# NTSB ERA10FA040: Cessna 310J, N308J, Lawrenceville, GA, October 30, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 30, 2009, 13:17 local (17:17 UTC) - Place: Lawrenceville, GA - Coordinates: 34.028057, -84.004722 - Nearby events: https://openairdocs.org/map.md?lat=34.0281&lon=-84.0047&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal; on the ground: 1 fatal - Status: Completed, report December 27, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Engines, Federal Aviation Administration, Cessna Aircraft Company - NTSB case key (mKey): 74980 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10FA040 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74980/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74980 - Page: https://openairdocs.org/ntsb/ERA10FA040 ## Probable cause The pilot’s loss of aircraft control while maneuvering in instrument meteorological conditions, as a result of spatial disorientation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 310J, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2074226), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 310J, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2074226), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot departed from the airport under instrument meteorological conditions on an instrument flight rules flight plan. Weather included a 300-foot overcast cloud layer and 1 mile visibility with light rain and mist. Shortly after takeoff, the air traffic controller lost radio contact with the pilot, and witnesses observed the airplane rolling under full power as it descended out of the clouds. The airplane subsequently collided with a house about 4 miles northwest of the airport. A postaccident examination of the airplane and engine did not reveal any evidence of a pre-existing mechanical failure or malfunction that precluded normal operation. Based on the wreckage and the environmental conditions present at the time of the accident, it is likely that the pilot experienced spatial disorientation. ## Factual narrative HISTORY OF FLIGHT On October 30, 2009, at 1317 eastern daylight time, a Cessna 310J, N308J, registered to KM Aviation LLC, and operated by a certificated private pilot, impacted a house shortly after takeoff from runway 7, at Gwinnett County Airport-Briscoe Field, (LZU), Lawrenceville, Georgia. The personal flight was operated under the provisions of 14 Code of Federal Regulations (CFR) part 91 with an instrument flight rules (IFR) flight plan filed. Instrument meteorological conditions prevailed. The pilot and one occupant of the house were killed and the airplane and house were destroyed by impact forces and a post-crash fire. The flight was destined for Sparta, Tennessee. According to witnesses who could hear the airplane, but could not see it initially due to the overcast conditions, stated that the airplane sounded normal, but at a low altitude. They then heard the engines go to what they believed was full power. One witness stated that the airplane came “screaming” out of the sky in a right-wing-low attitude, hit a tree and then the house, and exploded. Another witness, who saw the airplane as it descended out of the overcast, said the airplane was rolling to the right and the engines were at full power. He stated that it sounded like an air show airplane in a dive. The owner of the house stated that he and his wife were in the house when it was struck. He escaped out the front doors which were “blown out” and then attempted to go back in and get his wife. However, the house was fully involved with the fire and a neighbor pulled him away. The local residents called 911 and reported the accident. According to the Federal Aviation Administration (FAA) LZU air traffic control tower (ATCT), after takeoff, the pilot was given heading instructions by a LZU air traffic controller and told to contact Atlanta Approach. The pilot confirmed the instructions, but never contacted Atlanta Approach. At 1307:38. The pilot was cleared to takeoff by the LZU Tower Controller. The controller requested the pilot report the base of the overcast. At 1309:46, the controller instructed the pilot to turn left to a heading of 360 degrees and contact Atlanta departure. At1709:51, the controller asked the pilot “how do you hear.” The pilot reported back that he could hear him fine. At 1310:02, the controller responded “okay November zero eight contact Atlanta departure turn left heading three three zero.” The pilot acknowledged the controller. At 1312:15, the controller again asked the pilot to contact Atlanta departure. At 1312:20, The controller asked the pilot if he was “up.” The tower controller asked the pilot three more times if he could hear him, with no response from the pilot. At 1316:55, the tower was notified by a 911 operator that the airplane had crashed. PERSONNEL INFORMATION The pilot, age 58, held a private pilot certificate for airplane single engine land, multi-engine land, and instrument airplane, issued on September 29, 2005. He held a third-classairman medical certificate issued on August 2, 2009, with a restriction requiring the pilot to wear corrective lenses. The pilot’s logbook was not recovered. He reported on his most recent medical certificate application that the he had accumulated about 1,200 civilian flight hours. AIRCRAFT INFORMATION The Cessna 310J was a six-seat, low-wing, retractable gear twin-engine airplane, serial number 310J0142, and was manufactured in 1965. It was powered by two Continental IO-470, 260 horsepower engines. A review of the aircraft logbooks revealed that an annual inspection was performed on March 13, 2009, at a total airframe time of 6327.1 hours. METEOROLOGICAL INFORMATION A review of recorded weather data from the LZU automated weather observation station, elevation 1061 feet, revealed the following, winds from 040 degrees at 10 knots, visibility 1 statute mile in light rain and mist, overcast clouds at 300 feet, temperature 15 degrees Celsius, dew point temperature 15 degrees Celsius, and altimeter 30.10 inches of mercury. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on October 31, 2009, by the Office of the Medical Examiner, Gwinnett County, Lawrenceville, Georgia. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report indicated that testing for carbon monoxide and cyanide was not performed, and 23 mg/dL of ethanol was detected in kidney, and no ethanol was detected in muscle. The report also indicated the putrefaction was positive. WRECKAGE AND IMPACT INFORMATION Examination of the wreckage site revealed that the airplane struck a tree about 18 feet above the ground, separating the top of the tree. The airplane impacted the ground 25 feet from the base of the tree in a 35-degree nose down attitude, in a 90-degree right bank, and on a 140-degree heading. The airplane then cart wheeled, impacting and penetrating a 4-inch thick concrete driveway with the left wing. The airplane entered the garage and impacted two automobiles before penetrating a concrete wall into the house and striking one of the occupants. A fire and explosion ensued, destroying the automobiles, the airplane, and the house. Airframe and engine fragments were observed throughout the burned-out house and property, and in the yards of neighboring homes. Impact and fire damage prevented a thorough evaluation of the airframe, engine and propellers. A large track hoe was used to clear the debris from the basement of the house. Each bucket of debris was spread out on the basement floor and examined for airplane fragments by the investigation team before being removed to a separate pile for removal. Recovered aircraft fragments were laid out in a tent for identification and further examination. The fuselage was fragmented in the impact sequence and was not evaluated. Airplane flight controls, aerodynamic surfaces, and flight control systems werefragmented in the impact sequence and damaged by a post-impact fire. All fragments were recovered at the impact site. Torque tubes (front spar assembly) for both elevators and the rudder were recovered. Fragments from the right horizontal stabilizer were recovered. The elevator bob-weight from the control yokes, and an elevator or rudder weight was recovered. Fragmented flap and aileron components were recovered. Signatures consistent with ductile overload and tension overload were observed on flight control system components. Impact and fire damage prevented a complete evaluation of the airplane flight control cable and trim systems. Both engines fragmented in the impact. Crankshafts and camshafts displayed impact damage. The crankshaft bearings did not display pre-impact defects. Twelve connecting rods were recovered and their bearings did not display pre-impact defects. One damaged vacuum pump remained attached to the engine. It contained fractured vanes and rotor. The frangible drive was melted, and fire and heat damage prevented an evaluation of any possible rotational signatures. The second vacuum pump separated at the mounting base and was not recovered. The frangible drive was melted. The examination of the engines did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower. The propellers separated from the engines and the blades separated from the propeller hubs. Five blades displayed extensive leading edge damage, tip curling, “S” bending and separations. One blade separated approximately 8 inches outboard of the hub. The separation surface displayed signatures consistent with ductile overload. Two blades displayed thermal damage that destroyed the outboard portion of the blades. ADDITIONAL INFORMATION Federal Aviation Administration Advisory Circular 60-4A states that attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot simply means the inability to tell which way is up. Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight minimums. Lack of a natural horizon or a surface reference is common on overwater flights, at night and especially at night in extremely sparsely populated areas or in low viability conditions. Therefore, the use of flight instruments is essential to maintaining proper attitude when encountering any of the elements which may result in spatial disorientation. ## Aircraft - Registration: [N308J](https://openairdocs.org/deregistered/N308J-2017-02-17), registration cancelled 2017-02-17, S/N 310J0142, built 1965 (OpenAirDocs) - Reported make and model: CESSNA 310J - Registry model: [Cessna 310J](https://openairdocs.org/model/cessna-310j) (registry code 2074226) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 310J0142 - Airframe hours: 6327 - Engines: CONT MOTOR IO-470 260 horsepower reciprocating; CONT MOTOR I0-470 260 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, March 13, 2009 - Departed: LZU, Lawrenceville, GA - Destination: SRB, Sparta, TN - Flight plan: IFR - Airport: LZU, Gwinnett County Airport-Brisco ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 29, 2009; seat: left; toxicology performed; flight hours: 1,200 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 40° at 10 knots - Visibility: 1 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 59 °F, dew point 59 °F - Altimeter: 30.10 inHg - Observed at: LZU, 4 nm away ## Docket (14 files) The files NTSB released with the investigation on October 26, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74980. 4.8 MB in all. - Transcript of Radio Communications (item 1, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355823&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Other Pertinent Forms and Reports; Maintenance Records (item 2, .PDF, 323 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355826&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Maintenance%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355827&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Toxicological Report (item 4, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355830&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Weather Reports and Records (item 5, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355831&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Redacted.PDF - Witness Statements (item 6, .PDF, 436 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355832&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Photo; NTSB Digital Photo 1, Automobiles. (item 7, .PDF, 535 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355833&FileExtension=.PDF&FileName=Photo;%20NTSB%20Digital%20Photo%201,%20Automobiles.-Master.PDF - Photo; NTSB Photo 2, In Basement looking towards the pool. (item 8, .PDF, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355834&FileExtension=.PDF&FileName=Photo;%20NTSB%20Photo%202,%20In%20Basement%20looking%20towards%20the%20pool.-Master.PDF - Photo; Cessna Photo 1, overall picture of crash site. (item 9, .PDF, 621 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355835&FileExtension=.PDF&FileName=Photo;%20Cessna%20Photo%201,%20overall%20picture%20of%20crash%20site.-Master.PDF - Photo 3, NTSB photo of Crankshaft (item 10, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355836&FileExtension=.PDF&FileName=Photo%203,%20NTSB%20photo%20of%20Crankshaft-Master.PDF - Photo NTSB Photo 4, Crankshaft. (item 11, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355837&FileExtension=.PDF&FileName=Photo%20NTSB%20Photo%204,%20Crankshaft.-Master.PDF - Photo 5 NTSB, Fragments of airplane. (item 12, .PDF, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355839&FileExtension=.PDF&FileName=Photo%205%20NTSB,%20Fragments%20of%20airplane.-Master.PDF - Photo 6, NTSB Propeller Blades (item 13, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355840&FileExtension=.PDF&FileName=Photo%206,%20NTSB%20Propeller%20Blades-Master.PDF - Photo 7, NTSB cut on tree limb (item 14, .PDF, 523 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40355841&FileExtension=.PDF&FileName=Photo%207,%20NTSB%20cut%20on%20tree%20limb-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.