FTW04FA022

NTSB accident investigation · Cessna 210M · Tolar, TX · November 16, 2003

Accident · FatalField investigationFinal report
Date
November 16, 2003, 08:35 local (14:35 UTC)
Place
Tolar, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N777SGCessna 210M
Weather
Instrument (IMC) · Day
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
FAA/FSDO, Teledyne Continental Motors, Cessna A Textron Company
FAA report
20031116032759A
Case key
58342

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's improper pre-flight planning and loss of engine power for undetermined reasons. A factor was the fog.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - fogFactor
Preflight planning/preparation - improperPilot in commandCause
Loss of engine power(total) - nonmechanicalDescent - emergency
Reason for occurrence undeterminedFactor
Forced landingDescent - emergency
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - ground

Analysis

Shortly after takeoff, the non-instrument rated private pilot reported over the radio that the engine was losing power and she was turning back to the departure airport. She said that she was unable to maintain altitude and was descending into fog. Her husband, who heard her radio transmissions, told her to lower the landing gear and flaps in an attempt to slow the airplane down. He then departed in his airplane to assist her. The pilot's husband said he saw a plume of black smoke about 5 miles southeast of the airport and flew over the sight, but was unable to see the ground due to fog, which was about 500 feet thick. The 150-hour pilot did not receive a weather briefing before departing. Weather reported at the destination airport, about 23 nautical miles away, included 1/4-mile visibility, fog, and an overcast ceiling at 100 feet. Examination of the airplane and engine revealed no mechanical deficiencies.

Factual narrative

History of flight

On November 16, 2003, approximately 0835 central standard time, a Cessna 210M single-engine airplane, N777SG, was destroyed when it impacted the ground during a forced landing following a reported loss of engine power near Tolar, Texas. The non-instrument rated private pilot, sole occupant of the airplane, was fatally injured. The airplane, registered to and operated by the pilot, was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight that departed Granbury Municipal Airport (GDJ), near Granbury, Texas, about 0830, destined for Clark Field Municipal Airport (SEP), near Stephenville, Texas.

According to the pilot's husband, who was an airline pilot, the weather north of the airport was "unrestricted", and there was, "no weather in sight south of the airport." Prior to departure, he taxied the airplane to the end of the runway with his wife and performed an engine run-up. The husband said that he did not normally do the run-up with his wife, but they had not flown the airplane in two weeks, and he wanted to make sure everything was operating correctly. After the run-up was completed, the pilot taxied the airplane back to their hangar and he deplaned. His wife then taxied back to the end of the runway, and departed.

About five minutes later, while preparing his Cessna 195 for departure (he planned to follow his wife to Stephenville), he heard his wife transmit over the airport's UNICOM frequency. She stated that the engine was losing power, had encountered fog, and was returning to the airport. The husband told his wife to put the gear down, and to reduce the airplane's speed. After hearing his wife's radio transmissions, he departed Granbury to search for her. Shortly after he departed, he noticed a black plume of smoke about 5 miles southwest of the airport. He flew over the area, but could not see the ground due to fog. The husband said there was ground fog up to 500 feet. He recorded the position of the smoke plume on his GPS, which he later provided to rescue personnel. He does not know why it took 10 hours for the airplane to be located.

In addition, the pilot's husband said that both he and his wife had recently flown the airplane to and from California, and it flew "flawlessly."

A witness, who was a commercial pilot, stated that he was at Granbury Airport when he heard that the pilot had "gone down." He said that the pilot's husband had returned to the airport, but never reported seeing a plume of smoke or its location until later in the day. The witness departed with two other airplanes in an attempt to locate the airplane, but they could not see through the fog.

The pilot did not obtain a weather briefing prior to departure.

Personnel information

The pilot held a private pilot certificate with a rating for airplane single engine land. Her most recent Federal Aviation Administration (FAA) third class medical was issued on May 28, 2003. A review of the pilot's logbooks revealed she had accumulated a total of 149.4 flight hours, of which 3.7 were simulated instrument and 20 were in the same make and model as the accident airplane.

Aircraft information

Examination of the airframe and engine logbooks revealed the airplane underwent its most recent annual inspection on July 20, 2003.

The airplane was serviced with 54.6 gallons of 100LL aviation fuel prior to departure, which topped-off both fuel tanks.

Meteorological information

The weather at GDJ, at 0825, was reported wind calm, 7 statute miles visibility, clear skies, and a barometric pressure of 30.05 inches of Mercury. The temperature was 59 degrees Fahrenheit, and the dew point was 57 degrees Fahrenheit.

The weather at SEP, about 23 nautical miles southwest of GDJ, at 0825 was reported as wind calm, 1/4 statute mile visibility, overcast at 100 feet, and a barometric pressure of 30.03 inches of Mercury. The temperature was 54 degrees Fahrenheit, and the dew point was 51 degrees Fahrenheit.

Wreckage and impact information

An on-scene examination of the airplane wreckage was conducted on November 17, 2003. All major components were accounted for at the scene. The airplane came to rest oriented on a heading of 030 degrees magnetic, at a ground elevation of approximately 941 feet, about 5 nautical miles southwest of GDJ. The accident occurred during the hours of daylight approximately 32 degrees, 22 minutes north latitude, and 097 degrees, 52 minutes west longitude.

The fuselage was consumed by post-impact fire from the cockpit to the tail section, and both wings exhibited fire damage. Control cable continuity was established for all flight control surfaces to the cockpit area.

The right wing exhibited impact and fire damage. The outboard portion of the wing, and the aileron were consumed by fire. The flap was in the up position, and was intact with fire damage. The right wing tip was separated from the wing.

The left wing was separated from the fuselage, and exhibited fire damage. The wing was located to the left of the fuselage, and partially suspended in brush and trees. The flap was in the up position, and exhibited fire and impact damage. The aileron was intact, and exhibited fire and impact damage.

The tail was twisted, and upside down. Both stabilizers were intact, and exhibited fire and impact damage. The rudder was secured to the attachment points, displaced to the left with fire damage.

The engine did not reveal a lot of impact damage, and remained attached to the firewall by cables. Some accessories were burnt. The engine was manually rotated, and compression and valve train continuity were established for each cylinder. During the compression check, spark was produced to each ignition lead. The turbocharger was disassembled and no discrepancies were noted. The spark plugs were removed and appeared dark gray in color.

The throttle control was found in the full forward position, and the mixture control was found half forward.

The flaps and the landing gear were found in the retracted position.

All 3 propeller blades were separated from the hub. The first and second blades had some scoring on the trailing edge of the blade. The third blade had some of the hub attached, and a small impact mark. There were scratches noted about 8 inches from the tip of the third blade, and a white chordwise paint transfer mark found.

Examination of the airplane and engine revealed no mechanical problems.

Medical and pathological information

An autopsy was performed, on November 17, 2003, by the Office of Chief Medical Examiner Tarrant County District. The cause of death was determined as blunt force injuries.

Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. Cyclobenzaprine, a muscle relaxant commonly known as Flexeril, was detected in the pilot's kidney and liver. However, a value concentration was unobtainable. According to the pilot's husband, his wife had been in a car accident several years before, and she would take this medication at night to relieve pain in her back and legs. He did not know when she last took the medication. According to an FAA Flight surgeon, "If the airman had reported taking this medication to the FAA, she would have been given a 24-hour restriction warning before performing safety-sensitive activities."

Additional information

The airplane wreckage was released on December 2, 2003, to a representative of the owner's insurance company.

Aircraft

Registration
N777SG
Reported as
Cessna 210M
Category
Airplane
Serial number
21061903
Engine
Continental TSIO-520-R, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Leo Orlowski
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 20, 2003
Departed
GDJ · Granbury, TX
Destination
SEP · Stephenville, TX
Airport
KGDJ · Granbury Municipal Airport, runway 14, 3,603 × 60 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
July 21, 2003
Seat
Left
Toxicology
Performed
Flight hours
150 total · 20 in this make and model · 115 as pilot in command · 19 in the last 90 days · 14 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
100° at 9 knots
Visibility
10 statute miles
Temperature
79 °F, dew point 64 °F
Altimeter
29.96 inHg
Observed at
GDJ, 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.