# NTSB LAX93FA125: Cessna T210M, N761NE, Coalinga, CA, February 16, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 15, 1993, 18:55 local (Feb 16, 1993, 02:55 UTC) - Place: Coalinga, CA - Coordinates: 36.190067, -120.389648 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.1901&lon=-120.3896&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 15, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 28318 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93FA125 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28318/pdf - Page: https://openairdocs.org/ntsb/LAX93FA125 ## Probable cause THE PILOTS INADEQUATE PREFLIGHT PLANNING AND HIS FAILURE TO SELECT A CRUISE ALTITUDE WHICH WOULD ENSURE ADEQUATE TERRAIN CLEARANCE DURING THE NIGHT CROSS COUNTRY. FACTORS IN THE ACCIDENT WERE: THE MOUNTAINOUS NATURE OF THE TERRAIN AND THE DARK NIGHT LIGHT CONDITIONS ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, cruise - terrain condition - mountainous/hilly (contributing factor) - light condition - dark night (contributing factor) - visual/aural detection, pilot in command (contributing factor) - preflight planning/preparation - inadequate, pilot in command (cause) - proper altitude - not selected, pilot in command (cause) ## Analysis THE PILOT AND HIS PASSENGER DEPARTED THE SOUTHERN CALIFORNIA AREA FOR AN EVENING FLIGHT TO THE CENTRAL PART OF THE STATE. HE CONTACTED APPROACH CONTROL FOR ENTRY INTO THE LOS ANGELES TCA AND THROUGH THE VFR CORRIDOR OVER LAX. THE PILOT THEN CLIMBED OVER MOUNTAINOUS TERRAIN TO 10500 FEET MSL, AND INTERCEPTED THE V 107 AIRWAY. AFTER PASSING THE MOUNTAINOUS TERRAIN THE PILOT DESCENDED TO 4500 FEET MSL, ON V 107. ACCORDING TO THE JEPPESEN LOW ALTITUDE ENROUTE CHARTS THREE AND FOUR, THE MINIMUM ENROUTE ALTITUDE FOR THAT SEGMENT OF THE AIRWAY IS 7000 FEET MSL. ACCORDING TO THE SAN FRANCISCO SECTIONAL AERONAUTICAL CHART THE MAXIMUM ELEVATION FIGURE (MEF), FOR THE ACCIDENT AREA IS 5600 FEET MSL. THE AIRPLANE IMPACTED 4500 FOOT WRIGHT MOUNTAIN ABOUT 80 FEET BELOW A RIDGE LINE IN LEVEL FLIGHT. ACCORDING TO THE RADAR DATA THE AIRPLANE GROUND SPEED WAS ABOUT 160 KNOTS WHEN RADAR CONTACT WAS LOST ABOUT TWO AND ONE HALF MILES WEST OF V 107. WEATHER CONDITIONS WERE VMC, HOWEVER, THE NIGHT WAS DARK. THE PILOT WAS FLYING WITH AN INVALID MEDICAL CERTIFICATE ## Factual narrative HISTORY OF FLIGHT: On February 15, 1993, at about 1855 hours PST, a Cessna T210M, N761NE, collided with mountainous terrain near Coalinga, California, during a night personal cross country flight. Visual meteorological conditions prevailed at the accident site and no flight plan was filed. The airplane was destroyed. The private pilot and his passenger both received fatal injuries. The flight originated at John Wayne Airport, Orange County, California, at about 1730 hours PST, and was enroute to Lincoln, California. After departure from John Wayne Airport the pilot contacted departure control for advisories into the Los Angeles TCA and through the VFR corridor over LAX. According to radar data obtained for search purposes, after clearing the TCA the pilot climbed to 10,500 feet MSL over the mountainous terrain to the north of the Los Angeles basin and intercepted federal airway V 107. After crossing the mountains the pilot descended to a mode C reported altitude of 4,500 feet MSL and continued to track north bound on airway V 107. Radar data retrieved utilizing the National Tracking Analysis Program (NTAP), revealed that the airplane was tracking on or near airway V 107, and reporting an altitude of 4,500 feet MSL, northbound when radar contact was lost at 1853:58 hours PST. According to the Jeppesen low altitude enroute charts numbers three and four, the minimum enroute altitude for the routing between Avenal Vortac (navaid) and Panoche Vortac is 7,000 feet MSL. According to the San Francisco Sectional Aeronautical Chart the maximum elevation figure (MEF) for the accident area is 5,600 feet MSL. At the time of the accident several witnesses near Coalinga reported seeing a fireball or fire in the area of the wreckage. The airplane was located on February 19, 1993, by the Fresno County Search And Rescue personnel during a ground search on the east side of Wright Mountain between 4300 and 4400 feet MSL. During the search period the weather prevented an air search due to mountain obscuration. The emergency locator transmitter (ELT) was destroyed. PERSONNEL INFORMATION At the private pilots last third class flight physical on October 24, 1991, he reported a total flight time of 2700 hours with no hours for the last six months. According to the pilots last log book entry dated October 7, 1992, he had accumulated about 2888 hours of flight time. The pilot possessed a medical waiver (statement of demonstrated ability) issued to him on December 16, 1983, for an enucleated eye. Investigation of the pilot's history revealed that he had a history of cardiovascular problems which included atherosclerotic heart disease and a anteroseptal myocardial infarction, which he suffered on April 11, 1990. According to the FAA Western Pacific Regional Flight Surgeon, Dr. Stephen H. Goodman, the pilot's medical condition and history invalidated his medical certificate. Review of the pilots last application for an FAA medical certificate revealed that he did not disclose the history of cardiovascular problems. Details of the pilot's medical history are contained in the MEDICAL AND PATHOLOGICAL INFORMATION section of this narrative and the pilot's medical records, which are attached. AIRCRAFT INFORMATION According to maintenance records obtained during the investigation, the 1978 Cessna T210M had accumulated about 1485.2 hours of flight at the last documented annual inspection on July 17, 1992. At that time a Continental factory remanufactured engine and a new propeller were installed along with extensive repairs to the exhaust system and other components. METEOROLOGICAL INFORMATION The nearest official weather reporting station was Naval Air Station Lemoore, California, which is located about 30 miles to the east. At 1855 hours PST, they were reporting in part: four thousand scattered, two five thousand scattered, visibility one zero, temperature five six degrees fahrenheit, dewpoint three nine degrees fahrenheit, wind one six zero degrees at two knots and the altimeter was two nine nine eight six inches of mercury. The altimeter setting reported at Orange County Airport at the time of departure was two nine nine six inches of mercury. At the time of the accident several ground witnesses who observed the fire in the mountains at the approximate location of the accident site stated that the weather was clear and there was no obscuration of the mountain tops in that area. The official sunset time was determined by a Safety Board sun and moon database program. According to the data, sunset occurred at 1748 hours PST, and the end of twilight was 1814 hours PST. The moon was below the horizon at the estimated time of the accident. WRECKAGE AND IMPACT INFORMATION An on scene examination of the wreckage was conducted on February 20, 1993. The airplane wreckage was viewed on the southeast side of Wright Mountain. The terrain was measured to be about 30 degrees from the horizontal descending to the southeast. Personnel from the California Highway Patrol estimated the elevation of the accident site to be about 4,300 feet MSL, according to the altimeter in their helicopter. A California Department of Forestry battalion chief stated that according to his quadrangle chart the elevation at the accident site was about 4,400 feet MSL. According to an area topography chart elevation of Wright Mountain is about 4,500 feet MSL at the highest point. At the beginning of the wreckage path, down hill, was located an impact crater in muddy soil. At the upper end of the crater was located two propeller blades. The blades remained attached to the propeller hub and the hub was broken from the engine crankshaft flange. Looking either left or right revealed a pattern of brush and ground disturbance matching the wing span of the airplane. The outer fringes of the disturbance contained wing tip and navigation light lens debris. A third propeller blade was found uphill about 20 feet from the two propeller blades. The blade was bent in an "S" shape. Examination of all propeller blades revealed leading edge damage, chordwise striations and torsional twisting. The aircraft engine was found inverted about 40 feet further uphill and partially buried in the mud. The nose landing gear and wheel were extended over the engine. Located behind the engine was the inverted cabin section, which was totally consumed by the post crash fire. On the uphill side of the cabin section the bottom side of the left wing was located. Examination of the wing revealed accordioning of the wing leading edge over the entire span. The wing was noted to be heavily fire damaged. The aileron and the wing flap was still attached to the wing and were observed to have varying degrees of damage. The plastic wing tip cap assembly was located near the wing with a portion of it noted to be missing. The right wing structure was found on the down hill side of the cabin structure. Examination revealed leading edge accordioning and heavy post crash fire damage. The aileron and the flap remained attached to the structure. The flap actuator was found in the retracted position. The plastic wing tip cap was missing from the wing. The main landing gear retract and uplock components are examined and found to be in the retracted position. The entire empennage was intact and upright though heavily fire damaged. The empennage remained semi attached to the aft cabin section by the control cables. MEDICAL AND PATHOLOGICAL INFORMATION Due to the extent of the post crash fire there was no autopsy or toxicological specimens suitable for analysis. According to medical records obtained from the University Of Utah Medical Center at Salt Lake City, Utah, the pilot was admitted to their facility on April 11, 1990, and discharged on April 20, 1990. According to the staff cardiologist the final clinical impression was: 1) Coronary artery disease, ## Aircraft - Registration: [N761NE](https://openairdocs.org/deregistered/N761NE-1993-06-16), registration cancelled 1993-06-16, S/N 21062380 (OpenAirDocs) - Reported make and model: CESSNA T210M - Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs) - Category: Airplane - Serial number: 21062380 - Engines: CONTINENTAL TSIO-520-R 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Csy Investments - Registered owner: Csy Investments - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 17, 1992 - Departed: SNA, SANTA ANA, CA - Destination: 051, LINCOLN, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: invalid medical for flight; flight hours: 2,888 total ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 160° at 2 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 39 °F - Altimeter: 29.00 inHg - Observed at: NLC, 30 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 19930215004889A](https://openairdocs.org/incident/19930215004889A), Feb 15, 1993: Cessna T210M, Coalinga, CA, Destroyed, 2 fatal. Flew into side of a mountain on clear dark night. Pilot history of heart disease,hypertension and heart infarction. 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.