# NTSB ERA11FA218: Cessna 310R, N1914G, Pikeville, KY, March 30, 2011

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 30, 2011, 12:48 local (16:48 UTC)
- Place: Pikeville, KY
- Coordinates: 37.552776, -82.572219
- Nearby events: https://openairdocs.org/map.md?lat=37.5528&lon=-82.5722&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report March 20, 2012
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Cessna Aircraft Company, FAA/FSDO, Continental Motors
- NTSB case key (mKey): 78716
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11FA218
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78716/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78716
- Page: https://openairdocs.org/ntsb/ERA11FA218

## Probable cause

The pilot's flight below the published minimum descent altitude in instrument meteorological conditions, which resulted in a collision with trees and the ground. Contributing to the accident was the pilot's use of nighttime cold medication at doses above therapeutic levels that may have resulted in impairment and posed a hazard to flight safety.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 310R, 2 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2074245), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 310R, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2074245), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna 310R, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2074245), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md)
- [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna 310R, 3 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=2074245), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md)
- [Impairment/incapacitation: oTC medication](https://openairdocs.org/ntsb-findings/02012030): Personnel issues › Physical · Pilot (probable cause); cases with it: [Cessna 310R, 1 case](https://openairdocs.org/ntsb-findings/02012030/cases.md?model=2074245), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02012030/cases.md)
- [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 310R, 3 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2074245), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md)
- [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 310R, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2074245), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 310R, 4 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2074245), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)

## Analysis

The pilot requested and was cleared for a non-precision instrument approach to the mountaintop airport that was obscured by clouds and fog; a precision approach to the same airport was also available. Review of the radar data revealed that the last two data points were aligned with the runway but below the published minimum descent altitude. Witnesses at a worksite 200 to 300 feet below the airport elevation heard the airplane approach and then saw it appear from beneath the clouds directly on top of, and parallel to, a ridgeline approximately in line with the final approach course. The witnesses heard and saw the airplane hit small branches in the treetops of some trees and then strike a large tree before disappearing from view. They each said that the sound of the airplane’s engines was smooth and continuous until contact with the trees. They stated that the fog was heavy and that the clouds were on top of the trees. The first identifiable tree strikes were 1,100 feet right of the runway centerline and about 100 feet below the airport elevation. The local director of public safety who responded to the airport immediately after the accident estimated that visibility was less than 30 feet due to fog. A postaccident examination of the wreckage revealed no preimpact mechanical anomalies. Toxicological testing of the pilot revealed use of nighttime cold medication at doses above therapeutic levels; such levels may have posed a hazard to flight safety.

## Factual narrative

HISTORY OF FLIGHT On March 30, 2011, about 1248 eastern daylight time, a Cessna 310R, N1914G, operated by Miller Aviation, LLC, was destroyed from collision with trees and terrain while performing an instrument approach procedure to Pike County Airport (PBX), Pikeville, Kentucky. The certificated airline transport pilot and the sole passenger were fatally injured. The airplane departed Dayton-Wright Brothers Airport (MGY), Dayton, Ohio, about 1148. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the on-demand passenger flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 135. Voice and radar data from the Federal Aviation Administration (FAA) revealed that the pilot requested and was cleared for the RNAV (GPS) RWY 09 instrument approach procedure at PBX. The minimum descent altitude for the approach was 1,960 feet mean sea level (msl), and the airport elevation was 1,473 feet msl. According to an airport employee who was monitoring the airport's common traffic frequency, the pilot radioed that he was 20 miles from the airport and requested the weather conditions. The airport employee provided the Automated Weather Observation Service (AWOS) weather of 1-11/2 miles visibility and 200-300 foot ceilings, but told the pilot that the weather conditions were worse than what was reported. According to witnesses who were at a worksite 200-300 feet below the airport elevation, they heard the airplane approach, and observed it appear from beneath the clouds directly on top of and parallel to a ridgeline approximately in line with the runway 09 final approach course. The witnesses heard and saw the airplane impact several treetops, strike a large tree, then disappear from view. They each said the sound of the airplane’s engines was smooth and continuous to tree contact. They stated that the fog was “heavy” and that the clouds were at treetop level. The last four radar plots depicted the airplane at 1,900 feet, 1,900 feet, 1,800 feet, and 1,700 feet msl, respectively. The last plot was located about ½ mile prior to the runway threshold, and aligned with the runway. PERSONNEL INFORMATION The pilot was co-owner of Miller Aviation. He held an airline transport pilot certificate with ratings for airplane single engine and multi-engine land. His most recent FAA second-class medical certificate was issued on January 24, 2011. On that date, the pilot reported 19,600 total hours of flight experience. According to the operator, the pilot had 15,300 hours of flight experience in the Cessna 310. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 1975, and was equipped with two Teledyne-Continental engines. The airplane's most recent annual inspection was conducted on March 29, 2011, at which time it had accumulated 15,667 total hours of operation. METEOROLOGICAL INFORMATION At 1250, the weather reported at PBX included calm winds, with an overcastceiling at 300 feet and 1 ½ miles visibility. At 1255, the weather reported included calm winds, overcast ceiling at 200 feet, and ½ mile visibility. The terminal area forecast (TAF) around the destination airport was for IFR conditions with light drizzle and mist at the estimated time of arrival. AIRMET Sierra Update 2 was valid for IFR conditions and mountain obscuration in the area surrounding the destination airport until 1700. The Pikeville Director of Public Safety, who responded to the airport immediately after the accident, stated that while entering an access code at an airport gate, the fog was so thick that he could not see the gate, which was 30 feet from the keypad. AIRPORT INFORMATION PBX was located in mountainous terrain about 5 miles north of Pikeville, Kentucky, and built atop a ridgeline in a reclaimed surface mine area. The official airport elevation was 1,473 feet. The airport was not tower-controlled, but the UNICOM frequency was monitored by an airport employee at the time of the accident. Runway 09/27 was 5,350 feet long and 100 feet wide. Runway 02/20 was 3,600 feet long and 75 feet wide and was located along the east side of the field. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the site, which was located approximately 37 degrees, 33 minutes north latitude, and 82 degrees, 34 minutes west longitude, on March 31, 2011. All major components of the airplane were accounted for at the scene. The first identifiable tree strikes were located 1,100 feet right of the runway centerline, and about 100 feet below the airport elevation. The wreckage path was oriented approximately 138 degrees magnetic, and pieces associated with both wings were scattered along the path. The main wreckage came to rest upright about 1,200 feet beyond the first tree strike, and 650 feet below the airport elevation. The nose compartment, cockpit, and cabin areas were consumed by post-crash fire. Both engines and propeller systems displayed significant impact and fire damage. The empennage, vertical fin, horizontal stabilizer, and elevator were largely intact. The counterweight separated from the top of the rudder and was found 30 feet beyond the main wreckage. Control cable continuity was established from the flight control surfaces at the tail to the cockpit area. The engines and propeller systems were removed from the site and relocated to the airport for a detailed examination on April 1, 2011. The right engine displayed significant impact and fire damage. The crankshaft was rotated by hand, and continuity was established from the powertrain through the valvetrain to the accessory section. Cylinder compression was confirmed using the thumb method, and borescope examination revealed no evidence of mechanical anomaly. The magnetos were rotated by hand and spark was produced at all terminal leads. The right engine propeller had separated from the engine at impact. All three blades showed similar twisting, bending, leading edge gouging,and chordwise scratching. The propeller spinner displayed a torsional twist. The left engine displayed significant impact damage. The crankshaft was rotated by hand, and continuity was established from the powertrain through the valvetrain to the accessory section. Cylinder compression was confirmed using the thumb method, and borescope examination revealed no evidence of mechanical anomaly. The magnetos were rotated by hand and spark was produced at all terminal leads. The left engine propeller remained attached to the engine. One blade showed similar twisting, bending leading edge gouging, and chordwise scratching as the blades on the right propeller. The two remaining blades showed spanwise bending and smearing that obscured chordwise scratches beneath. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Associate Chief Medical Examiner, for the Commonwealth of Kentucky, performed an autopsy on the pilot. The cause of death was reported as the result of multiple blunt force injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed the toxicological testing for the pilot. The following Tested-for-Drugs were detected: >> 14.24 (ug/ml, ug/g) Acetaminophen detected in Urine - Acetaminophen (Tylenol®) - This over the counter analgesic medication was used to treat aches and pains as well as fever >> Dextrorphan detected in Blood (Cavity) - A metabolite of dextromethorphan, with a lesser cough suppressant (antitussive) activity. >> Dextrorphan detected in Urine >> 0.26 (ug/ml, ug/g) Doxylamine detected in Blood (Heart) Doxylamine (NyQuil® or Unisom®, etc..) - This was a common over the counter antihistamine marketed as NyQuil® and used in the treatment of the common cold and hay fever. It was also marketed as Unisom®; a sleep aid. The range of therapeutic levels in the blood were listed as: Therapeutic Low 0.0500 ug/ml - Therapeutic High 0.1500 ug/ml. The half life was 6 to 12 hours. Warnings – "may impair mental and/or physical ability required for the performance of potentially hazardous tasks." Based on the finding of cough drop wrappers in the pilot's clothing, this pilot may have had an upper respiratory condition but it could not be determined if the condition caused any hazard to flight safety. Based on toxicological analysis, the pilot used a cold medication and had high therapeutic levels of doxylamine in the heart blood; this medication can cause impairment and pose a hazard to flight safety. ADDITIONAL INFORMATION The pilot requested and was cleared for the RNAV (GPS) RWY 9 approach at PBX. The RNAV (GPS) RWY 9 approach was a non-precision approach with a minimum descent altitude of 1,960 feet, which was 506 feet above the runway touchdown zone elevation. The ILS RWY 27 approach at PBX was also available to the pilot at the time of the accident. The ILS RWY 27 approach was a precision approach with a decision height of 1,666 feet, which was 200 feet above the touchdown zone elevation.

## Aircraft

- Registration: [N1914G](https://openairdocs.org/deregistered/N1914G-2011-06-29), registration cancelled 2011-06-29, S/N 310R0059, built 1974 (OpenAirDocs)
- Reported make and model: CESSNA 310R
- Registry model: [Cessna 310R](https://openairdocs.org/model/cessna-310r) (registry code 2074245) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 310R0059
- Airframe hours: 15667
- Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating; CONT MOTOR IO 520 SERIES 285 horsepower reciprocating
- Damage: Substantial damage
- Fire: On-Ground
- Flight: Part 135
- Operator: Miller Aviation LLC
- Registered owner: Miller Aviation LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 29, 2011, 2 hours before
- Departed: MGY, Dayton, OH
- Destination: PBX, Pikeville, KY
- Flight plan: IFR
- Airport: PBX, Pike County-Hatcher Field, runway 09, 5,350 × 100 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 50; injuries: fatal; airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 19, 2011; seat: left; toxicology performed; flight hours: 19,000 total, 15,300 in this make and model

## Weather

- Conditions: Instrument (IMC), Day
- Wind: calm
- Visibility: 2 statute miles
- Lowest ceiling: 300 ft overcast
- Temperature: 46 °F, dew point 45 °F
- Altimeter: 29.77 inHg
- Observed at: PBX

## 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 20110330006029A](https://openairdocs.org/incident/20110330006029A), Mar 30, 2011: Cessna 310R, Pikeville, KY, Destroyed, 2 fatal. On Wednesday, March 30, 2011, at approximately 12:48 eastern time, a Cessna 310R, operated by a certificated airline transport pilot, (ATP), was destroyed on…

## Docket (20 files)

The files NTSB released with the investigation on December 30, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78716. 9.1 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359780&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Witness Statements (item 2, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359781&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF
- Record of Conversation: Chief Pilot (item 3, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359782&FileExtension=.PDF&FileName=Record%20of%20Conversation%3A%20Chief%20Pilot-Master.PDF
- Radar Data and Airplane Impact Path (item 4, .PDF, 778 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359783&FileExtension=.PDF&FileName=Radar%20Data%20and%20Airplane%20Impact%20Path-Master.PDF
- Flight Service Station Transcript (item 5, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359784&FileExtension=.PDF&FileName=Flight%20Service%20Station%20Transcript-Redacted.PDF
- RNAV GPS Runway 9 Approach Plate (item 6, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359785&FileExtension=.PDF&FileName=RNAV%20GPS%20Runway%209%20Approach%20Plate-Master.PDF
- JKL Weather Observations (item 7, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359786&FileExtension=.PDF&FileName=JKL%20Weather%20Observations-Master.PDF
- Weather Data - NTSB Meteorologist (item 8, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359787&FileExtension=.PDF&FileName=Weather%20Data%20-%20NTSB%20Meteorologist-Redacted.PDF
- Emergency Dispatcher Report (item 9, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359788&FileExtension=.PDF&FileName=Emergency%20Dispatcher%20Report-Redacted.PDF
- Most Recent Maintenance Inspection (item 10, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40359790&FileExtension=.PDF&FileName=Most%20Recent%20Maintenance%20Inspection-Redacted.PDF
- Toxicological Report (Pilot) (item 11, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360290&FileExtension=.PDF&FileName=Toxicological%20Report%20(Pilot)-Master.PDF
- Toxicological Report (Passenger) (item 12, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360003&FileExtension=.PDF&FileName=Toxicological%20Report%20(Passenger)-Master.PDF
- FAA Medications and Flying Brochure (item 13, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360299&FileExtension=.PDF&FileName=FAA%20Medications%20and%20Flying%20Brochure-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360057&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360101&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360102&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Overhead View of Radar Track (item 17, .PDF, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360009&FileExtension=.PDF&FileName=Overhead%20View%20of%20Radar%20Track-Master.PDF
- Profile View of Radar Track (item 18, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360010&FileExtension=.PDF&FileName=Profile%20View%20of%20Radar%20Track-Master.PDF
- Radar Track with Approach Fixes (item 19, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360011&FileExtension=.PDF&FileName=Radar%20Track%20with%20Approach%20Fixes-Master.PDF
- Photo 1. Airplane Wreckage (item 20, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437734&FileExtension=.PDF&FileName=Photo%201.%20Airplane%20Wreckage-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.

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