LAX96FA052

NTSB accident investigation · Cessna 210L · Grand Canyon, AZ · November 23, 1995

Accident · FatalField investigationFinal report
Date
November 22, 1995, 20:00 local (Nov 23, 1995, 03:00 UTC)
Place
Grand Canyon, AZ
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N5138QCessna 210L
Weather
Visual (VMC) · Night/dark
Status
Completed · report October 22, 1996
Report
Approved by Office Director
FAA report
19951122038109A
Case key
29242

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 loss of aircraft control as a result of spatial disorientation. Factors were: the pilot's lack of experience in instrument and night flight conditions, inadequate transition/upgrade training, and the dark night light condition.

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
Light condition - dark nightFactor
Aircraft control - uncontrolledPilot in commandCause
Spatial disorientationPilot in commandCause
Lack of total experience in type operationPilot in commandFactor
Inadequate transition/upgrade trainingOther personFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

There were no witnesses to the nighttime departure accident. In response to an emergency locator transmitter signal, the aircraft was located 3/4 mile off the departure end of the runway. The aircraft had impacted level terrain in a nose-low, left wing-low attitude. Local pilots report that the departure area is devoid of lighting at night and is a black hole requiring flight by reference to instruments after takeoff. The recently licensed private pilot had trained in a Cessna 172 and had 3.2 hours of night flight time and 1 hour of simulated instrument flight time. His 20-flight-hour checkout in the accident aircraft, which was also his high performance aircraft checkout, was completed the day before the accident. The checkout was conducted in daylight, visual flight conditions, and did not include any actual or simulated instrument flight.

Factual narrative

History of flight

On November 22, 1995, at 2000 hours mountain standard time, a Cessna 210L, N5138Q, impacted the terrain after takeoff approximately 1 mile south of the Grand Canyon Airport, Grand Canyon, Arizona. The aircraft was destroyed and the private pilot and one passenger were fatally injured. The aircraft departed Grand Canyon Airport destined for Flagstaff, Arizona. Visual meteorological conditions prevailed and no flight plan was filed.

A friend of the pilot and his passenger dropped them off at the airport terminal about 1930 and left. According to the friend, the pilot's intent was to fly to Flagstaff, drop off his passenger and then continue on to Phoenix, Arizona. The Grand Canyon Air Traffic Control Tower closes at 1900 and there were no witnesses to the departure. The aircraft was not serviced while at Grand Canyon.

This same friend told the NTSB investigator that the pilot appeared healthy, rested, and not at all apprehensive about the flight. He was irritated with himself for having skidded one tire on the previous landing earlier in the day and putting a flat (bald) spot on a new tire. In response to a question about the safety of flying at night, the pilot replied that it was no different than flying in the daytime.

At 2009, a surveillance satellite operated by the United States Air Force reported receiving an emergency locator transmitter (ELT) signal and initially fixed the position in northern Arizona. Personnel at the USAF Rescue Coordination Center at Langley, Virginia, notified the Los Angeles Air Traffic Control Center and the FAA Flight Service Station at Prescott, Arizona, of the signal at 2015. A second surveillance satellite at 2200 refined the position of the ELT to the area immediately south of Grand Canyon airport. Personnel at the Prescott Flight Service Station then notified the Coconino County Sheriff's Department of the potential of a downed aircraft near Grand Canyon Airport at 2230. Search and rescue personnel located the aircraft and the two fatally injured occupants at 0025 (November 23, 1995).

The location of the accident is approximately 3/4 mile off the end of runway 21. The latitude is 35 degrees, 56.2 minutes north and the longitude is 112 degrees, 09.7 minutes west.

Personnel information

The 25-year-old private pilot received his license on October 20, 1995, and had 66 hours total flying time at issuance, all in Cessna 172 aircraft. Included in the 66 hours were 3.2 hours of night time and 1.0 hours of simulated IFR (hood) time. Of the 3.2 hours of night time, 1.2 hours was acquired September 18, 1995, and 2.0 was acquired October 2, 1995. Of the simulated instrument time, 0.5 hours was acquired June 27, 1995, and approximately 0.5 hours was acquired during the private pilot practical test (checkride).

The Designated Pilot Examiner who administered the private pilot checkride told the NTSB investigator that his records of the checkride included the comment "good, strong flight." The examiner said that the pilot/applicant flew approximately 0.5 hours of simulated IFR during the checkride which included straight and level flight, turns of 90 degrees in both directions, a climb at best rate of climb speed, a descent, a VOR radial intercept, and recovery from unusual attitudes. The examiners comment in his records regarding the simulated IFR portion of the checkride was "a little rough."

On November 13, 1995, the pilot purchased the accident aircraft and had logged no flying time since issuance of his private license on October 20. As a requirement for obtaining insurance on the aircraft, the pilot was required to obtain 20 hours of checkout in the aircraft from a certified flight instructor prior to operating the aircraft as pilot-in-command (PIC). That training was accomplished between November 14 and November 21, 1995, and the pilot was signed off for PIC in high performance aircraft on November 21, 1995. The flight the following day from Flagstaff to Grand Canyon and return, on which the accident occurred, was his first operation of the aircraft as PIC. All of the 20-hour checkout in type was conducted in daylight, VFR conditions.

Aircraft information

At the time of the accident the aircraft had accumulated 2,614 hours total flying time. The aircraft's last maintenance was an annual inspection conducted on January 2, 1995, at 2,439 hours. The flight instructor who flew with the pilot during the 20-hour checkout period stated that the aircraft was well maintained and that all equipment items functioned properly. The only discrepancy he reported noticing during the 20 hours of flying was a occasional brief flicker in the ammeter needle in the direction of discharge, after which the needle returned to center each time. Cessna Aircraft Corporation reported that this flicker is a normal system response to intermittent electrical loads on the system, and indicates that the electrical system was functioning properly.

A pre-purchase inspection was performed on the aircraft on November 3, 1995, and the report noted that the instrument panel trim covers, which would have contained the instrument post lights, were not installed. The aircraft was equipped for day, night, VFR, and IFR flight. Although the instrument panel post lights were not installed, there were two overhead instrument panel flood lights and four additional flood lights under the instrument panel glare shield.

Meteorological information

The accident occurred during a clear, dark, moonless night. At 2200, a special weather observation taken by control tower personnel reported the weather as: no clouds below 12,000 feet; visibility greater than 10 miles; temperature 29; dew point 19; wind 290 degrees at 3 knots; and altimeter 30.32 inHg.

A Safety Board moonlight analysis computer program disclosed that the moon was about 25 degrees below the horizon at the time of the accident. The moon's illumination of the night sky was zero percent. Infrared satellite imagery at the time of the accident was obtained from the National Climatic Center and was interpreted by the National Weather Service (NWS). The NWS forecaster concluded that the skies were clear over northern Arizona at the time of the accident and that stars should have been visible to the pilot.

Airport information

The Grand Canyon Airport is located on a plateau in north central Arizona at an elevation of 6,606 feet. The airport has one runway, 3-21, which is 8,999 feet long and 150 feet wide. The runway slopes downhill to the southwest at an average gradient of 0.008. There are ILS and VOR approaches available to runway 3. The Grand Canyon Air Traffic Control Tower operates between 0700 and 1900 MST daily. At other times, the airport operates as an uncontrolled facility using the tower radio frequency as the common traffic advisory frequency (CTAF).

During hours of darkness the runway has medium intensity edge lighting (MIRL). Runway 21 has runway end identifier lights (REIL) and a visual approach slope indicator (VASI). Runway 3 is equipped with a medium intensity approach light system with runway alignment indicator lights (MALSR). The MALSR is focused in a southwesterly direction and is not visible to aircraft departing runway 21. When the air traffic control tower is not operating, runway and approach lighting is activated by pilot controlled lighting (PCL) by keying the radio on CTAF frequency five times in 5 seconds. The lights then remain on for 15 minutes.

Ramp and parking facilities are located at the northeast end of the airport opposite the runway 21 threshold. According to interviews of local area pilots, when air traffic and surface winds permit, it is common practice for aircraft to takeoff on runway 21 and land on runway 3 in order to minimize taxi time and distance to the ramp.

Several area pilots and airport personnel told the NTSB investigator that the area sou

Aircraft

Registration
N5138Q
Reported as
Cessna 210L
Category
Airplane
Serial number
21059638
Airframe hours
2,614
Engine
Continental IO-520-L3, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Jason E. Cook
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 2, 1995 · 175 hours before
Departed
GCN
Destination
FLG · Flagstaff, AZ
Airport
GCN · Grand Canyon Natl Park, runway 21, 8,999 × 150 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
25
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
87 total · 21 in this make and model · 23 as pilot in command · 47 in the last 90 days · 21 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
50° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
28 °F, dew point 19 °F
Altimeter
30.00 inHg
Observed at
GCN, 1 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.