# NTSB ERA15LA238: Cessna T210, N732VN, Palmyra, PA, June 14, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 14, 2015, 14:45 local (18:45 UTC) - Place: Palmyra, PA - Coordinates: 40.288333, -76.58139 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.2883&lon=-76.5814&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of lift](https://openairdocs.org/ntsb-events/500) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report February 3, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 91369 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA238 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91369/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91369 - Page: https://openairdocs.org/ntsb/ERA15LA238 ## Probable cause The pilot's delay in conducting an aborted landing and his subsequent failure to establish a proper airspeed during the attempted go-around on a hot day, which resulted in the airplane’s inability to climb and a subsequent stall/mush. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210M, 11 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073451), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2073451), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna T210M, 4 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2073451), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=2073451), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Temp/humidity/pressure: high temperature](https://openairdocs.org/ntsb-findings/03031015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/03031015/cases.md?model=2073451), [All aircraft, 30 cases](https://openairdocs.org/ntsb-findings/03031015/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Not specified; cases with it: [Cessna T210M, 2 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2073451), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna T210M, 4 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073451), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing-landing roll: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Cessna T210M, 3 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=2073451), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Landing-aborted after touchdown: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=2073451), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Initial climb: Loss of lift](https://openairdocs.org/ntsb-events/500) (defining event); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-events/500/sequence.md?model=2073451), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T210M, 18 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073451), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to the private pilot, following the personal flight and during the approach, he observed that the windsock was indicating light wind and that it was favoring the use of runway 31. He reported that, during the landing attempt, it felt as if "the braking had little effect," so he released the brakes and then reapplied them. However, he believed that there was insufficient runway remaining to safely stop, so he applied full engine power to attempt a go-around. The airplane lifted off, but it subsequently settled into the corn field at the departure end of the runway, which resulted in damage to the wing and engine mounts. The pilot reported no mechanical malfunctions or abnormalities that would have precluded normal operation, and a postaccident examination of the airplane revealed no preimpact anomalies. An observation from a recording station 5 miles north of the airport indicated that the wind was from the southwest at 6 knots around the time of the accident, which could have resulted in about a 2-knot tailwind. According to the Pilot's Operating Handbook, with a 2-knot tailwind, the airplane would have required about 1,700 ft to land, and the runway had about 1,655 ft of available landing surface. The high temperature at the time of the accident would have decreased the airplane's climb performance by about 20 percent. It is likely that the pilot did not establish a proper airspeed for the go-around and that the high temperature decreased the airplane's climb performance, which resulted in a stall/mush during the attempted go-around. ## Factual narrative Cessna T210 Pilot Operating Handbook Section 5 "Performance" provided a landing distance table and certain conditions that had to be met, one of those conditions was "zero wind." The table also contained "Notes" at the top of the performance chart. One of the notes stated "Decrease distances 10% for each 10 knots [of] headwind. For operation with tailwinds up to 10 knots, increase distances by 10% for each 2.5 knots." The chart provided two columns of information the first column was ground roll and the second column was the "total to clear 50 ft [foot] obs [obstacle]." The chart only provided performance numbers for the maximum landing weight of 3,800 pounds, the pilot reported the weight at the time of the accident was 3100 pounds. At the maximum weight and recorded temperature, 1,560 feet of runway would have been required in a "zero wind" condition. FAA Airplane Flying Handbook Chapter 5 "Takeoffs and Departure Climbs" states in part "…under conditions of high-density altitude, high temperature, and/or maximum gross weight, the airplane may be able to become airborne at an insufficient airspeed, but unable to climb out of ground effect. Consequently, the airplane may not be able to clear obstructions, or may settle back on the runway…" Density Altitude FAA Pamphlet FAA-P-8740-2 "Density Altitude" defines density altitude as "pressure altitude corrected for non-standard temperature variations." Density altitude can affect aircraft performance. As density altitude increase, air density decreases, which results in decreased aircraft performance. According to the Koch chart on page 3 of the pamphlet, based on the conditions at the time for the accident, 30 degrees C and pressure altitude of about 400 feet, the airplane's climb rate would have been reduced by about 20 percent. According to the pilot and FAA records, the airplane was issued a standard airworthiness certificate on March 16, 1977. It was powered by a Continental TSIO-520-R9, Serial number 294452-R, 310-hp engine and driven by a McCauley propeller. The airplane's most recent annual inspection was recorded on October 9, 2014, and at that time it had accrued 2,903 hours total time in service. The engine had accrued 870 hours of time in service since the most recent overhaul. The airport was privately owned and at the time of the accident did not have a control tower. There was one runway designated runway 13/31. The asphalt runway was 1,955 feet long and 40 feet wide and runway 31 had a displaced threshold of 300 feet. The approach end of the runway had a road about 45 feet from the beginning of the paved surface and about 350 feet from the threshold for runway 31. The airport was 489 feet above mean sea level On June 14, 2015, about 1445 eastern daylight time, a Cessna T210M, N732VN, was substantially damaged when it impacted terrain following an aborted landing attempt and subsequent go-around maneuver at Reigle Field (58N), Palmyra, Pennsylvania. The private pilot was not injured.Visual meteorological conditions prevailed and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated from Bloomsburg Municipal Airport (N13), Bloomsburg, Pennsylvania about 1415. According to the pilot, prior to his departure he checked the weather and determined that the flight would be in visual flight conditions. Prior to landing he observed the windsock, at the airport, and a flag, mounted at the top of a rollercoaster, at a nearby amusement park. Both indicated that the wind was "light" and favoring the use of runway 31. During the landing attempt, he stated that "the runway was hot" and it felt as though the "braking had little effect," he released the brakes and applied braking again. However, he felt that there may not have been enough remaining runway to safely stop and applied "full power" to begin a go-around maneuver. During the initial climb the airplane was not performing as he thought it should and the airplane subsequently impacted the ground at the departure end of the runway and came to rest in a cornfield with its right wing and then nosed into the ground. The pilot reported that there were no mechanical problems or abnormalities with the airplane. The pilot did not report where the airplane first contacted the runway. According to a Federal Aviation Administration (FAA) inspector that responded to the accident location, the airplane impacted the ground and came to rest, approximately 300 feet from the departure end of the runway, in a muddy cornfield. Examination of the airplane revealed the right wing spar was damaged and the engine had separated from the airframe. No preimpact malfunctions were noted that would have precluded normal operations. The 1458 record weather observation at Muir Army Airfield (MUI), Annville, Pennsylvania, located approximately 5 miles north of the accident location indicated wind from 240 degrees at 6 knots, visibility 10 miles, scattered clouds at 4,900 feet above ground level, temperature 29 degrees C, dew point 21 degrees C, and a barometric altimeter of 30.03 inches of mercury. The recorded weather 1 hour before and 1 hour following the accident, indicated variable winds between 4 and 6 knots. The density altitude calculated was about 2,000 feet. The recorded weather at other airports within 17 miles of the accident location revealed calm winds to wind from the southwest at 9 knots. According to pilot and FAA records, he held a private pilot certificate with rating for airplane single-engine land and multiengine land. His most recent third-class medical certificate was issued on March 4, 2015. He had accumulated about 819 total hours of flight experience, and of those hours, 310 total hours were in the accident aircraft make and model. ## Aircraft - Registration: [N732VN](https://openairdocs.org/deregistered/N732VN-2017-07-14), registration cancelled 2017-07-14, S/N 21061810, built 1977 (OpenAirDocs) - Reported make and model: CESSNA T210 (M) - Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061810 - Year built: 1977 - Airframe hours: 2903 - Engines: CONT MOTOR TSIO-520-R 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 9, 2014 - Departed: N13, BLOOMSBURG, PA - Destination: 58N, Palmyra, PA - Airport: 58N, Reigle Field, runway 31, 1,955 × 40 ft, asphalt - Equipment: Auto-pilot, ADS-B, Stall warning system, Onboard weather, Handheld GPS, Electronic multifunction display, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: none; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, with waivers/limitations; last flight review March 22, 2015; seat: left; restraint: lap only; flight hours: 819 total, 310 in this make and model, 819 as pilot in command, 1 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 70 °F - Altimeter: 30.03 inHg - Observed at: KMUI, 9 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 20150614010339A](https://openairdocs.org/incident/20150614010339A), Jun 14, 2015: Cessna T210M, Palmyra, PA, Substantial damage. The PIC flew (solo) from N13 (bloomsburg, PA) to 58N (Reigle, PA). During landing on runway 31 at 58N, the PIC attempted to abort the landing after the… ## Docket (9 files) The files NTSB released with the investigation on December 24, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91369. 6.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435181&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435182&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Memorandum of Record - FAA Statement (item 3, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435183&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20-%20FAA%20Statement-Master.PDF - Muir Army Airfield Weather (item 4, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435184&FileExtension=.PDF&FileName=Muir%20Army%20Airfield%20Weather-Master.PDF - Nearby Recorded Weather - 2 Other Airports (item 5, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435185&FileExtension=.PDF&FileName=Nearby%20Recorded%20Weather%20-%202%20Other%20Airports-Master.PDF - Google Map of Accident Location - FAA Provided (item 6, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435186&FileExtension=.PDF&FileName=Google%20Map%20of%20Accident%20Location%20-%20FAA%20Provided-Master.PDF - T201M Pilot Operating Handbook Landing Chart (Excerpts) (item 7, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435187&FileExtension=.PDF&FileName=T201M%20Pilot%20Operating%20Handbook%20Landing%20Chart%20(Excerpts)-Master.PDF - Koch Chart (item 8, .PDF, 500 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435188&FileExtension=.PDF&FileName=Koch%20Chart-Master.PDF - Accident Photographs (Courtesy of FAA) (item 9, .PDF, 6 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435189&FileExtension=.PDF&FileName=Accident%20Photographs%20(Courtesy%20of%20FAA)-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.