CHI06MA115

NTSB accident investigation · Cessna 210A · Ludville, GA · April 19, 2006

Accident · FatalMajor investigationFinal report
Date
April 19, 2006, 11:10 local (15:10 UTC)
Place
Ludville, GA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6579XCessna 210A
Weather
Instrument (IMC) · Day
Status
Completed · report September 27, 2007
Report
Approved by Office Director
Parties
FAA - Office of Accident Investigation, Teledyne Continental Motors, Cessna Aircraft Company, National Air Traffic Controllers Association
FAA report
20060419030749A
Case key
63536

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to obtain updated en route weather information, which resulted in his continued instrument flight into a widespread area of severe convective activity, and the air traffic controller's failure to provide adverse weather avoidance assistance, as required by Federal Aviation Administration directives, both of which led to the airplane's encounter with a severe thunderstorm and subsequent loss of control.

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
In flight weather avoidance assistance - not performedAtc personnel(artcc)Cause
Flight into known adverse weather - attemptedPilot in commandFactor
Weather condition - thunderstormFactor
Loss of control - in flightCruise
Aircraft control - not possiblePilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane flew into an area of severe thunderstorms identified as a mesoscale convective system (or "MCS") with intense to extreme intensities during cruise flight at 11,000 feet then descended rapidly and impacted the terrain. The on-scene investigation revealed no preimpact mechanical malfunctions or anomalies that would have prevented the normal operation of the airplane or its systems.

The airplane entered the severe convective weather; the pilot then requested and received clearance from the air traffic controller to initiate a turn to escape the weather. The airplane was lost from radar about 30 seconds after the pilot initiated the turn. Before the airplane entered the weather, the controller's radar scope depicted a band of moderate to extreme weather along the accident airplane's projected flightpath that was consistent with an embedded, heavy-precipitation, supercell-type thunderstorm; however, the controller did not provide the pilot with any severe weather advisories and did not advise the pilot of the weather depicted on his radar scope.

Although Federal Aviation Administration directives state that controllers should give first priority to separating aircraft and issuing safety alerts, the directives further state that controllers should use good judgment and first perform the action that is most critical from a safety standpoint. Review of air traffic communications and radar data identified no air traffic control (ATC) radar limitations, no excessive traffic, no radio frequency congestion, and no controller workload issues that would have prevented the controller from issuing pertinent weather information to the accident pilot. On the basis of the controller's workload and available resources, he should have recognized that the adverse weather represented an immediate safety hazard to the accident flight and should have provided appropriate advisories to the pilot.

The pilot obtained several weather briefings before departure. At that time, the current weather along the route of flight showed significant convective activity and a moving squall line, and the forecast predicted significant thunderstorm activity along the planned route of flight. The pilot also discussed the weather with an acquaintance, mentioning that he might need to work his way around some weather. On the basis of the weather information obtained by the pilot and his comments regarding the weather, the pilot was aware before departure that he would likely encounter adverse weather along the planned route of flight; however, by the time the airplane encountered the weather, the pilot had been airborne for over an hour and had not requested any updated weather information from air traffic controllers. The airplane was equipped with a BF Goodrich WX-950 Stormscope, which has some ability to depict the location and frequency of lightning strikes in the vicinity of the airplane; however, the investigation could not determine if and how this equipment may have been used during the flight. The airplane was not configured to display satellite weather information on its global positioning systems.

In October 2006, the National Transportation Safety Board issued Safety Alert SA-11, "Thunderstorm Encounters," as a result of this accident and three other fatal accidents that involved in-flight encounters with severe weather. The safety alert addresses ATC involvement in these accidents. The alert also states that IFR pilots need to actively maintain awareness of severe weather along their route of flight, and it provides suggestions to assist pilots in avoiding involvement in similar accidents. The safety alert can be found at the Safety Board's Web site at http://www.ntsb.gov/alerts/SA_011.pdf.

Factual narrative

History of flight

On April 19, 2006, about 1110 (all times referenced are eastern daylight time), a Cessna 210A, N6579X, owned and piloted by a commercial pilot, crashed into remote mountainous terrain near Ludville, Georgia, after entering thunderstorms. The pilot, the sole occupant, was fatally injured. Instrument meteorological conditions prevailed at the time of the accident. The personal flight was operating under the provisions of 14 Code of Federal Regulations Part 91 while on an instrument flight rules (IFR) flight plan. The accident flight departed Prattville/Grouby Field Airport, Prattville, Alabama, about 1005, and was en route to Manassas Regional/Harry P. Davis Field Airport (HEF), Manassas, Virginia.

The flight's planned route was over Rome, Georgia; Snowbird, Tennessee; Roanoke, Virginia; Montebello, Virginia; Casanova, Virginia; to HEF. The pilot's requested cruise altitude was 11,000 feet mean sea level. After departure, the pilot contacted Montgomery air traffic control and was cleared to climb to 10,000 feet. About 1011, the accident airplane was handed off to Atlanta Air Route Traffic Control Center (ARTCC) sector 9. About 1018, the pilot checked in with Atlanta ARTCC and reported that he was climbing through 8,000 feet for 10,000 feet. The accident airplane was then cleared to 11,000 feet. About 1026, the pilot was told to contact Atlanta ARTCC sector 4 when the airplane was level at 11,000 feet. When the airplane reached 11,000 feet, the pilot contacted Atlanta ARTCC sector 4 and was given the local altimeter setting.

About 1038, another controller took over the sector 4 radar position, and the outgoing controller provided a position relief briefing. Included in that briefing was information about an area of severe weather north of Atlanta that was causing departing aircraft to deviate to the west instead of continuing northbound after takeoff. The briefing did not include specific references to the accident airplane. About 1045, the sector 4 controller told the pilot to contact Atlanta ARTCC sector 5. About 1046, the pilot checked in with the sector 5 controller and reported being level at 11,000 feet. The pilot was subsequently given two local altimeter settings. About 1100, the pilot was told to contact Atlanta ARTCC sector 38. The pilot checked in about 1101, stating that he was level at 11,000 feet. The pilot's initial call did not receive a response, so he repeated it, and the sector 38 controller provided the local altimeter setting.

About 1109, the pilot transmitted, "Atlanta, this is seven niner x-ray I'd like to deviate south weather." The controller replied, "Six five seven niner x-ray roger we'll show you deviating south for weather and your mode C indicates one one thousand five hundred." The pilot did not respond. About 1110, radar contact was lost with the airplane at 5,500 feet.

A plot of the aircraft radar track data indicated that the airplane entered a level 6 (extreme) thunderstorm before the loss of radar contact. Local law enforcement located the wreckage on April 20, 2006. The airplane impacted remote mountainous terrain about 3.3 nautical miles (nm) northwest of Ludville.

Personnel information

According to Federal Aviation Administration (FAA) records, the pilot, age 84, held a commercial certificate with airplane single-engine land, multiengine land, and instrument airplane ratings. The pilot's multiengine airplane rating was limited to visual flight rules (VFR). The pilot's last aviation medical examination was completed on December 14, 2004, when he was issued a third-class medical certificate with the restriction "Must wear lenses for distance vision and possess glasses for near vision."

On the pilot's application for his most recent medical certificate, he reported his total flight experience exceeded 9,000 hours. The pilot's logbook recovered at the accident site indicated that he had flown 95.5 hours during the previous 12 months, 28.5 hours during the prior 6 months, and 23.1 hours during the previous 30 days. During the prior year, all of the pilot's logged flights were in the accident airplane. The pilot's last flight review was competed on August 27, 2004.

The pilot's logbook indicated that his total flight experience in actual instrument conditions was 423.1 hours and that an additional 106.0 hours were accumulated using a view-limiting device. The pilot logged 5.4 hours of instrument flight time and completed two instrument approaches during the previous 12 months. The pilot had not logged any instrument flight time or instrument approaches during the 6 months before the accident flight. According to the logbook, the pilot did not receive instrument instruction or complete an instrument proficiency flight within the previous 12 months.

The pilot formerly was an aeronautical research pilot with the National Advisory Committee for Aeronautics (NACA) High-Speed Flight Station at Edwards Air Force Base, California. During his 5 years with NACA, he flew the X-1, XF-92, X-4, X-5, Douglas D-558-I Skystreak, and the Douglas D-558-II Skyrocket. On November 20, 1953, he became the first human to fly faster than twice the speed of sound in the Douglas D-558-II Skyrocket. From 1955 to 1960, he was employed by North American Aviation as the chief engineering test pilot during the development and testing of the X-15 rocketplane.

Aircraft information

The accident airplane was a 1960 Cessna 210A, serial number 21057579. The Cessna 210A was an all-metal airplane that incorporated a semimonocoque fuselage and empennage design. The airplane was equipped with externally braced wings, wing flaps, a constant speed propeller, and a retractable tricycle landing gear. The airplane was configured to seat four occupants and had a certified maximum takeoff weight of 2,900 pounds.

Owned and operated by the accident pilot, the airplane was issued an FAA standard airworthiness certificate on December 6, 1960. The FAA issued the current aircraft registration certificate on December 11, 1989. The airplane (and its engine) had a total service time of 4,987.4 hours at the time of the accident. The last annual inspection was completed on March 19, 2006, and the airplane had accumulated 27.5 hours since the inspection. On March 22, 2006, tests on the static system, altimeter system, automatic pressure altitude reporting system, and transponder were completed. A review of the airframe maintenance records found no history of unresolved operational issues.

The airplane was equipped with a 260-horsepower Teledyne Continental Motors IO-470-E engine, serial number 77583-0-E. The IO-470-E is a six-cylinder, horizontally opposed, 470 cubic inch displacement, fuel-injected, reciprocating engine. The engine had accumulated 1,259.8 hours since the last major overhaul. A review of the engine maintenance records found no history of unresolved operational issues.

The propeller was a three-bladed McCauley D3A36C435/80VEA-0, hub serial number 042476. The propeller was installed on the accident engine on October 13, 2005.

The airplane was equipped with a BFGoodrich WX 950 stormscope, a Garmin GNC 250 GPS/Com (global positioning system), and a Garmin GNS 430 GPS/Com/Nav. The GNC 250 was limited to VFR flight only. The Garmin GNS 430 system was approved for IFR domestic flight, including en route and non-precision approaches.

On April 17, the airplane was topped off with 77.1 gallons of 100 low-lead aviation fuel at the departure airport. The accident occurred during the first flight after being refueled.

Meteorological information

At the time of the accident, the area forecast for northern Georgia expected an area of IFR to marginal VFR conditions during the morning hours, with isolated thunderstorms and moderate rain expected after 1000. These thunderstorms had a possibility of being severe, with cloud tops reaching 43,000 feet.

About

Aircraft

Registration
N6579X
Reported as
Cessna 210A
Category
Airplane
Serial number
21057579
Airframe hours
4,987.4
Engine
Teledyne Continental IO-470-E, 260 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2006 · 27.5 hours before
Departed
1A9 · Prattville, AL
Destination
HEF · Manassas, VA
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
84
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 1, 2006
Seat
Left
Toxicology
Performed
Flight hours
9,000 total · 28 in the last 90 days · 23 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
340° at 5 knots, gusting 13
Visibility
3 statute miles
Lowest ceiling
4,800 ft broken
Temperature
61 °F, dew point 59 °F
Altimeter
29.94 inHg
Observed at
DNN, 16 nm away

Docket · 36

The files NTSB released with the investigation on July 20, 2007, on NTSB’s docket system: statements, records, photos and specialists’ reports.

ATC 3 - Factual Report of Group ChairmanItem 1 · .PDF · 326 KBATC 3 - ZTL Communication TranscriptsItem 2 · .PDF · 327 KBATC 3 - Attachment 1A Low Altitude WARP PlotItem 3 · .PDF · 83 KBATC 3 - Attachment 1B Composite WARP PlotItem 4 · .PDF · 89 KBATC 3 - Controller Personnel StatementsItem 5 · .PDF · 1.2 MBATC 3 - ZTL Time/Attendance LogsItem 6 · .PDF · 521 KBATC 3 - Position Sign-on/Sign-off LogsItem 7 · .PDF · 1.8 MBATC 3 - ZTL Report of Aircraft AccidentItem 8 · .PDF · 174 KBATC 3 - ZTL Facility Evaluation / Audit DataItem 9 · .PDF · 2.3 MBATC 3 - ZTL 2005-2006 Training MaterialsItem 10 · .PDF · 10.7 MBATC 3 - Weather Advisory Strips from SectorsItem 11 · .PDF · 522 KBATC 3 - CWSU Log and Weather DataItem 12 · .PDF · 3.1 MBMeteorology 5 - Factual Report of Group ChairmanItem 13 · .PDF · 1.6 MBMeteorology 5 - Attachment 1 DUAT Weather BriefingItem 14 · .PDF · 248 KBStructures 7 - Factual Report of Group ChairmanItem 15 · .PDFWitness StatementItem 16 · .PDF · 171 KBToxicological ReportItem 17 · .PDF · 34 KBStatement of Party Representatives to NTSB InvestigationItem 18 · .PDF · 39 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 19 · .PDF · 86 KBPhoto 01. Accident Site OverviewItem 20 · .PDFPhoto 02. Accident Site OverviewItem 21 · .PDFPhoto 03. Accident Site OverviewItem 22 · .PDFPhoto 04. Accident Site OverviewItem 23 · .PDF · 1.3 MBPhoto 05. Wreckage LayoutItem 24 · .PDF · 1.3 MBPhoto 06. Wreckage LayoutItem 25 · .PDF · 1.4 MBPhoto 07. Aft Fuselage/Empennage LayoutItem 26 · .PDF · 1.3 MBPhoto 08. Aft Fuselage/Empennage LayoutItem 27 · .PDF · 1.4 MBPhoto 09. Right Wing LayoutItem 28 · .PDF · 1.2 MBPhoto 10. Left Wing LayoutItem 29 · .PDF · 1.2 MBPhoto 11. Engine OverviewItem 30 · .PDF · 1.4 MBPhoto 12. Engine OverviewItem 31 · .PDF · 1.3 MBPhoto 13. Engine OverviewItem 32 · .PDF · 1.2 MBPhoto 14. Propeller Blade "A" OverviewItem 33 · .PDF · 1.3 MBPhoto 15. Propeller Blade "A" OverviewItem 34 · .PDF · 1.2 MBPhoto 16. Propeller Blade "B" OverviewItem 35 · .PDF · 1.3 MBPhoto 17. Propeller Blade "B" OverviewItem 36 · .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.

Other investigations on N6579X · 1

Matched to the same aircraft by N-number and date.