# NTSB ERA22FA314: Cessna 210C, N3659Y, Shelby, MI, July 15, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 15, 2022, 18:15 local (22:15 UTC) - Place: Shelby, MI · Wooded area adjacent to residence - Coordinates: 43.623044, -86.30351 - Nearby events: https://openairdocs.org/map.md?lat=43.6230&lon=-86.3035&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, FAA/FSDO - NTSB case key (mKey): 105484 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22FA314 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105484/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105484 - Page: https://openairdocs.org/ntsb/ERA22FA314 ## Probable cause The non-instrument rated pilot’s decision to commence the flight in instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control. Contributing to the accident was the pilot’s self-induced pressure to initiate the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073412), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2073412), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot; cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=2073412), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=2073412), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2073412), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna 210C, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=2073412), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 210C, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073412), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident occurred shortly after the non-instrument rated pilot and passenger departed the airport on a visual flight rules flight in instrument meteorological conditions. Two pilots at the airport reported that the weather was poor at the time of the takeoff, with low ceilings and rain prevailing. After the departure, a local resident who lived about 1.5 miles south of the airport heard the airplane over his property for about 30 seconds, and the engine was “revving up” before the airplane crashed in the woods near his house. The airplane impacted trees and terrain at a steep, nose-low descent angle. The fragmentation of the wreckage and damage to the terrain at the accident site were indicative of a high-speed impact. Examination of the wreckage did not reveal evidence of a preexisting mechanical failure or anomaly that would have precluded normal operation of the airframe or engine. There was no evidence that the pilot obtained a weather briefing prior to the flight. The family of the pilot reported that the purpose of the flight was to attend an event in another state, that he had missed a similar previous event, and that did not want to miss this one. The pilot most likely entered instrument meteorological conditions immediately after takeoff, experienced spatial disorientation, and lost control of the airplane. The pressure that the pilot placed upon himself to attend the event was likely a factor in the accident. ## Factual narrative On July 15, 2022, about 1815 eastern daylight time, a Cessna 210C, N3659Y, was destroyed when it was involved in an accident near Shelby, Michigan. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight departed from runway 9 at Oceana County Airport (C04), Shelby, Michigan, with a destination of Warsaw Municipal Airport (ASW), Warsaw, Indiana. Two witnesses, who were both commercial pilots, were at the airport and observed the airplane depart. One witness reported that the ceiling at the time of takeoff was no higher than 100 ft, and the other witness reported that the airplane entered instrument meteorological conditions as it crossed a road about 1,300 ft past the departure end of the runway. Both witnesses reported that the visibility was poor and it was raining at the time. Another witness, who owned the land were the airplane impacted the ground, was inside his home at the time. He heard a “big roar outside.” He got up to look, thinking it was a tractor-trailer going by his house. He then heard a “big bang,” looked outside his picture window, and saw smoke or dust. He realized that an airplane had crashed adjacent to his house in the woods and the big roar was the engine running and it was “revving up.” The entire sequence lasted about 30 seconds. No recorded radar or automatic dependent surveillance-broadcast (ADS-B) data was recorded for the accident flight. According to Medical Examiner’s autopsy report from the Western Michigan University School of Medicine, Kalamazoo, Michigan, the cause of death of the pilot was multiple severe injuries and the manner of death was accident. Testing for ethanol and drugs was negative. At the time of the accident, a low-pressure system was located in Iowa associated with a cold front and stationary front that stretched from Nebraska through southern Iowa and Illinois and eastward through Kentucky. Also, a mid-level trough was located above the accident site. Troughs and fronts can act as lifting mechanisms to help produce clouds and precipitation if sufficient moisture is present. In addition to the Fremont, Michigan Municipal Airport (FFX) weather detailed in this report, C04 weather was provided to investigators by the airport manager. No ceiling information was available for C04; however, at 1815:03, the Automated Weather Observing System recorded wind from 130° at 5 knots, visibility 2 miles, temperature 17° C, relative humidity 98%, and an altimeter setting of 30.09 inches of mercury. National Weather Service forecast information for the area surrounding the accident site included instrument meteorological conditions that were expected to persist beyond 2300. A search of the Leidos and ForeFlight systems revealed that the accident pilot did not request weather information from these providers before the flight. The pilot’s widow was asked if her husband showed any sense of urgency incommencing the flight in instrument weather conditions. She stated that their son was driving in a demolition derby race in Warsaw and her husband had missed his previous races and did not want to miss this race. The wreckage was located in a wooded area about 1.5 nautical miles southeast of C04. There was no fire. The wreckage was highly fragmented. The measured descent angle through the broken tree limbs was about 50°. All structural components of the airplane were accounted for within the wreckage path. Smooth, angular cuts, consistent with propeller blade contact, were found on several tree branches scattered throughout the wreckage path. The right wing struck a large-diameter tree and was impact-separated from the fuselage. The right wing was located about 30 ft west of the fuselage. The right flap and a portion of the outboard right aileron were separated from the crushed wing structure. The nose of the aircraft impacted soft, sandy soil and the propeller was embedded about 4 ft deep into the ground. The left wing was also impact-separated and was located about 40 ft east of the fuselage. The left wing was fractured into multiple pieces. The majority of the left flap and the left aileron remained attached to a section of the aft spar. The empennage sustained significant compression damage and remained attached to the crushed fuselage. The left and right horizontal stabilizer and both elevators remained attached. The vertical stabilizer and rudder sustained tree impact damage at approximately mid-span. An approximate 3-ft section of the top of the rudder, with the balance weight attached, was found adjacent to the empennage. Control cable continuity within the flight control system was not established due to the general fragmentation of the wreckage and multiple impact-related cable separations. The hydraulic flap actuators indicated the flaps were in the fully retracted positions. The fuel tanks were fragmented, and pieces of rubber bladder were observed throughout the accident site; no residual fuel was observed. The instrument panel was fractured into multiple pieces. The directional gyro, attitude indictor, and turn coordinator were found near the impact crater. The gyro instruments were disassembled by investigators. All three gyros exhibited minor scoring, indicative of rotation at the time of impact. The airspeed indicator was separated and recovered from the impact crater. The needle was bent aft and captured in place near 230 knots indicated airspeed. Engine compression and valve train continuity could not be established due to impact damage. The magnetos were found loose on top of the engine. Both magnetos sustained impact damage and spark was not produced. The top spark plugs were removed and exhibited normal color and wear when compared to a Champion inspection chart. The engine accessories, including the engine-driven hydraulic pump, fuel pump, vacuum pump, and alternator, were impact-separated from the engine. The fuel pumpdrive coupling and vacuum pump coupling were found intact. The fuel control inlet screen and fuel manifold screen were clean and free of obstructions. Fuel was observed inside the manifold during disassembly. The oil filter paper element was clean. The propeller assembly was found in the impact crater. One propeller blade was separated from the hub. It was twisted, bent aft, and exhibited polishing and chordwise scratches on the cambered side. The second propeller blade remained attached to the hub. It was bent aft approximately 90 degrees at mid-span. Chordwise scratches were observed on the face of the second blade near the propeller hub, consistent with rotation at the time of bending and impact with the engine cowling. ## Aircraft - Registration: [N3659Y](https://openairdocs.org/aircraft/N3659Y), registered now, S/N 21058159, built 1963 (OpenAirDocs) - Reported make and model: CESSNA 210C - Registry model: [Cessna 210C](https://openairdocs.org/model/cessna-210c) (registry code 2073412) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21058159 - Year built: 1963 - Airframe hours: 4277 - Engines: Continental IO-470S 260 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 11, 2022 - Destination: ASW, Warsaw, IN - Airport: C04, Oceana County - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review May 31, 2021; seat: left; restraint: 3-point; toxicology performed; flight hours: 239 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 100° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 1,000 ft overcast - Temperature: 64 °F, dew point 64 °F - Altimeter: 30.07 inHg - Observed at: FFX, 17 nm away - METAR: METAR KFFX 152215Z AUTO 10005KT 10SM SCT005 OVC010 18/18 A3007 RMK AO2 T01830175= ## 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 20220715012379A](https://openairdocs.org/incident/20220715012379A), Jul 15, 2022: Cessna 210C, Shelby, MI, Destroyed, 2 fatal. On July 15, 2022 at approximately 1830 local time, a Cessna 210C aircraft, [privacy data omitted]registered under a partnership and operated by a private pilot… ## Docket (16 files) The files NTSB released with the investigation on November 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105484. 45.5 MB in all. - NTSB memorandum for record - witnesses (item 1, PDF, 5 pages, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556768&FileExtension=pdf&FileName=1%20Memorandum%20for%20Record%20508%20Witnesses_Redacted-Rel.pdf - Fueling information (item 2, PDF, 1 page, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556565&FileExtension=pdf&FileName=2%20Fuel%20Receipt%20for%20N3659Y-Rel.pdf - NTSB memorandum for record - pilot experience (item 3, PDF, 1 page, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556575&FileExtension=pdf&FileName=2b%20Memorandum%20for%20Record%20508%20Dannecker_Redacted-Rel.pdf - Excerpt - aircraft logbook (item 4, PDF, 1 page, 6.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556872&FileExtension=pdf&FileName=3%20Excerpt%20-%20Aircraft%20Logbook_Redacted-Rel.pdf - Excerpt - engine logbook (item 5, PDF, 1 page, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557018&FileExtension=pdf&FileName=4%20Excerpt%20-%20Engine%20Logbook_Redacted-Rel.pdf - Weather factual report (item 6, PDF, 28 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14606945&FileExtension=pdf&FileName=ERA22FA314_weatherfactualSuffernfinal-Rel.pdf - Weather attachment 1 (item 7, GIF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14607105&FileExtension=gif&FileName=attachment1_era22fa314wxradaranimation_2150to2219utc-Rel.gif - Weather attachment 2 (item 8, PDF, 5 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14607005&FileExtension=pdf&FileName=attachment2-Rel.pdf - Photo array (item 9, PDF, 10 pages, 10.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557090&FileExtension=pdf&FileName=5%20Photo%20Array-Rel.pdf - Diagram - oceana county airport and accident site (item 10, PDF, 1 page, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556228&FileExtension=pdf&FileName=6%20Oceana%20County%20Airport%20and%20Accident%20Site-Rel.pdf - Wreckage diagram (item 11, PDF, 1 page, 533 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556373&FileExtension=pdf&FileName=6a%20Wreckage%20Diagram-Rel.pdf - NTSB examination summary (item 12, PDF, 3 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14556778&FileExtension=pdf&FileName=6b%20Examination%20Summary-Rel.pdf - Toxicological report (item 13, PDF, 1 page, 542 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557100&FileExtension=pdf&FileName=10%20Tox%20Pilot_Redacted-Rel.pdf - NTSB memorandum for record - autopsy findings (item 14, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557444&FileExtension=pdf&FileName=11a%20Memorandum%20for%20Record%20508%20Autopsy%20Findings-Rel.pdf - Statement of party representatives to NTSB investigation (item 15, PDF, 14 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557036&FileExtension=pdf&FileName=13%20Party%20Form%20Textron_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 16, PDF, 1 page, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14560641&FileExtension=pdf&FileName=N3659Y%20-%20ERA22FA314%20NTSB%20Wreckage%20Release%20Signed_Redacted-Rel.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.