# NTSB DEN03FA068: Cessna 310D, N6861T, Provo, UT, April 17, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 17, 2003, 17:39 local (23:39 UTC) - Place: Provo, UT - Coordinates: 40.241664, -111.717781 - Nearby events: https://openairdocs.org/map.md?lat=40.2417&lon=-111.7178&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: FAA Flight Standards District Office - ADs cited in the narratives: [AD 69-15-09](https://openairdocs.org/ad/69-15-09) (OpenAirDocs) - NTSB case key (mKey): 56851 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN03FA068 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56851/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56851 - Page: https://openairdocs.org/ntsb/DEN03FA068 ## Probable cause failure of the student to maintain aircraft control. Contributing factors were the instructor's inattention to the fuel supply, fuel exhaustion, an inadvertent stall/spin during the turn from base leg to final approach. and the instructor's inadequate supervision of the flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - vfr pattern - downwind - fuel management - inattentive, pilot in command(cfi) (contributing factor) - fluid,fuel - exhaustion (contributing factor) - rudder trim - performed - aileron trim - performed - Loss of control - in flight, approach - vfr pattern - base leg/base to final - aircraft control - not maintained, dual student (cause) - supervision - inadequate, pilot in command(cfi) (contributing factor) - stall/spin - inadvertent, dual student - In flight collision with terrain/water, descent - uncontrolled - terrain condition - open field ## Analysis The airplane's main fuel tanks were full (100 gallons useable) when it departed on a 1.6 hour instructional flight. The auxiliary fuel tanks had been placarded inoperative. Visual inspection confirmed the tanks were half-full at the conclusion of the flight. The accident flight took off and was aloft for approximately 1.7 hours. It, too, was an instructional flight. According to a tape recording and transcript of radio communications, the instructor reported they would be entering a right downwind for runway one eight, flying a single engine pattern. Shortly thereafter, he called the pilot of an airplane that was in front on them and asked, "Can we get priority to the runway? We've got a difficulty." The consensus of 27 witnesses was that the airplane made a steep right turn from base leg to final approach, and then it descended vertically to the ground, exploded on impact, and burned. Measurements taken indicated the landing gear was retracted and the flaps were extended 5 degrees. It was noted that when the rudder was aligned with the vertical stabilizer, the rudder trim tab was fully deflected to the right. Measurement of the rudder actuator confirmed this observation (left rudder). The right aileron trim tab was deflected full up (aileron down, wing up). Measurement of the elevator trim tab actuator indicated the tab was 15 degrees down (elevator up). According to the Cessna Aircraft Company, this is about half of the total deflection range. Disassembly of the engines revealed no anomalies. Components and accessories were bench tested and found to operate satisfactorily within service limits. Disassembly of the propellers revealed neither propeller was feathered. The left propeller was at the low pitch stop, and the right propeller was just past this position (low power). According to the airplane's Climb Data and Cruise Performance Charts, each engine will consume between 14.9 and 26.6 gallons per hour (gph) at 7,500 feet msl and under standard atmospheric conditions, depending on power setting (manifold pressure and rpm). During climb between 5,000 and 7,500 feet msl, each engine will consume between 6.2 and 7.5 gph (depending on power setting). Airworthiness Directive 69-15-09, entitled "To Prevent Fuel Starvation During High Angle Descent," was issued to mandate compliance with Cessna Service Letter ME69-19, entitled "Minimum Fuel and Power Setting Placards." The service letter stated (in part), "Operation with less than five gallons of fuel in each main tank is prohibited. Useable fuel in each tank is 45 gallons. Maintain power within the green arc during descent." ## Factual narrative HISTORY OF FLIGHT On April 17, 2003, at 1739 mountain daylight time, a Cessna 310D, N6861T, registered to Smith & Barlow Enterprises, Inc., and operated by Advantage Aviation, Inc., both of Provo, Utah, impacted terrain 1.07 miles north of the Provo Municipal Airport, Provo, Utah. Three commercially certificated flight instructors were fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the instructional flight being conducted under Title 14 CFR Part 91. The flight originated at Provo approximately 1600. According to the operator, 19.0 gallons of 100-LL fuel were used to fill the airplane's main fuel tanks to capacity (50 gallons each tank, 100 gallons total useable) at the end of the day before the accident. The auxiliary fuel tanks had been inoperative for some time, and the fuel gauges and fuel filler caps had been placarded accordingly. The next day, the airplane flew once before the accident flight. The instructor on that flight said he visually "checked the main tanks and confirmed that the airplane was topped off with fuel." He did not check the auxiliary fuel tanks. The flight departed shortly after 1400. According to the flight instructor, he and his student and an observer (the observer was also the observer on the accident flight) flew for 1.6 hours, and performed a simulated right engine failure and subsequent rejected takeoff, several other simulated engine failures, and a complete right engine shutdown. They also made three takeoffs and landings. The instructor said that at the conclusion of the flight, he verified the fuel quantity. The tanks were half-full. The airplane was released to the accident pilot approximately 1630. According to the operator, the accident flight departed Provo approximately 1600 and was aloft for approximately 1.7 hours. It, too, was an instructional flight. The pilot-in-command, identified as being in the right front seat, was giving multiengine instructor training to the pilot-in-training, identified as being in the left front seat. The other flight instructor, seated on a rear bench seat, was observing. The operator (which is also the fixed base operator at Provo Municipal Airport), routinely tape-recorded the airport's Common Traffic Advisory Frequency (CTAF). The recorder was voice-activated and had no time channel. According to the tape recording and transcript, approximately 1730 the pilot reported they were "descending south of the airport. We'll be entering [a] left downwind [for] runway one eight, flying single engine pattern. Correction, right downwind." In the next transmission, he reported they were "on a right downwind one eight behind three eight hotel. We're going to be breaking off to the west, Provo." Shortly thereafter, the pilot called "three hotel this is six (unintelligible) yo we're inside of you. Can we get priority to the runway? We've got a difficulty." The pilot of N5338H agreed to yield and extended his downwind leg. The pilot on N6861T thanked him. This was the last transmission from the airplane. Twenty-seven written witness statements were collected by the Provo Police Department, Utah County Sheriff's Office, and the Utah State Patrol. Although there were variances, the consensus was that the airplane made a steep right turn from base leg to final approach, and then it descended vertically to the ground, exploded on impact, and burned. The captain of Executive Jet flight 93, who was waiting for N6861T to land so that he could take off on (the opposite) runway 36, said the airplane "appeared to do a snap roll to the right." Witnesses said that they thought the airplane was doing "trick maneuvers" (2). The airplane was at low altitude (4) and flying slow (1), when it made a sharp (4), steep (1), or severe (1) bank to the right (3) or left (4) and descended vertically (13) to the ground. The airplane was spinning (4), "twisting" (1), "swaying back and forth" (1), or spiraling (1). Some witnesses said it sounded as if the airplane was having engine trouble (1), because the engine were "sputtering" (3), and "cutting out" (2), like they "ran out of gas" (1), then the engines stopped (2), or the engine noise decreased in volume (1). The first 9-1-1 call was received by the Utah County Sheriff's Office at 1739. The accident occurred during day visual meteorological conditions at a location of 40 degrees, 14.494 minutes north latitude, and 111 degrees, 43.072 minutes west longitude, or 1.07 miles from the threshold of runway 18. Bearing from the runway was 006 degrees magnetic. PERSONNEL INFORMATION The pilot-in-command, age 47, held a commercial pilot certificate, dated April 30, 2002, with airplane single/multiengine land and instrument ratings. He also held a flight instructor certificate, dated March 4, 2002, with airplane single/multiengine and instrument ratings. His first class airman medical certificate, dated March 12, 2003, contained the limitation, "Must wear corrective lenses." Two logbooks belonging to the pilot-in-command were recovered from the wreckage and examined. The first logbook contained entries from December 23, 1999, to April 3, 2003. The second logbook contained entries from April 3, 2003, to April 12, 2003. According to these logbooks, he had accumulated the following flight time (in hours): Total time: 863.8 Pilot-in-command: 731.4 Airplane single-engine land: 622.9 Airplane multiengine land: 241.9 Cessna 310: 142.7 Instruction given: 354.2 Instruction received: 279.2 Cross-country: 309.4 Night: 97.5 Actual instruments: 32.6 Simulated instruments: 91.2 According to the logbooks, the pilot-in-command first flew a Cessna 310 on January 24, 2002, and first flew N6861T on November 20, 2002. His last recorded flight in a Cessna 310 (and in N6861T) was on July 9, 2002. The pilot-in-training, age 32, held a commercial pilot certificate, dated July 9, 2002, with airplane single/multiengine land and instrument ratings. He also held a flight instructor certificate, dated October 2, 2002, with airplane single-engine and instrument ratings. At the time of the accident, he was working on the multiengine instructor rating. His second class airman medical certificate, dated March 18, 2002, contained no limitations or restrictions. According to his application for this medical certificate, he estimated he had logged 300 hours total flight time, 70 hours of which were accrued within the previous 6 months. The pilot-observer, age 42, held a commercial pilot certificate, dated May 4, 2002, with airplane single/multiengine land and instrument ratings. He also held a flight instructor certificate, dated June 12, 2002, with airplane single-engine and instrument ratings. At the time of the accident, he was working on the multiengine instructor rating, and was observing to gain additional insight. His second class airman medical certificate, dated January 15, 2003, contained the restriction, "Must wear corrective lenses." According to his application for this medical certificate, he estimated he had logged 580 hours total flight time, 200 hours of which were accrued within the previous 6 months. AIRCRAFT INFORMATION N6861T (s/n 39161), a model 310D, was manufactured by the Cessna Aircraft Company in 1960. It was powered by two Continental IO-470-D engines (s/n CS105533-R, left; 79764-1-D, right), each rated at 260 horsepower, driving two Hartzell 3-blade, all-metal, constant speed, full-feathering propellers (m/n HC-A2VF-2B). According to the aircraft's maintenance records, the airplane received an annual inspection on December 20, 1994, at a Hobbs meter reading of 4,230.0 hours. The next logbook entry was 5 years later, on December 10, 1999, when the airplane was certified as airworthy to be ferried from Richfield, Utah, to Provo. The Hobbs meter reading was 4,232.5 hours. The next annual inspection was fifteen months later, on March 15, 2001, at a tachometer reading of 4,256 ## Aircraft - Registration: [N6861T](https://openairdocs.org/deregistered/N6861T-2006-03-06), registration cancelled 2006-03-06, S/N 39161, built 1960 (OpenAirDocs) - Reported make and model: Cessna 310D - Registry model: [Cessna 310D](https://openairdocs.org/model/cessna-310d) (registry code 2074212) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 39161 - Airframe hours: 4256 - Engines: Continental IO-470-D 260 horsepower reciprocating; Continental IO-470-D 260 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Advantage Aviation, Inc. - Registered owner: Smith & Barlow Enterprises, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 6, 2002 - Departed: PVU, Provo, UT - Destination: PVU, Provo, UT - Airport: PVU, Provo Municipal, runway 18, 6,614 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 47; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: right; flight hours: 864 total, 143 in this make and model, 731 as pilot in command, 145 in the last 90 days, 37 in the last 30 days - Pilot; age 32; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 300 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 30 °F - Altimeter: 29.64 inHg - Observed at: PVU, 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 (OpenAirDocs). - [Accident 20030417005669A](https://openairdocs.org/incident/20030417005669A), Apr 17, 2003: Cessna 310D, Provo, UT, Destroyed, 3 fatal. (-23) Cessna 310-D, N6861T, impacted the ground approximately 1.1 miles north of the runway 18 threshold at Provo Municipal Airport at approximately 5:40 p.m.… ## Docket (24 files) The files NTSB released with the investigation on February 13, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56851. 8.5 MB in all. - Supplement E (item 1, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204906&FileExtension=.PDF&FileName=Supplement%20E-Master.PDF - Supplement S (item 2, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204907&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Statement from Chad Slocum, Flight Instructor (item 3, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205617&FileExtension=.PDF&FileName=Statement%20from%20Chad%20Slocum,%20Flight%20Instructor-Master.PDF - Witness Statements (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357535&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 5, .PDF, 419 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205619&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Wreckage Distribution Diagram (item 6, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205621&FileExtension=.PDF&FileName=Wreckage%20Distribution%20Diagram-Master.PDF - Weather Reports and Records (item 7, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205622&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Cessna Multiengine Service Letter ME69-19 (item 8, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205623&FileExtension=.PDF&FileName=Cessna%20Multiengine%20Service%20Letter%20ME69-19-Master.PDF - FAA Airworthiness Directive 69-15-09 (item 9, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205624&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Directive%2069-15-09-Master.PDF - Fuel Invoice (item 10, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205631&FileExtension=.PDF&FileName=Fuel%20Invoice-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357538&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357537&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 13, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357536&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo #1 - Front view of airplane (item 14, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205635&FileExtension=.PDF&FileName=Photo%20%231%20-%20Front%20view%20of%20airplane-Master.PDF - Photo #2 - Left side of airplane (item 15, .PDF, 905 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205636&FileExtension=.PDF&FileName=Photo%20%232%20-%20Left%20side%20of%20airplane-Master.PDF - Photo #3 - Rear of airplane (item 16, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205637&FileExtension=.PDF&FileName=Photo%20%233%20-%20Rear%20of%20airplane-Master.PDF - Photo #4 - Right side of airplane (item 17, .PDF, 660 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205638&FileExtension=.PDF&FileName=Photo%20%234%20-%20Right%20side%20of%20airplane-Master.PDF - photo #5 - Manifold pressure gauge. Note #1 indicates 26 inches, and #2 indicates 14 inches (item 18, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205640&FileExtension=.PDF&FileName=photo%20%235%20-%20Manifold%20pressure%20gauge.%20Note%20%231%20indicates%2026%20inches,%20and%20%232%20indicates%2014%20inches-Master.PDF - Photo #6 - Power quadrant (item 19, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205671&FileExtension=.PDF&FileName=Photo%20%236%20-%20Power%20quadrant-Master.PDF - Photo #7 - The rudder. Note trim tab position (item 20, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205672&FileExtension=.PDF&FileName=Photo%20%237%20-%20The%20rudder.%20Note%20trim%20tab%20position-Master.PDF - Photo #8 - Rudder trim was found to be deflected fully to right. Rudder trim actuator showed full left rudder, or nose left (item 21, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205673&FileExtension=.PDF&FileName=Photo%20%238%20-%20Rudder%20trim%20was%20found%20to%20be%20deflected%20fully%20to%20right.%20Rudder%20trim%20actuator%20showed%20full%20left%20rudder,%20or%20nose%20left-Master.PDF - Photo #9 - Recovered right wing (inverted). Note trim tab is deflected full up (aileron down, right wing up) (item 22, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205674&FileExtension=.PDF&FileName=Photo%20%239%20-%20Recovered%20right%20wing%20(inverted).%20Note%20trim%20tab%20is%20deflected%20full%20up%20(aileron%20down,%20right%20wing%20up)-Master.PDF - Photo #10 - Measurement of trim actuator indicated right aileron trim tab deflected 21 degrees, or full up (right wing up) (item 23, .PDF, 405 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205675&FileExtension=.PDF&FileName=Photo%20%2310%20-%20Measurement%20of%20trim%20actuator%20indicated%20right%20aileron%20trim%20tab%20deflected%2021%20degrees,%20or%20full%20up%20(right%20wing%20up)-Master.PDF - Photo #11 - Measurement of chain links on flap motor sprocket indicated flaps were extended approximately 5 degrees (item 24, .PDF, 861 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205677&FileExtension=.PDF&FileName=Photo%20%2311%20-%20Measurement%20of%20chain%20links%20on%20flap%20motor%20sprocket%20indicated%20flaps%20were%20extended%20approximately%205%20degrees-Master.PDF From the NTSB's public API. 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