LAX94LA091

NTSB accident investigation · Cessna P210N · San Martin, CA · January 10, 1994

Accident · Serious injuriesLimited investigationFinal report
Date
January 10, 1994, 07:30 local (15:30 UTC)
Place
San Martin, CA
Injuries
2 serious, 1 minor
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5384WCessna P210N
Weather
Instrument (IMC) · Day
Status
Completed · report November 14, 1994
Report
Approved by Office Director
FAA report
19940110000249A
Case key
28634

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 aircraft preflight inspection, and his failure to use pitot heat during the takeoff in icing conditions, which led to a blocked pitot tube. The blockage resulted in erroneous airspeed indications during the initial climb, which induced the pilot to reduce the aircraft pitch attitude to a point where the aircraft entered an uncorrected descent to ground impact.

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.

Loss of control - in flightTakeoff - initial climb
Weather condition - fog
Weather condition - icing conditions
Aircraft preflight - inadequatePilot in commandCause
Ice/frost removal from aircraft - not performedPilot in commandCause
Anti-ice/deice system - not usedPilot in commandCause
Flight/nav instruments,airspeed indicator - incorrect
Proper climb rate - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Descent - not correctedPilot in commandCause

Analysis

The pilot said that as the aircraft entered the initial climb after rotation, the airspeed began decreasing. He lowered the nose slightly to counter the decreasing airspeed and the aircraft hit the ground shortly thereafter. FBO personnel at the airport said the pilot attempted to takeoff with ground visibility of 150 feet in heavy fog. The FBO line person who fueled the aircraft just prior to departure stated that he had to 'scrape ice away from the fuel filler ports on the wings in order to open the fuel caps.' The line person said the ice was like frozen dew and very rough in character. An FAA inspector stated that he found a series of propeller slashes in the ground just beyond the end of the runway. A path of ground scars led through a damaged fence and terminated at the aircraft wreckage about one eighth of a mile from the runway end. No discrepancies were noted in the examination of the aircraft or engine.

Factual narrative

On January 10, 1994, at 0730 hours Pacific standard time, a Cessna P210N, N5384W, collided with the ground following an inflight loss of control during the takeoff initial climb at South County Airport, San Martin, California. The aircraft was owned and operated by the pilot. Instrument meteorological conditions prevailed at the time, and included a witness reported indefinite ceiling, visibility 150 feet in heavy fog. The aircraft was destroyed in the ground collision sequence and post crash fire. The certificated private pilot and one passenger sustained serious injuries; however, the remaining passenger incurred minor injuries. The flight was originating at the time of the mishap as a personal cross country flight to Mammoth Lakes, California.

In a verbal statement, the pilot said that as the aircraft entered the initial climb after rotation, the airspeed began decreasing. He lowered the nose slightly to counter the decreasing airspeed and the aircraft hit the ground shortly thereafter.

The owner of a fixed base operation at the airport reported that the aircraft attempted to takeoff on runway 32. The witness stated that the ground visibility was 150 feet in heavy fog at the time, and, that ice was present on the wings of aircraft parked on the flight line. The FBO line person who fueled the accident aircraft just prior to departure stated that he had to "scrape ice away from the fuel filler ports on the wings in order to open the fuel caps." The line person said the ice was like frozen dew and very rough in character.

All of the ground witnesses at the airport stated that strong engine sounds were heard during the takeoff sequence to ground impact.

An FAA inspector from the San Jose, California, Flight Standards District Office responded to the accident site. He reported that when he arrived at 0930 hours the visibility was still near zero in heavy fog. The inspector stated that he found a series of perpendicular ground scars similar to propeller slashes in the ground just beyond the end of the runway. A path of ground scars was observed proceeding through a damaged fence and terminating at the aircraft wreckage, which came to rest near a freeway onramp about one eighth of a mile from the departure end of the runway.

The fuselage and inboard portions of both wings were consumed by fire. The inspector reported that he found the landing gear retracted and the flap actuator extended to five degrees. No discrepancies were noted in the examination of the dual vacuum pump installation. No cockpit instrumentation survived the post crash fire. No discrepancies were noted during examination of the engine.

Aircraft

Registration
N5384W
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000681
Airframe hours
2,039
Engine
Continental TSIO-520-P, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Robert J. Kushner
Registered owner
Robert J. Kushner
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 1993 · 225 hours before
Departed
Q99
Destination
MMH · Mammoth Lakes, CA
Airport
Q99 · South County Airport, runway 32, 3,100 × 75 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
43
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
700 total · 300 in this make and model · 45 in the last 90 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
0.05 statute miles
Temperature
36 °F, dew point 36 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.