# NTSB FTW03FA093: Cessna T210N, N4945Y, Mission, TX, February 5, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 5, 2003, 08:46 local (14:46 UTC) - Place: Mission, TX - Coordinates: 26.206111, -98.401664 - Nearby events: https://openairdocs.org/map.md?lat=26.2061&lon=-98.4017&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report March 30, 2005 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Administration, Cessna Aircraft Company - NTSB case key (mKey): 56437 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW03FA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56437/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=56437 - Page: https://openairdocs.org/ntsb/FTW03FA093 ## Probable cause The pilot's failure to maintain aircraft control, which resulted in his exceeding the airplane's design limitation. Contributing factors were the pilot's decision to fly the airplane with known deficiencies with the attitude indicator, and the failure of the attitude indicator. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - flight/nav instruments,attitude gyro - failure,total (contributing factor) - operation with known deficiencies in equipment - attempted, pilot in command (contributing factor) - Loss of control - in flight, cruise - aircraft control - not maintained, pilot in command (cause) - Airframe/component/system failure/malfunction, descent - uncontrolled - wing - failure,total - design stress limits of aircraft - exceeded, pilot in command (cause) - horizontal stabilizer - failure,total - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The high-wing airplane suffered an in-flight breakup, while on a cross-country flight in instrument meteorological conditions. The pilot received a weather briefing and filed an instrument flight plan for a cross-country that was to depart from the eastern part of Mexico and was destined for another Mexican city 318 miles west of the departure airport. The pilot was cleared for the flight along a victor airway that headed due west of the departure point. Radar data depicted the airplane parallel to, but north of the airway for the first few minutes of the flight. The airplane then drifted to the northwest and eventually crossed the U.S./Mexican border. The air traffic controllers discussed the airplane's position and whether or not they should notify the pilot he was off course. The controller asked the pilot to confirm his position, and was told, "let me see…we are on your radial…we have a problem with my [unintelligible]…let me check with my other radio." The pilot never reiterated what the problem was. Shortly after this communication, the airplane's mode C data depicted the airplane entering a right descending turn before disappearing from radar. The airplane wreckage was located ¼ mile north of the U.S./Mexican border. All of the airplane fracture surfaces and separated control cables were consistent with overload failures. The attitude indicator gyro and its housing did not display any evidence of rotation at the time of impact, unlike the horizontal situation indicator, which displayed heavy rotational scoring and gouging. No additional anomalies were observed; however, it should be noted that the cockpit sustained heavy impact and fire damage. The pilot records were not located during the investigation, and his total instrument time and instrument currency could not be determined. The maintenance records were destroyed in the accident; however, interviews with maintenance personnel indicated the pilot was aware of attitude indicator problems; however, he had not waited for maintenance to be conducted prior to taking the airplane on the accident flight. ## Factual narrative HISTORY OF FLIGHT On February 5, 2003, approximately 0850 central standard time (CST), a Cessna T210N single-engine airplane, N4945Y, was destroyed when it experienced an in-flight break up and collision with terrain near Mission, Texas. The airplane was in sales negotiations with a private individual in Mexico, but was registered to the pilot at the time of the accident. The pilot operated the airplane as a Mexican business flight. The U.S. commercial pilot and his two passengers (one of Mexican citizenry and one of U.S.) sustained fatal injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the cross-country flight. The flight originated from Matamoros, Mexico (MMMA), approximately 30 minutes prior to the accident and was destined for Torreon, Mexico (MMTC). Matamoras is located south of the U.S./Mexican border near Brownsville, Texas. Torreon is approximately 318 nautical miles west of Matamoros. According to personnel familiar with the passengers, the purpose of the flight was to transport the passengers to MMTC for business. It is unknown as to what relationship the pilot had with the passengers, under what regulations the flight was conducted in Mexico, or if any financial transactions had been made to conduct the flight. Review of air traffic control information provided by the Federal Aviation Administration (FAA) and the Direccion General de Aeronautical Civil (DGAC) revealed the accident airplane departed MMMA approximately 0820 with a clearance via victor airway 42 (V42) to Monterey and V10 to MMTC. The pilot was cleared to 6,000 feet mean sea level (msl) and was informed that he could expect 12,000 feet after Monterey. The flight was assigned a discrete transponder code of 1714 and was cleared for the Matamoros Alpha One departure (standard instrument departure - SID). The following is a summary of the communications between the pilot and air traffic control. Pertinent radar data gleaned from the Houston Air Route Traffic Control Center will be in parentheses following the communications. It should be noted that the communications transcripts and radar data times are off by up to five minutes at some points, and the time noted in this report is from the U.S. radar data. At 0829, an air traffic controller asked the pilot what the position of N4549Y was. The pilot responded that they were "10 miles out" and they were "leaving 3,000 feet for 6,000 feet on the 268 radial from Matamoros." The air traffic controller acknowledged the pilot's response and requested that he report 20 miles out. At 0834, the pilot reported that they were at 6,000 feet and 20 miles out. Air traffic control responded by asking the pilot to confirm they were "established on an airway?" The pilot confirmed with an affirmative (during this exchange, the aircraft's mode C depicted the airplane around 5 miles north of V42, between V42 and V2-10, tracking toward the northwest toward the U.S./Mexican border). It should be noted that N4945Y never became established on V42 and instead tracked parallel to the airway approximately three miles north until six minutes into the flight when the airplane began a track toward the northwest. Approximately 0839, the pilot called Reynosa's approach controller and said, "we are…the airway…we are at…12 miles from your station, level at 6,000 feet on the airway" (at this point on the depicted radar track, the airplane is on V2-10 at 6,000 feet approximately 12 miles southeast of the Reynosa very high omnidiretional range navigational aid - VOR). The Reynosa controller responded by providing an altimeter setting of 29.97 inches of mercury, and by requesting the pilot report 25 miles west of the station. The pilot acknowledged the request. At 08 42, the pilot called Reynosa and indicated they were crossing their station 3 miles west and requested 8,000 feet if available (the radar data depicted the airplane east of the Reynosa VOR. The airplane stayed in the northeast quadrant of the VOR until the last three minutes of the flight when it crossed into the northwest quadrant approximately six miles north of the VOR). The controller asked the pilot to repeat his position. The pilot responded with "we are 3 miles west of the station sir." The controller responded with a "roger" and asked him to hold on. At 0843, the Reynosa controller contacted another controller from a separate sector regarding N4945Y, and indicated that the pilot had requested 8,000 feet, and the aircraft was three miles west of the station (at this point, the radar data depicted the airplane three miles northeast of the Reynosa VOR. It had completed an s-turn to the south and was flying back toward the northwest). The other controller approved the altitude request. Shortly thereafter, the Reynosa controller asked the other controller what transponder code they had for the airplane. The other controller confirmed that it was 1714. The Reynosa controller asked the other controller if he observed the airplane crossing the U.S./Mexican border, to which the other controller answered in the affirmative and said the pilot was correcting himself. The Reynosa controller said, "Wow," to which the other controller responded, "If he is on 42, he is very off course. He is over your station." The other controller added, "How do you like that? He is about five miles north of your station" and suggested that the Reynosa controller pass the data on to Del Valle. The controllers commented to each other that the airplane was crossing the border into the U.S. At 0844, the Reynosa controller asked the pilot of N4945Y to confirm his position, to which the pilot responded, "let me see…we are on your radial…we have a problem with my [unintelligible]…let me check with my other radio." The controller asked the pilot if they were utilizing transponder code 1714 to which the pilot responded in the affirmative. The Reynosa controller then asked another person in the tower if he should tell the pilot he was off course. Shortly thereafter, Reynosa contacted Corpus Christi approach control (CRP) to let them know that he had "traffic with problem with the…with the instruments…the squawk code is one seven one four." The CRP controller acknowledged and asked Reynosa what the pilot was doing, to which the Reynosa controller responded, "I don't know." The CRP controller asked Reynosa if the pilot was in danger, to which the Reynosa controller responded, "No, he is off course." As the two controllers discuss the aircraft's status, the CRP controller observed the airplane descending and eventually "disappeared off my scope" (the radar data depicted the airplane initiate a left turn at 6,000 feet, then initiate a right turn while entering a descent. The last five mode C returns, at 9-second intervals, depict the airplane's elevation at 5,900 feet, 5,600 feet, 5,500 feet, 5,100 feet, and 3,900 feet, respectively). One witness was in her home at the time of the accident and heard an airplane engine. She looked out the window and observed an airplane descending at a 45-degree angle before it impacted the ground. Another witness located outdoors, observed the "tail come apart" while the airplane was "turning". He could not tell whether the wings were still on the airplane at that point. The aircraft wreckage was located approximately ¼-mile north of the U.S. Mexican border and five miles southwest of the McAllen Miller Airport, McAllen, Texas. PERSONELL INFORMATION The pilot (registered owner of the airplane) held a United States (U.S.) Federal Aviation Administration (FAA) commercial pilot certificate that was originally issued on July 27, 1967. He held single- and multi-engine land, and instrument airplane ratings. He held a FAA second-class medical certificate that was issued on July 4, 2002. The medical certificate contained one limitation for vis ## Aircraft - Registration: [N4945Y](https://openairdocs.org/deregistered/N4945Y-2003-02-11), registration cancelled 2003-02-11, S/N 21064052, built 1980 (OpenAirDocs) - Reported make and model: Cessna T210N - Registry model: [Cessna T210N](https://openairdocs.org/model/cessna-t210n) (registry code 2073456) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21064052 - Airframe hours: 920 - Engines: Continental TSIO-520-R 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Business, Non-U.S., non-commercial - Registered owner: Lowell S. Laake - Airworthiness certificate: Standard, Normal - Departed: MMTC, Matamoros - Destination: MMTC, Torreon - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 21,402 total ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 2,600 ft overcast - Temperature: 63 °F, dew point 57 °F - Altimeter: 30.00 inHg - Observed at: MFE, 5 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 20030205017549A](https://openairdocs.org/incident/20030205017549A), Feb 5, 2003: Cessna T210N, Destroyed, 3 fatal. (-23) Aircraft N495Y took off from matamoros, Mexico on a mexican instrument flight to torreon, Mexico. The pilot could not maintain course and crashed inside… ## Docket (30 files) The files NTSB released with the investigation on December 31, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=56437. 9.7 MB in all. - Witness Statements (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223293&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 2, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223294&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Radar Data (item 3, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223295&FileExtension=.PDF&FileName=Radar%20Data-Master.PDF - Flight Service Station Weather Brief Transcript (item 4, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223297&FileExtension=.PDF&FileName=Flight%20Service%20Station%20Weather%20Brief%20Transcript-Master.PDF - Transcript of Radio Communications (DGAC) (item 5, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223298&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications%20(DGAC)-Master.PDF - Transcript of Radio Communications (DGAC Interpatation) (item 6, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223299&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications%20(DGAC%20Interpatation)-Master.PDF - Reports from Federal Agencies (FAA) (item 7, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223300&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20(FAA)-Master.PDF - Reports from Parties to the Investigation (Cessna Aircraft) (item 8, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223301&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20(Cessna%20Aircraft)-Master.PDF - Excepts from Cessna 210 Information Manual (item 9, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223302&FileExtension=.PDF&FileName=Excepts%20from%20Cessna%20210%20Information%20Manual-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223303&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 654 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382968&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 12, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223305&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 01 Main wreckage at accident site (NTSB) (item 13, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223309&FileExtension=.PDF&FileName=Photo%2001%20Main%20wreckage%20at%20accident%20site%20(NTSB)-Master.PDF - Photo 02 Main wreckage at accident site 2 (NTSB) (item 14, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223310&FileExtension=.PDF&FileName=Photo%2002%20Main%20wreckage%20at%20accident%20site%202%20(NTSB)-Master.PDF - Photo 03 Main wreckage with rudder (NTSB) (item 15, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223311&FileExtension=.PDF&FileName=Photo%2003%20Main%20wreckage%20with%20rudder%20(NTSB)-Master.PDF - Photo 04 Right cabin door (NTSB) (item 16, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223312&FileExtension=.PDF&FileName=Photo%2004%20Right%20cabin%20door%20(NTSB)-Master.PDF - Photo 05 Left horizontal stabilizer (NTSB) (item 17, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223313&FileExtension=.PDF&FileName=Photo%2005%20Left%20horizontal%20stabilizer%20(NTSB)-Master.PDF - Photo 06 Right horizontal stabilizer (NTSB) (item 18, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223314&FileExtension=.PDF&FileName=Photo%2006%20Right%20horizontal%20stabilizer%20(NTSB)-Master.PDF - Photo 07 Left inboard wing (NTSB) (item 19, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223315&FileExtension=.PDF&FileName=Photo%2007%20Left%20inboard%20wing%20(NTSB)-Master.PDF - Photo 08 Right wing layout (NTSB) (item 20, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223316&FileExtension=.PDF&FileName=Photo%2008%20Right%20wing%20layout%20(NTSB)-Master.PDF - Photo 09 Right horizontal stabilizer and elevator (NTSB) (item 21, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223317&FileExtension=.PDF&FileName=Photo%2009%20Right%20horizontal%20stabilizer%20and%20elevator%20(NTSB)-Master.PDF - Photo 10 Right horizontal stabilizer and elevator 2 (NTSB) (item 22, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223318&FileExtension=.PDF&FileName=Photo%2010%20Right%20horizontal%20stabilizer%20and%20elevator%202%20(NTSB)-Master.PDF - Photo 11 Left horizontal stabilizer and elevator (NTSB) (item 23, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223319&FileExtension=.PDF&FileName=Photo%2011%20Left%20horizontal%20stabilizer%20and%20elevator%20(NTSB)-Master.PDF - Photo 12 Empennage layout (NTSB) (item 24, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223320&FileExtension=.PDF&FileName=Photo%2012%20Empennage%20layout%20(NTSB)-Master.PDF - Photo 13 Left wing layout (NTSB) (item 25, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223321&FileExtension=.PDF&FileName=Photo%2013%20Left%20wing%20layout%20(NTSB)-Master.PDF - Photo 14 Left wing layout 2 (NTSB) (item 26, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223322&FileExtension=.PDF&FileName=Photo%2014%20Left%20wing%20layout%202%20(NTSB)-Master.PDF - Photo 15 Propeller (NTSB) (item 27, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223324&FileExtension=.PDF&FileName=Photo%2015%20Propeller%20(NTSB)-Master.PDF - Photo 16 Vacuum Pump (NTSB) (item 28, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223325&FileExtension=.PDF&FileName=Photo%2016%20Vacuum%20Pump%20(NTSB)-Master.PDF - Photo 17 Attitude Indicator gyro and gyro housing (NTSB) (item 29, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223326&FileExtension=.PDF&FileName=Photo%2017%20Attitude%20Indicator%20gyro%20and%20gyro%20housing%20(NTSB)-Master.PDF - Photo 18 Horizontal situation indicator gyro housing (NTSB) (item 30, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40223327&FileExtension=.PDF&FileName=Photo%2018%20Horizontal%20situation%20indicator%20gyro%20housing%20(NTSB)-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.