GPS%20Readings%20of%20Items,%20Supplied%20By%20a%20Department%20of%20Natural%20Resources%20Warden-Master.PDF - Cessna Supplied Plots of Radar Data (item 7, .PDF, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230046&FileExtension=.PDF&FileName=Cessna%20Supplied%20Plots%20of%20Radar%20Data-Master.PDF - Graph of Groundspeeds From Radar Data (item 8, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230047&FileExtension=.PDF&FileName=Graph%20of%20Groundspeeds%20From%20Radar%20Data-Master.PDF - Billing Records For Engine Driven Vacuum Pump Installaion (item 9, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230048&FileExtension=.PDF&FileName=Billing%20Records%20For%20Engine%20Driven%20Vacuum%20Pump%20Installaion-Master.PDF - Billing Records for Last Annual Inspection (item 10, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230051&FileExtension=.PDF&FileName=Billing%20Records%20for%20Last%20Annual%20Inspection-Master.PDF - Billing Records for Maintenance Work (item 11, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230055&FileExtension=.PDF&FileName=Billing%20Records%20for%20Maintenance%20Work-Master.PDF - Fueling Receipts (item 12, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230056&FileExtension=.PDF&FileName=Fueling%20Receipts-Master.PDF - Insurance Application (item 13, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459565&FileExtension=.PDF&FileName=Insurance%20Application-Master.PDF - Parker Hannifin Report (item 14, .PDF, 13.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230060&FileExtension=.PDF&FileName=Parker%20Hannifin%20Report-Master.PDF - Logbook Excerpts (item 15, .PDF, 997 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459566&FileExtension=.PDF&FileName=Logbook%20Excerpts-Master.PDF - Toxicological Report (item 16, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459567&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459568&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 18, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459569&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1. Accident Site (item 19, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230065&FileExtension=.PDF&FileName=Photo%201.%20%20Accident%20Site-Master.PDF - Photo 2. Accident Site (item 20, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230066&FileExtension=.PDF&FileName=Photo%202.%20%20Accident%20Site-Master.PDF - Photo 3. Accident Site (item 21, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230067&FileExtension=.PDF&FileName=Photo%203.%20%20Accident%20Site-Master.PDF - Photo 4. Accident Site (item 22, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230068&FileExtension=.PDF&FileName=Photo%204.%20%20Accident%20Site-Master.PDF - Photo 5. Engine (item 23, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230069&FileExtension=.PDF&FileName=Photo%205.%20%20Engine-Master.PDF - Photo 6. Empennage (item 24, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230070&FileExtension=.PDF&FileName=Photo%206.%20%20Empennage-Master.PDF - Photo 7. Vacuum Manifold (item 25, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230071&FileExtension=.PDF&FileName=Photo%207.%20%20Vacuum%20Manifold-Master.PDF - Photo 8. Rotor Housing (item 26, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230072&FileExtension=.PDF&FileName=Photo%208.%20%20Rotor%20Housing-Master.PDF - Photo 9. Rotor (item 27, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230073&FileExtension=.PDF&FileName=Photo%209.%20%20Rotor-Master.PDF - Photo 10. Turn Coordinator Rotor (item 28, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230074&FileExtension=.PDF&FileName=Photo%2010.%20%20Turn%20Coordinator%20Rotor-Master.PDF - Photo 11. Wing Tip and Empennage With Transfer Marks (item 29, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230092&FileExtension=.PDF&FileName=Photo%2011.%20%20Wing%20Tip%20and%20Empennage%20With%20Transfer%20Marks-Master.PDF - Photo 12. Airplane Layout (item 30, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230094&FileExtension=.PDF&FileName=Photo%2012.%20%20Airplane%20Layout-Master.PDF - Photo 13. Propeller (item 31, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230096&FileExtension=.PDF&FileName=Photo%2013.%20%20Propeller-Master.PDF - Photo 14. Electric Auxilliary Vacuum Pump Motor's Armature (item 32, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230097&FileExtension=.PDF&FileName=Photo%2014.%20%20Electric%20Auxilliary%20Vacuum%20Pump%20Motor%27s%20Armature-Master.PDF - Photo 15. Auxilliary Pump's Compressor Section (item 33, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230099&FileExtension=.PDF&FileName=Photo%2015.%20%20Auxilliary%20Pump%27s%20Compressor%20Section-Master.PDF - Photo 16. Manufacturer's Rivets (item 34, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230101&FileExtension=.PDF&FileName=Photo%2016.%20%20Manufacturer%27s%20Rivets-Master.PDF - Photo 17. Non-Manufacturer's Rivets (item 35, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230103&FileExtension=.PDF&FileName=Photo%2017.%20%20Non-Manufacturer%27s%20Rivets-Master.PDF - Photo 18. Vacuum Manifold Flapper Valve (item 36, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230106&FileExtension=.PDF&FileName=Photo%2018.%20%20Vacuum%20Manifold%20Flapper%20Valve-Master.PDF - Photo 19. Vacuum Manifold Flapper Valve (item 37, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230108&FileExtension=.PDF&FileName=Photo%2019.%20%20Vacuum%20Manifold%20Flapper%20Valve-Master.PDF - Photo 20. Engine Driven Vacuum Pump (item 38, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230109&FileExtension=.PDF&FileName=Photo%2020.%20%20Engine%20Driven%20Vacuum%20Pump-Master.PDF - Photo 21. Witness Mark From Vane on Engine Driven Vacuum Pump's Housing (item 39, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230111&FileExtension=.PDF&FileName=Photo%2021.%20%20Witness%20Mark%20From%20Vane%20on%20Engine%20Driven%20Vacuum%20Pump%27s%20Housing-Master.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.