NYC01FA064

NTSB accident investigation · Cessna 310R · Bluefield, WV · January 8, 2001

Accident · FatalField investigationFinal report
Date
January 8, 2001, 07:00 local (12:00 UTC)
Place
Bluefield, WV
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N123RACessna 310R
Weather
Instrument (IMC) · Day
Status
Completed · report August 13, 2001
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Teledyne Continental, Rader Aviation, FAA/FSDO
FAA report
20010108039379A
Case key
50909

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 failure to execute the published missed approach procedure. A factor was heavy snowfall during the approach.

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 collision with terrain/waterMissed approach (ifr)
Weather condition - snowFactor
Ifr procedure - not followedPilot in commandCause

Analysis

The pilot initiated an ILS approach during a period of light snow, and a ceiling of 400 feet. During the approach, a band of heavy snow, with reduced visibility, moved over the airport. The pilot reported established on the approach, then acknowledged a frequency change to the airport's common traffic advisory frequency. No further transmissions were received. Radar data revealed that the airplane joined the localizer outside the initial approach fix, and proceeded inbound, on course. Due to limited radar coverage, the last radar contact with the airplane was about 3/4 of a mile inside the final approach fix, still on course, about 1,850 feet above the airport. A witness, about 1/3 to 1/2 mile to the east of the airport, saw the airplane fly overhead at a very low altitude, then heard the engines rev up, and saw the airplane climb. The airplane disappeared into the falling snow, and the witness then heard the sound of a crash. Airplane wreckage was later found on rising terrain, about 1/2 nautical mile to the left of the runway's departure end. The landing gear and flaps were up, and the elevator was trimmed for a climb. Trees were initially cut at an ascending angle of about 5 degrees for approximately 50 feet, then a descending angle of about 5 degrees for another 250 feet. The wreckage elevation was approximately the same as the decision height for the ILS approach. There was no evidence of pre-accident mechanical failure.

Factual narrative

History of flight

On January 8, 2001, about 0700 Eastern Standard Time, a Cessna 310R, N123RA, operated by Rader Aviation, Inc., was destroyed when it impacted rising terrain during a missed approach at Mercer County Airport (BLF), Bluefield, West Virginia. The certificated commercial pilot was fatally injured. Instrument meteorological conditions prevailed at the time of the accident. The flight was operating on an instrument flight rules flight plan, between Greenbrier Valley Airport (LWB), Lewisburg, West Virginia, and Bluefield. The positioning flight was conducted under 14 CFR Part 91.

According to a Federal Aviation Administration (FAA) voice transcript, at 0644 the pilot contacted Indianapolis Center, and reported that the airplane was at 6,000 feet. The controller then provided the pilot with the weather at Bluefield, which included "wind...two seven zero at three, visibility one and a quarter, and light snow, four hundred broken, niner hundred overcast...," and asked what kind of approach the pilot wanted. The pilot requested the ILS RWY 23 approach, and was told to proceed direct to DROWE intersection. He was then told to maintain 6,000 feet, and report when established on the approach. At 0651, the pilot reported established on the approach, then acknowledged a frequency change to the airport's common traffic advisory frequency. He subsequently advised the controller that he would contact him after the airplane had landed. No further transmissions were received from the pilot.

Radar data revealed that the airplane joined the localizer outside DROWE Intersection, and proceeded inbound, on course. Due to limited radar coverage, the last radar contact with the airplane was about 3/4 of a mile inside the final approach fix, still on course, at 4,700 feet.

During the timeframe that the approach took place, a witness at the airport saw that the runway lights had been activated, and then heard the sound of an airplane "off in the distance." He was not sure which direction the sound was coming from, but was positive that the airplane did not fly over the runway. Shortly thereafter, the sound of the engines ceased, and the office he was in "shuddered." He then received a telephone call from the Elkins, West Virginia, Flight Service Station about an emergency locator transmitter (ELT) being activated. He heard an ELT in the background of the telephone conversation, then noticed that the sound of the ELT ceased.

Another witness, who lived "1/3 to 1/2 mile east" of the airport, was letting his horses out when the airplane flew overhead. He heard the airplane and looked up. He noticed that it was "real low" and thought that if it didn't pull up, it wasn't going to clear the mountain that rose to the south. He heard the airplane's engines "rev up," then watched it climb. Shortly thereafter, he heard a "big crash, and the whole sky lit up."

The accident occurred during daylight hours, in the vicinity of 37 degrees, 17.04 minutes north latitude, 81 degrees, 12.37 minutes west longitude.

Personnel information

The pilot held a commercial pilot certificate with ratings for single engine land and multiengine land airplanes. He also held a flight instructor certificate for single engine airplanes. His latest second class medical certificate was dated December 11, 2000.

According to the operator, the pilot had 3,750 hours of flight time, with 640 hours flight time in airplane make and model. He also had 440 hours of actual instrument flight time and 20 hours of simulated instrument flight time.

On September 14, 2000, the pilot took a FAR 135 Competency/Proficiency Check and was marked unsatisfactory under "ILS Approaches Single Engine." On September 18, 2000, he again took the check, and was graded satisfactory in all areas.

Wreckage and impact information

A debris path, consisting of cut and broken hardwood trees, and airplane wreckage, was located near the summit of Stoney Ridge, about 1/2 nautical mile, 150 degrees magnetic from the departure end of Runway 23. The debris path was about 300 feet in length, on a magnetic heading of 225 degrees, and approximately 3,150 feet above mean sea level (msl). Approximately the first 50 feet of debris path exhibited tree cuts at an ascending angle of about 5 degrees. Along the remainder of the debris path, trees were cut at a descending angle of about 5 degrees. Initial tree cuts across the width of the debris path were approximately horizontal, consistent with an approximately wings-level airplane attitude.

All airplane flight control surfaces were accounted for at the accident scene. The cockpit and cabin area were consumed in a post-impact fire. Control continuity was confirmed from the cabin area to the elevator and rudder, and to the left aileron. The right wing and the control cables had separated, with the cables exhibiting a broom-straw appearance. Landing gear and flaps were up, and the elevator trim tab was 5 degrees down.

Both propellers were separated from their propeller shaft flanges, and the blades exhibited leading edge gouging and "s-bending." Engine cylinder compression could not be confirmed due to the engines' locations within the wreckage field. However, both engines' crankshafts were rotated about 30 degrees, and continuity was confirmed. The upper spark plugs from both engines were gray in color, and the shafts of both wet vacuum pumps were intact.

Meteorological information

Weather, recorded at the airport about 8 minutes before the accident, included winds from 290 degrees at 4 knots, 1 statute mile of visibility in light snow and mist, a broken cloud layer at 400 feet above the ground, another broken layer at 900 feet, and an overcast layer at 2,100 feet. The temperature and dewpoint were 30 degrees Fahrenheit.

The airport witness reported that at the time of the accident, the airport was engulfed in a heavy snowstorm. When he learned the airplane was missing, he went around the airport property to see if he could find the airplane. From the ends of the runway, he could not see the two-story terminal building due to the heavy snowfall.

The other witness, whose property the airplane flew over, stated that he attempted to find the then-burning wreckage and got within an estimated 100 yards of it. However, he could not find it due to the heavy snow that was falling at the time.

Airport and instrument approach information

The touchdown zone elevation for Runway 23 was 2,857 feet msl. The runway was 4,742 feet long and 100 feet wide.

The inbound course for the ILS RWY 23 approach was 227 degrees magnetic, and the decision height was 3,157 feet msl. The missed approach required a climb to 3,800 feet, then a climbing right turn to 5,000 feet, direct to the Bluefield VORTAC and hold.

On January 9, 2001, the ILS RWY 23 approach was flight tested by the Federal Aviation Administration. According to the flight inspection report, "facility operation [was] found satisfactory."

Medical and pathological information

On January 9, 2001, an autopsy was performed on the pilot's remains by the State of West Virginia, Office of Chief Medical Examiner, South Charleston, West Virginia. Toxicological testing was subsequently performed by the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma.

Additional information

According to the Aeronautical Information Manuel, decision height was defined as "a specified...height in the precision approach at which a missed approach must be initiated if the required visual reference to continue the approach has not been established." The applicable federal aviation regulation was 14 CFR 91.175.

On January 9, 2001, the wreckage was released to a representative of the operator's insurance company.

Aircraft

Registration
N123RA
Reported as
Cessna 310R
Category
Airplane
Serial number
310R0221
Airframe hours
10,697
Engines
Continental IO-520, 285 horsepower, reciprocatingContinental IO-520, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Registered owner
Rader Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 26, 2000 · 51 hours before
Departed
LWB · Lewisburg, WV
Destination
BLF · Bluefield, WV
Flight plan
IFR
Airport
BLF · Mercer County, runway 23, 4,742 × 100 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
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
September 18, 2000
Seat
Left
Toxicology
Performed
Flight hours
3,750 total · 640 in this make and model · 3,650 as pilot in command · 60 in the last 90 days · 20 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
290° at 4 knots
Visibility
1 statute miles
Lowest ceiling
400 ft broken
Temperature
30 °F, dew point 30 °F
Altimeter
29.76 inHg
Observed at
BLF, 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.