DEN05FA074

NTSB accident investigation · Cessna T210G · Ouray, CO · May 11, 2005

Accident · FatalField investigationFinal report
Date
May 11, 2005, 12:56 local (18:56 UTC)
Place
Ouray, CO
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6807RCessna T210G
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft Company, FAA Flight Standards District Office
FAA report
20050511007879A
Case key
61494

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 inadvertent flight into adverse weather conditions, loss of control, and resulting exceedence of the design stress limits of the aircraft. which led to an in-flight structural failure. Factors in the accident included the pilot's inadequate preflight and in-flight planning and decision making, the severe turbulence, and the mountain wave.

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
Preflight planning/preparation - inadequatePilot in commandFactor
In-flight planning/decision - inadequatePilot in commandFactor
Flight into known adverse weather - inadvertentPilot in commandCause
Weather condition - mountain waveFactor
Weather condition - turbulenceFactor
Loss of control - in flightCruise
Aircraft control - not possiblePilot in commandCause
Airframe/component/system failure/malfunctionCruise
Design stress limits of aircraft - exceededPilot in commandCause
Wing - separationCause
Wing - overload
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Analysis

The airplane was reported missing and the Civil Air Patrol located the wreckage near Mt. Whitehouse. A debris path, approximately 1/2 mile wide and 1 1/2 miles long was located in mountainous terrain, varying in elevation from 10,000 feet to 12,800 feet mean seal level. National Track Analysis Program radar data depicted the accident flight from 1252:27 until 1856:17, and the altitude varied from 17,500 feet msl to 19,200 feet msl. The aircraft ground speed during this time was measured to be between 124 knots and 314 knots. No flight plan had been filed and no weather briefing had been obtained. An Airman's Meteorological Information (AIRMET) for occasional moderate turbulence below FL180 (Flight Level 18,000 feet) was valid. The last radar return from the accident airplane was located within this advisory area. In addition, an AIRMET for occasional moderate turbulence between FL180 and FL410 and possible mountain wave action had been issued. The last radar return from the accident airplane was located within this advisory area. The right wing was located 4,461 feet (0.8 miles) west of the main wreckage at an elevation of 11,175 feet msl. The left wing was located 2,772 feet (0.5 miles) west of the main wreckage at an elevation of 11,500 feet msl.. The debris path started with the right wing and continued in an easterly direction towards the main wreckage. The propeller was located directly above the main wreckage at an estimated altitude of 12,800 feet msl. The fuselage, engine, propeller, horizontal stabilizer, and elevator were not recovered. These could not be examined for anomalies. The airplane's systems, including the vacuum, pitot static, electrical, and powerplant, could not be examined for anomalies. No evidence of fatigue cracking or other type of preexisting fracture was noted within the recovered wings. No record of a preflight or in-flight weather briefing, obtained by the pilot, was located.

Factual narrative

History of flight

On May 11, 2005, at 1256 mountain daylight time, a Cessna T210G, N6807R, operated by a private pilot, was destroyed when it impacted terrain 3 nautical miles northwest of Ouray, Colorado. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot and three passengers were fatally injured. The cross-country flight departed Page Municipal Airport (PGA), Page, Arizona, approximately 1150 and was en route to Kelly Airpark, Elbert, Colorado.

Concerned family members reported the airplane missing on May 12, 2005. The Civil Air Patrol (CAP) located the wreckage, near Mt. Whitehouse, at approximately 1700 mountain daylight time on May 13, 2005. A debris path, approximately 1 1/2 miles long and 1/2 mile wide was located in mountainous terrain, varying in elevation from 10,000 feet to 12,800 feet mean seal level (msl).

According to the family, the airplane departed California early in the morning on May 11, 2005. The airplane landed at PGA, and according to airport personnel and fuel receipts, the airplane took on 30 gallons of fuel; 20 gallons in the left tank and 10 in the right tank. The fueler stated that he did not top off the fuel tanks and that the airplane departed shortly after the fueling services. No other services were rendered.

National Track Analysis Program (NTAP) radar data depicted the accident flight, progressing in an easterly direction, at an altitude of 18,000 feet msl, from 1243:00 until 1252:17. From 1252:27 until 1856:17, the altitude varied from 17,500 feet msl to 19,200 feet msl. The NTAP recorded the last radar information at 1856:17, in a location of 38 degrees, 02 minutes, 23 seconds north latitude, and 107 degrees, 45 minutes, 24 seconds west longitude, and an encoded altitude of 19,200 feet msl (2.7 miles west of the main wreckage). The aircraft ground speed during this time was measured to be between 124 knots and 314 knots.

Personnel information

The pilot, age 59, held a private pilot certificate issued on January 20, 2000, with an airplane single engine land and instrument rating. He held a third class airman medical certificate issued on February 28, 2005. The certificate contained the limitation "must wear corrective lenses." At the time of medical application, the pilot reported a total flight time of 1,350 hours, 100 hours of which had been flown in the previous 6 months. According to the insurance company, the pilot had reported a total time of 1,360 hours, 1,210 hours of which had been logged in the make and model of the accident airplane.

Aircraft information

The accident airplane, a Cessna T210G (serial number T210-0207), was manufactured in 1967. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. The airplane was equipped with a Continental TSIO-520M6B, S/N: 532139 with a rated maximum continuous BHP of 285 at 2700 RPM and a rated maximum take-off BHP of 310 at 2700 RPM. The engine was equipped with a three bladed, controllable pitch McCauley propeller.

The airplane was registered to and operated by Robert R. Ford Trucking Incorporated, located in Chino, California, and was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been completed on March 15, 2005, at a tachometer time of 815 and an airframe total time of 4,225 hours. At the same time, a new aft bulkhead, wet vacuum pump, and new stall-warning unit were installed. On April 9, 2005, the standby vacuum system was removed.

Meteorological information

The closest official weather observation station was Telluride Regional Airport (TEX), Telluride, Colorado, located 9 nautical miles west, southwest, of the accident site. The elevation of the weather observation station was 9,078 feet msl. The aviation routine weather report (METAR), taken at 1248, reported winds, 190 degrees at 7 knots, varying from 160 to 230 degrees; visibility, 10 statute miles or greater; sky condition, clear; temperature 6 degrees Celsius (C); dewpoint, minus 14 degrees C; altimeter 29.94 inches.

An Airman's Meteorological Information (AIRMET) for occasional moderate turbulence below FL180 (Flight Level 18,000 feet) was valid for Arizona, New Mexico, and the southern half of Colorado. The last radar return from the accident airplane was located within this advisory area. In addition, an AIRMET for occasional moderate turbulence between FL180 and FL410 and possible mountain wave action for Colorado and portions New Mexico had been issued. The last radar return from the accident airplane was located within this advisory area.

No record of a preflight or in-flight weather briefing, obtained by the pilot, was located.

Wreckage and impact information

Due to deep snow, rugged terrain, and avalanche danger, the National Transportation Safety Board did not travel to the accident scene. According to the search and rescue teams, and civil air patrol, the accident site was located in mountainous terrain. A global positioning system (GPS) receiver recorded the main wreckage location as 38 degrees, 01.73 minutes north latitude and 107 degrees, 43.59 minutes west longitude. The elevation of the main wreckage was 11,524 feet msl.

A GPS receiver recorded the right wing location as 38 degrees, 01 minutes, and 57.278 seconds north latitude and 107 degrees, 44 minutes, 28.586 seconds west longitude. The elevation of the right wing was 11,175 feet msl. The right wing was located 4,461 feet (0.8 miles) west of the main wreckage on a magnetic bearing of 67 degrees (to the main wreckage).

A GPS receiver recorded the left wing location as 38 degrees, 02 minutes, and 1.793 seconds north latitude and 107 degrees, 44 minutes, 1.544 seconds west longitude. The elevation of the left wing was 11,500 feet msl. The left wing was located 2,772 feet (0.5 miles) west of the main wreckage on a magnetic bearing of 120 degrees (to the main wreckage).

The debris path started with the right wing and continued in an easterly direction towards the main wreckage. Portions of the interior panel, the left wing, a door, an inner door panel, and Plexiglas were all located within the debris path. The propeller was located directly above the main wreckage at an estimated altitude of 12,800 feet msl. Photographs of the propeller, provided by the CAP showed the propeller stuck in deep snow. A ground scar in the snow preceded the propeller and continued downhill, past the point where the propeller came to rest. A photograph of the airplane fuselage, provided by the CAP, illustrated that the fuselage, to include the cabin, firewall, instrument panel, and engine, was destroyed.

The fuselage, engine, propeller, horizontal stabilizer, and elevator were not recovered. These could not be examined for anomalies. The airplane's systems, including the vacuum, pitot static, electrical, and powerplant, could not be examined for anomalies.

Medical and pathological information

An autopsy was performed by Montrose Memorial Hospital, Division of Forensic Pathology, on May 20, 2005, as authorized by the Ouray Country Coroner's Office. During the autopsy, tissue samples were retained for toxicological purposes. The autopsy revealed the cause of death due to "multiple traumatic injuries."

A toxicology was performed by the Federal Aviation Administration's Civil Aerospace Medical Institute, Oklahoma City, Oklahoma. Tests for carbon monoxide and cyanide were not performed. No ethanol was detected in the liver or muscle. Morphine, Citalopram, N-Desmethylcitalopram, DI-N-Desmethylcitalopram, and Phentermine were detected in the liver and kidney. Levels of Butalbital (2.301 ug/ml, ug/g in the liver and 2.318 ug/ml, ug/g in the kidney), and Codeine (0.511 ug/ml, ug/g in the liver and 0.786 ug/ml, ug/g in the

Aircraft

Registration
N6807R
Reported as
Cessna T210G
Category
Airplane
Serial number
T210-0207
Airframe hours
4,225
Engine
Continental TSIO-520M6B, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2005
Departed
PGA · Page, AZ
Destination
Elbert, CO

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
59
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3
Seat
Left
Toxicology
Performed
Flight hours
1,360 total · 1,210 in this make and model · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 7 °F
Altimeter
29.94 inHg
Observed at
TEX, 9 nm away

Docket · 18

The files NTSB released with the investigation on June 16, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 26.1 MB in all.

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 N6807R · 1

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