# NTSB MIA08FA027: Cessna T210N, N5431C, Bloomfield, KY, December 8, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 8, 2007, 15:16 local (20:16 UTC) - Place: Bloomfield, KY - Coordinates: 37.95222, -85.235832 - Nearby events: https://openairdocs.org/map.md?lat=37.9522&lon=-85.2358&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report January 29, 2009 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Cessna Aircraft Company, FAA/FSDO - NTSB case key (mKey): 67221 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA08FA027 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67221/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67221 - Page: https://openairdocs.org/ntsb/MIA08FA027 ## Probable cause the pilot exceeded the design stress limits of the airplane, which resulted in the in-flight break up. Contributing to the accident was the pilot's loss of control in-flight due to spatial disorientation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - spatial disorientation, pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - Airframe/component/system failure/malfunction, descent - uncontrolled - design stress limits of aircraft - exceeded, pilot in command (cause) - wing,spar - separation - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis A review of recorded radar data showed that the airplane was heading northwest towards the destination airport, descending through an altitude of 6,800 feet mean sea level (msl) at a constant rate of about 650 feet-per-minute, when it began to make a subtle turn to the north. About 32 seconds later, the airplane continued to turn and descend at a constant rate, reaching a maximum bank angle of about 40 to 50 degrees and exceeding the structural cruise speed by 20 knots calibrated airspeed (13 knots less than never exceed speed). Trajectory calculations showed that a breakup of the airplane occurred about 5 seconds later. The debris field heading was in a southeasterly direction located in close proximity to the last three radar returns. A weather study revealed that based on available weather data at the time of the accident, the airplane was likely in visual meteorological conditions until just prior to the breakup. With cloud tops to 13,000 feet, the possibility existed that the airplane entered instrument meteorological conditions. All of the fracture surfaces examined exhibited features consistent with static overload and no evidence of metal fatigue. ## Factual narrative HISTORY OF FLIGHT On December 8, 2007, at 1516 eastern standard time, a Cessna T210N, N5431C, registered to a private individual and operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91, collided with the ground following an in-flight breakup in Bloomfield, Kentucky. Instrument meteorological conditions (IMC) prevailed and an instrument flight rules (IFR) flight plan was filed. The private instrument-rated pilot and passenger were killed, and the airplane sustained substantial damage. The personal flight originated from Charleston Executive Airport (JZI), Charleston, South Carolina at 1236, and was enroute to Clark Regional Airport (JVY), Jeffersonville, Indiana. After takeoff, the flight proceeded towards the destination airport and air traffic control (ATC) communications with several facilities occurred. At 1509, while in contact with the Louisville terminal radar approach control (Louisville TRACON) and flying at 8,000 feet mean sea level (msl), the controller instructed the pilot to descend and maintain 6,000 feet msl, which he correctly read back. Radar and radio contact were then lost. According to the National Transportation Safety Board Recorded Radar and Performance Study, the airplane was heading northwest towards the destination airport, descending through an altitude of 6,800 feet at a constant rate of about 650 feet-per-minute, when it began to make a subtle turn to the north. About 32 seconds later, the airplane continued to turn and descend at a constant rate, reaching a maximum bank angle of about 40 to 50 degrees and exceeding the structural cruise speed by 20 knots calibrated airspeed (13 knots less than never exceed speed). Trajectory calculations showed that the breakup of the airplane occurred about 5 seconds later. The debris field heading was in a southeasterly direction, located in close proximity to the last three radar returns. Witnesses in the local area reported hearing an airplane and then a crash. The witnesses stated that the airplane's engine sounded very loud until the impact. Witnesses telephoned 911 and reported the accident. PERSONAL INFORMATION The pilot, age 78, held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His certificate was issued June 27, 1998. He held a second-class medical certificate issued on September 22, 2006, with a restriction that he must wear corrective lenses. Review of the pilot's logbook revealed that he had accumulated 1,650 total flight hours, of which 500 hours were in the Cessna T210N. The pilot had also accumulated about 100 hours of actual instrument experience, and 150 hours of simulated instrument experience. The pilot's last flight review and instrument proficiency check were completed on April 20, 2007. AIRCRAFT INFORMATION The six-seat, high-wing, retractable-gear airplane was manufactured in 1979 by Cessna Aircraft Company. It was powered by a Continental TSIO-520-R, 300-horsepower engine and equipped with a McCauley constant-speed propeller. Review of maintenance logbook records showed that an annual inspection was completed on May 4, 2007, at 74 hours prior to the accident. The airframe total time at the time of the annual inspection was recorded at 4,264.7 hours. METEOROLOGICAL INFORMATION The 1456 surface weather observation at Louisville International Airport (SDF), Louisville, Kentucky, was wind 060 degrees at 6 knots, visibility 5 miles in haze, overcast ceiling at 1,200 feet, temperature 7 degrees Celsius, dew point temperature 4 degrees Celsius, and altimeter 30.28 inches of mercury. A weather study was conducted by a Safety Board meteorologist. The study found that based on available weather data at the time of the accident, the airplane was likely in visual meteorological conditions until just prior to the accident. While there was no direct evidence that the airplane entered clouds just before the accident, cloud tops reached a height of about 13,000 feet msl. WRECKAGE AND IMPACT INFORMATION The aircraft impacted hilly forested terrain at an elevation of about 750 feet msl. The wreckage path was approximately 3,000 feet long on a heading of 145 degrees. Sections of the composite right wing tip and a section of skin from the right aileron marked the beginning of the wreckage path, followed within 100 feet by the top-half of the right wing tip, an inboard 2-foot section of the right aileron and the outboard 2 1/2-foot section of the right flap. Scattered throughout the middle portion of the wreckage path, on a heading of approximately 145 degrees, were the following larger sections in their approximate order: right elevator, elevator trim tab, right aileron section, outboard 3 feet of the left horizontal stabilizer, outboard 5 feet of the left wing, right elevator balance weight, right wing, right wing spar cap section, and right aileron outboard section with attached balance weights. The right wing and an outboard section of the right aileron containing the balance weights were recovered approximately 500 feet from the end of the wreckage path. The fuselage with the left wing, sectioned empennage, and engine still attached made up the main wreckage, which marked the end of the wreckage path. Flight control cable continuity was established from the empennage surfaces to the cockpit controls. Aileron and flap control cable continuity was established from the individual surfaces through cable separation that bore signatures consistent with tension overload, to the cockpit controls and flap actuator. The right aileron bell crank displayed damage arising from repeated strikes to the stop bolts. The flap actuator measurement indicated retracted flaps. Precise Flight speed brakes had been installed. The engine remained attached to the airplane and the propeller remained attached to the engine. The landing gear was attached to the airframe. All of the fracture surfaces exhibited features consistent with static overload with no evidence of metal fatigue noted. There was no evidence of a postcrash fire in the area of the main wreckage site or at any of the secondary locations. A section of the left wing at the aileron to flap junction, outboard of the wing box structure, had separated in-flight. The aileron remained attached to the outboard wing section. The remainder of the wing remained attached to the fuselage. The flap remained attached to the inboard section of the wing. Separation signatures were consistent with a downward separation of the outboard wing section. A cable cut, created by the aileron balance return cable, extended across the entire width of the cabin roof, just aft of the top of the windshield. It continued along the leading edge of the inboard section of the wing, from the root of the wing to the outboard rib of the wing box structure, just inboard of the wing separation. The Precise Flight speed brake remained partially extended. The speed brake blades were distorted and interference between the two blades prevented their complete retraction. They appeared to be in the approximate mid-travel position. All of the right wing main spar plates, spar caps, spar reinforcements, and spar web separated from the main wing spar fitting assembly at the outboard end of the assemblies. The outboard 2 inches of the lower aft spar fitting assembly, and all attaching lower wing spar structures, were bent aft approximately 5 degrees. The lower forward spar fitting assembly was not displaced or bent. The upper spar fitting assemblies were not displaced or bent. The front spar attachment displayed signatures consistent with an aft bending of the right wing. The Precise Flight speed brake was observed in the retracted position. The right wing tip, aileron, and inboard 4 feet of the flap were not attached. The inboard 4 feet of the right wing, aft of the main spar, was fragmented and not attached to the remaining wing structure. The outboard 4 f ## Aircraft - Registration: [N5431C](https://openairdocs.org/deregistered/N5431C-2008-07-17), registration cancelled 2008-07-17, S/N 21063750, built 1979 (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: 21063750 - Airframe hours: 4264.7 - Engines: Continental TSIO-520-R 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Henry D. Garretson - Registered owner: Henry D. Garretson - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 4, 2007, 74 hours before - Departed: JZI, Charleston, SC - Destination: JVY, Jeffersonville, IN - Flight plan: IFR - Airport: JVY, Clark Regional Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 20, 2007; seat: left; toxicology performed; flight hours: 1,650 total, 500 in this make and model, 1,600 as pilot in command, 15 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 60° at 6 knots - Visibility: 5 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 45 °F, dew point 39 °F - Altimeter: 30.28 inHg - Observed at: SFD, 27 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 20071208829269A](https://openairdocs.org/incident/20071208829269A), Dec 8, 2007: Cessna T210N, Bloomfield, KY, Destroyed, 2 fatal. (-23) On December 8, 2007, at 1515 eastern standard time, a Cessna T210N, N5431C, registered to a private individual and operated under the provisions of title… ## Docket (14 files) The files NTSB released with the investigation on January 7, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67221. 24.7 MB in all. - ATC 3 - ATC radar plot for N5431C, Bloomfield, KY (item 1, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40288061&FileExtension=.PDF&FileName=ATC%203%20-%20ATC%20radar%20plot%20for%20N5431C,%20Bloomfield,%20KY-Master.PDF - Meteorology 5 - Factual Report of Group Chairman (item 2, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304560&FileExtension=.PDF&FileName=Meteorology%205%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Structures 7 - Factual Report of Group Chairman (item 3, .PDF, 16 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40296772&FileExtension=.PDF&FileName=Structures%207%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Aircraft Performance 13 - Study of Group Chairman (item 4, .PDF, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40294377&FileExtension=.PDF&FileName=Aircraft%20Performance%2013%20-%20Study%20of%20Group%20Chairman-Master.PDF - Materials Laboratory 15 - Factual Report of Group Chairman (item 5, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304556&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Pilot Logbook (item 6, .PDF, 9.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305912&FileExtension=.PDF&FileName=Pilot%20Logbook-Redacted.PDF - Excerpts From Airframe Logbook (item 7, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305913&FileExtension=.PDF&FileName=Excerpts%20From%20Airframe%20Logbook-Redacted.PDF - Excerpt From Engine Logbook (item 8, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305914&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Excerpts From Propeller Logbook (item 9, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305915&FileExtension=.PDF&FileName=Excerpts%20From%20Propeller%20Logbook-Redacted.PDF - Other Pertinent Forms and Reports; Speed Brake Teardown Report. (item 10, .PDF, 15 photos, 532 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445510&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Speed%20Brake%20Teardown%20Report.-Redacted.PDF - Toxicological Report (item 11, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305837&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304557&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445511&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo-Photographic Log (item 14, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304900&FileExtension=.PDF&FileName=Photo-Photographic%20Log-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.