CHI95FA041

NTSB accident investigation · Cessna P210N · Savoy, IL · November 13, 1994

Accident · FatalField investigationFinal report
Date
November 12, 1994, 18:57 local (Nov 13, 1994, 00:57 UTC)
Place
Savoy, IL
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N4895KCessna P210N
Weather
Instrument (IMC) · Night/dark
Status
Completed · report March 21, 1996
Report
Approved by Office Director
FAA report
19941112038139A
Case key
9720

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 failure of the pilot to maintain a positive rate of climb during the night takeoff. Factors related to the accident were: lack of visual cues, the weather conditions, and the dark night.

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.

Loss of control - in flightTakeoff - initial climb
Weather condition - drizzle/mistFactor
Weather condition - fogFactor
Weather condition - low ceilingFactor
Light condition - dark nightFactor
Proper climb rate - not maintainedPilot in commandCause
Visual/aural detectionPilot in commandFactor
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The local controller stated that he observed the airplane take off from runway 14R and '...enter the bases of the clouds....' The airplane then crashed into trees 1/4 mile off the departure end of the runway. Examination of the engine and airframe did not reveal any preexisting anomalies. Local pilots who use the airport on a regular basis stated that departure from runway 14R during periods of darkness and reduced visibility provides the pilot with little or no visual cues in the initial climb attitude; there are scant sources of light once the airplane reaches the end of the runway. The pilot had received an instrument competency check the day prior to the accident in a fixed instrument simulator.

Factual narrative

History of flight

On November 12, 1994, at 1857 central standard time, a Cessna P210N, N4895K, registered to an individual and operated by an instrument rated private pilot impacted trees and the terrain one-quarter mile southeast of runway 14R (8,100' x 150' wet/concrete) at the Willard Airport, Savoy, Illinois. The airplane was destroyed by impact and a post crash fire. The pilot and three passengers sustained fatal injuries. The personal 14 CFR Part 91 flight was operating in instrument meteorological conditions. An IFR flight plan was on file. The flight was departing at the time of the accident with the intended destination of Naperville, Illinois.

The Sheriff's report indicated that there were eyewitnesses to the accident; however, during the post accident investigation no persons were located who stated that they actually saw the airplane after it departed the airport and prior to the impact and post accident fire. One air traffic controller, working the local position, at the Willard Airport air traffic control tower (ATCT) stated that he observed the accident airplane turn onto runway 14R at intersection taxiway "B, initiate a takeoff and initial climb, and... enter the bases of the clouds... ." A number of people reported seeing a fire after the accident occurred. The ATCT became aware of the accident when another aircraft called ground control and reported seeing an "explosion" off the airport. The local controller then picked up binoculars and identified a fire which he estimated to be one half to one mile off the departure end of runway 14R.

Other damage

Two small trees sustained damage from impact of the airplane.

Personal information

The pilot was born April 8, 1937, He was the holder of private pilot certificate number 334306610, with privileges for single engine land and instrument airplane. At the time of the accident he had accumulated a total flight time of 1,437 hours with 423 hours in this make and model of airplane, 130 hours of actual instrument flight, 137 hours of simulated instrument time, and 261 hours of night flight. His most recent biennial flight review was conducted eight months prior to the accident in the accident airplane. His third class medical was dated August 27, 1993. He received an instrument competency check the day prior to the accident in a fixed instrument simulator.

Aircraft information

The airplane was a Cessna P210N, N4895K, serial number P210- 00357. The most recent annual inspection was conducted on October 18, 1994, at 3,542 hours time in service. At the time of the annual inspection the engine had a total time of 1,322 hours and 231 hours since a major overhaul. The most recent inspection of the pitot/static system, altimeter and transponder check was conducted on June 15, 1993.

Meteorological information

A weather observation taken three minutes after the accident was reported as ceiling 800 overcast, visibility 2 miles fog and drizzle, with winds from 170 degrees at 10 knots.

Communications

The only radio communications with the accident airplane occurred prior to the accident when no indication of difficulties were reported to the ATCT. ATCT gave taxi and takeoff instructions and an IFR clearance was issued in the radio communications prior to the aircraft departing runway 14R. A transcript of radio transmissions between ATCT and the accident airplane, is included as an addendum to this report.

Wreckage and impact information

Initial impact marks were located on 20 foot high trees about one quarter mile southeast of the departure end of runway 14R. The elevation of the tree tops approximated the elevation of the departure runway. Portions of the left horizontal stabilizer and elevator were found near the base of the trees. The airplane then struck the ground on an east southeast heading and a flat indentation about six inches deep and 15 feet long was made in the ground one hundred feet east of the trees. A belly mounted antenna was found in the indentation and to the left of the flat depression was a straight gouge in the ground oriented in the direction of travel, consistent with the location of the left wing tip. Nearby portions of a red navigation lens was found. The wreckage path continued for an additional 300 feet where various portions of the engine and airframe were located. These included portions of the interior and the left main cabin door. The fuselage came to rest inverted and headed northwest. The propeller was located to the south of the main wreckage path. The blades were distorted, bent and twisted. There were deep gouges present in the leading edges and tips. There was polishing of the camber side. The propeller had separated from the engine assembly at the propeller flange. leaving the attaching bolts in the flange on the engine. The engine had continued about 100 feet beyond the airframe and remained upright.

The oil cap was missing from the engine. Close examination of debris outside the fire area were examined for the presence of oil. The top engine cowling was found away from the fire and had little evidence of oil on the inside. A thorough search was conducted looking for the cap between the departure runway to the accident site and to date is has not been located. A check of the records at the fixed base operator's office where the most recent fuel service was performed, prior to the accident, revealed no oil being added to the airplane.

Flight control continuity was confirmed through the wings, fuselage and empennage. Engine control continuity was destroyed during the impact and loss of the engine during the impact sequence, and the fire damage to the cockpit and firewall; however, post accident examination of the airframe failed to reveal any pre-existing anomalies.

Medical and pathological information

A post mortem examination of the pilot was conducted by the Coroner of Champaign County, Illinois, on November 13, & November 14, 1994. No pre-existing anomalies were found during the autopsy. Specimens were obtained from the pilot and submitted for toxicological examination and were found to be negative for those drugs screened.

Fire

A post impact fire consumed much of the cockpit and cabin including the interior and instrument panel. The airplane had been serviced with fuel prior to the departure. The ignition source was not identified; however, during the impact sequence there was a general disintegration of the airframe and a fuel fire was evident throughout the wreckage path from the initial ground impact site to where the fuselage came to rest.

Tests and research

On February 22, 1995, at the Teledyne Continental Motors, Mobile, Alabama, the engine was examined and disassembled. A visual examination of the exterior and interior of the engine was conducted and no abnormalities were discovered during this examination that could be attributed to other than impact and post impact fire.

On February 22, 1995, at the Teledyne Continental Motors, Mobile, Alabama, the turbocharger was examined and disassembled for inspection. The damage to the turbocharger assembly was associated with impact and nothing was found during the post accident examination which could be associated as pre-existing anomalies.

Additional information

Local pilots who use Willard Airport on a regular basis stated that departure utilizing runway 14R during periods of darkness and reduced visibility provides the pilot with little or no visual ques when the airplane is in the initial climb attitude. They report there are scant sources of light once the airplane reaches the end of the departure runway.

Parties to the investigation were the Federal Aviation Administration, Flight Standards District Office, Springfield, Illinois; Cessna Aircraft, Wichita, Kansas; Teledyne Continental Motors, Mobile, Alabama; and Allied Signal Aerospace, Phoenix, Arizona.

The airplane wreckage was

Aircraft

Registration
N4895K
Reported as
Cessna P210N
Category
Airplane
Serial number
P210-00357
Airframe hours
3,542
Engine
Continental TSIO-520-P, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Lannon, John J.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 18, 1994
Departed
CMI
Destination
LL10 · Naperville, IL
Flight plan
IFR
Airport
CMI · Univ Of Ill-Willard, runway 14R, 8,100 × 150 ft, concrete

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
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,437 total · 423 in this make and model · 1,412 as pilot in command · 40 in the last 90 days · 18 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
170° at 10 knots
Visibility
2 statute miles
Lowest ceiling
800 ft overcast
Temperature
52 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
CMI, 1 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.