# NTSB NYC08FA157: Cartwright H Jr/Cottrell M RV-10, N210HM, Seale, AL, April 7, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 7, 2008, 12:26 local (16:26 UTC) - Place: Seale, AL - Coordinates: 32.36639, -85.149444 - Nearby events: https://openairdocs.org/map.md?lat=32.3664&lon=-85.1494&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 5, 2009 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 67769 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA157 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67769/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67769 - Page: https://openairdocs.org/ntsb/NYC08FA157 ## Probable cause The pilot-in-command's in-flight loss of control due to spatial disorientation. Contributing to the accident were the weather conditions and the pilot-in-command's lack of flight experience in the accident airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05622IC), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=05622IC), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=05622IC), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Experience/qualifications: total experience w/ equipment](https://openairdocs.org/ntsb-findings/02031025): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-findings/02031025/cases.md?model=05622IC), [All aircraft, 269 cases](https://openairdocs.org/ntsb-findings/02031025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Altitude deviation](https://openairdocs.org/ntsb-events/282); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-events/282/sequence.md?model=05622IC), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/282/sequence.md) - [Approach-IFR missed approach: Course deviation](https://openairdocs.org/ntsb-events/281); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-events/281/sequence.md?model=05622IC), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/281/sequence.md) - [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05622IC), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cartwright H Jr/Cottrell M RV-10, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05622IC), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The instrument-rated private pilot requested a very high frequency omnidirectional radio range (VOR) approach into an airport. Thereafter he began a descent from cruise flight into instrument meteorological conditions. The controller cleared the airplane for the approach about 20 miles north of the airport. The airplane then began a descending right turn and the pilot requested, and was provided, vectors to another airport. While en-route to that airport, he amended his request and asked for vectors to a third airport, stating that he required an airport with an instrument landing system (ILS) approach. The controller subsequently provided vectors, followed by an ILS approach clearance. Shortly after receiving the clearance, the airplane flew past the ILS localizer path, and the controller cancelled the approach clearance. The pilot then requested an airport with cloud bases 2,000 feet or better, and the controller advised him to check the weather at a nearby airport. The airplane then began a rapid descending right turn, followed by a steep climbing right turn. The airplane then began another rapid descent and was destroyed when it collided with wooded terrain. Throughout the approach portions of the flight, the airplane deviated multiple times from assigned altitudes and headings. The airplane was equipped with a liquid crystal display avionics suite, in a configuration commonly referred to as a "glass cockpit." No logbook entries were noted indicating that the instrument-rated pilot had flight experience in the accident airplane, and the majority of his flight experience in IMC took place in his own airplane, which was equipped with conventional flight instruments. The pilot-rated passenger/builder held a private pilot certificate and did not possess an instrument rating. No evidence of any preimpact mechanical anomalies was discovered. Weather reports for airports in the vicinity of the accident varied between 8 and 10 miles visibility, with cloud bases between 1,200 and 2,000 feet mean sea level (msl) and cloud tops at 4,500 feet msl. The airplane's turning ground track and the cloud conditions were conducive to the onset of pilot spatial disorientation. The airplane's multiple, rapid ascents and descents are consistent with the pilot's loss of control of the airplane because of spatial disorientation. ## Factual narrative HISTORY OF FLIGHT On April 7, 2008, at 1226 eastern daylight time, an amateur-built RV-10, N210HM, was destroyed when it impacted trees and terrain in Seale, Alabama, following a missed approach to Columbus Metropolitan Airport (CSG), Columbus, Georgia. The certificated private pilot, and the pilot rated passenger/builder were killed. The flight originated from Lebanon Municipal Airport, Lebanon, Tennessee. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 Code of Federal Regulations Part 91. According to relatives of the pilot, the reason for the flight was to visit the Sun 'n Fun Fly-In located in Lakeland, Florida. A handheld global positioning system (GPS), Garmin GPSMAP 196, was recovered from the airplane. The GPS unit was sent to the National Transportation Safety Board Office of Research and Engineering for data extraction. The GPS data, along with voice communication data provided by the Federal Aviation Administration (FAA), revealed that the pilot established communications with Atlanta Approach at 1148, while flying the airplane at an altitude 9,300 feet, and requested a very high frequency omnidirectional radio range (VOR) runway 18 approach to Weedon Field Airport (EUF), Eufaula, Alabama. The flight continued on a track of 173 degrees for approximately 13 minutes until it was cleared to descend to 4,000 feet by the controller. The controller then cleared the airplane for the approach about 20 miles north of the airport. The pilot then explained to the controller, "We may, I think we are going to fly the whole approach here, I think we'll let you know when[unreadable]." The airplane then began a descending right turn to a track of 090 degrees and the pilot further stated, "We're going to have to come up with an alternate plan here." The pilot then requested, and was provided, vectors to Auburn-Opelika Airport (AUO), Auburn, Alabama. While en-route to AUO, he amended his request and asked for vectors to CSG, stating that he required an airport with an instrument landing system (ILS) approach. The controller subsequently provided vectors, followed by an ILS approach clearance to runway 6 at CSG. Shortly after receiving the clearance, the airplane flew past the ILS localizer path. The controller then received a low altitude alert and relayed this to the pilot. The pilot responded, 'We're correcting altitude here, and we flew through the ILS.' The controller then cancelled the approach clearance and requested that he climb to 3,000 feet, and turn right to 270 degrees. The pilot then stated, "Do you have any location that the weather is 2,000 feet or better?" The controller responded that the pilot could consider checking the weather at AUO, to which the pilot responded, "Okay we'll do that." Over the next 17 seconds the airplane began a descending right turn from an altitude of 2,694 feet to 1,330 feet. The airplane then began a climbing right turn, and within 15 seconds reached an altitude of 2,770 feet. The last recorded GPS track occurred at 1226:41 and was observed at an altitude of 2,148 feet. The wreckage was located at an elevation of 270 feet, about 400 feet east of the location where the final GPS track was recorded. The airplane deviated approximately 400 feet above its assigned altitude, and 1,200 feet below, on multiple occasions throughout the last 14 minutes of the flight. The controller twice relayed low altitude alert warnings to the pilot, and on five occasions alerted him that he was not maintaining the assigned heading. The pilot did not declare an emergency to the controller at any point during their communications. PERSONNEL INFORMATION Investigators were unable to determine the seating location of the pilots in the airplane. Pilot The pilot, age 63, held a private pilot certificate with a rating for airplane single-engine land and instrument airplane. The pilot's most recent FAA second-class medical certificate was issued September, 2006, with the limitation that he wear lenses for near and distant vision. Review of his pilot logbooks revealed that as of March 22, 2008 he had accumulated about 1770 total hours of flight experience, which included about 358 hours in actual instrument conditions. According to the logbook, the pilot accumulated 6.4 hours of total flight experience in instrument conditions for the 6 months preceding the accident. During that time he performed three instrument approaches in instrument meteorological conditions, and one practice instrument approach in visual meteorological conditions. The logbook entry did not display a notation stating that the practice approach was performed under the supervision of a safety pilot. The pilot's logbook records further indicated that since June 2000, he had logged about 130 flight hours in his personal airplane, N19419 in simulated and instrument flight conditions. This airplane was a 1976 Cessna 177B, equipped with conventional cockpit instruments. Passenger/Builder The pilot rated passenger/builder, age 64, held a private pilot certificate with a rating for airplane single-engine land, and the limitation of night flying prohibited. He did not possess an instrument rating. His most recent FAA third-class medical certificate was issued January 3, 2008, with the limitation that the certificate was only valid for 12 months, and that he wear lenses for near vision. Review of his pilot logbooks revealed that he had accumulated about 526 total hours of flight experience, 68 hours of which were in the accident airplane. In the 90 days prior to the accident, the logbook indicated 5.2 hours of total flight time, all of which was flown in the accident airplane. A flight review was conducted in the accident airplane on February 9, 2007, and included 0.3 hours of simulated instrument training. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear amateur built airplane, was issued a special airworthiness certificate in January 2007. A review of the airplane's flight and maintenance logbooks revealed it had accrued a total time in service of 75 hours prior to the accident flight. The last conditional inspection occurred on February 1, 2008, at a total flight time of 71 hours. The Lycoming IO-540-C4B5 engine had accumulated a total time in service of 2,287 hours. The engine had accrued 75 flight hours since the most recent major overhaul which was completed in 2007. Pitot static, altimeter, and transponder inspections were accomplished on February 26, 2007, and a VOR check was completed on the day prior to the accident. The airplane was equipped with a liquid crystal display avionics suite, in a configuration commonly referred to as a, 'glass cockpit.' The equipment included a Dynon Avionics Electronic Flight Information System (EFIS) E10-A, two Grand Rapids Technologies Incorporated (GRT) EFIS Horizon Series 1 Multifunction Displays, and a GRT Engine Information System. Navigation and communication functions were supported with a single Garmin/Apollo SL30 Transceiver. The airplane was not equipped with any vacuum operated or analog flight instruments. A flight logbook located onboard the airplane indicated that prior to departing on the accident flight, the airplane was serviced with 13.6 gallons of fuel, bringing the total fuel on board to 61 gallons. METEOROLOGICAL INFORMATION The closest official weather observation station was Lawson Army Airfield (LSF), Fort Benning, Georgia, located 9.5 miles southeast of the accident site. The elevation of the weather observation station was 232 feet msl. An aviation routine weather report (METAR) for LSF was issued at 1227. It stated: winds variable at 3 knots; visibility 9 miles; skies 1,000 feet overcast; temperature 18 degrees Celsius; dew point 17 degrees Celsius; altimeter 30.05 inches of mercury. A METAR for CSG, which was located 16 miles northeast of the acc ## Aircraft - Registration: [N210HM](https://openairdocs.org/deregistered/N210HM-2010-01-12), registration cancelled 2010-01-12, S/N 40238, built 2006 (OpenAirDocs) - Reported make and model: CARTWRIGHT H JR/COTTRELL M RV-10 - Registry model: [Cartwright H Jr/Cottrell M RV-10](https://openairdocs.org/model/cartwright-h-jr-cottrell-m-rv-10) (registry code 05622IC) (OpenAirDocs) - Registry engine: [Lycoming IO-540-C4B5](https://openairdocs.org/engine/lycoming-io-540-c4b5) (registry code 41651, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 40238 - Airframe hours: 75 - Engines: LYCOMING IO-540-C4B5 250 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, February 1, 2008, 4 hours before - Departed: M54, Lebanon, TN - Destination: CSG, Columbus, GA - Flight plan: IFR - Airport: CSG, Columbus Metropolitan Airport, runway 06, 6,997 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 15, 2006; toxicology performed; flight hours: 1,770 total, 1,650 as pilot in command, 13 in the last 90 days, 9 in the last 30 days - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review February 9, 2007; toxicology performed; flight hours: 526 total, 74 in this make and model, 477 as pilot in command, 52 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: variable at 3 knots - Visibility: 9 statute miles - Lowest ceiling: 1,000 ft overcast - Temperature: 64 °F, dew point 63 °F - Altimeter: 30.04 inHg - Observed at: CSG, 95 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 20080407836889A](https://openairdocs.org/incident/20080407836889A), Apr 7, 2008: Cartwr RV10, Phenix City, AL, Destroyed, 2 fatal. (-23) Aircraft departed vft from lebanon municipal airport (M54) in Tennessee for direct flight to eufaula, Alabama (euf) filing IFR in flight on 04/07/2008.… ## Docket (21 files) The files NTSB released with the investigation on January 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67769. 15.2 MB in all. - GPS 17 - Factual Report of Group Chairman (item 1, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40300292&FileExtension=.PDF&FileName=GPS%2017%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Wreckage Diagram (item 2, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304241&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Reports and Records (item 3, .PDF, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304403&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Audio: Air Traffic Control Communications (item 4, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304193&FileExtension=.PDF&FileName=Audio%3A%20Air%20Traffic%20Control%20Communications-Master.PDF - Logbook Excerpts: Airframe (item 5, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304162&FileExtension=.PDF&FileName=Logbook%20Excerpts%3A%20Airframe-Redacted.PDF - Logbook Excerpts: Engine (item 6, .PDF, 455 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304165&FileExtension=.PDF&FileName=Logbook%20Excerpts%3A%20Engine-Redacted.PDF - Airplane Flight Log Sheet (item 7, .PDF, 500 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304168&FileExtension=.PDF&FileName=Airplane%20Flight%20Log%20Sheet-Master.PDF - Logbook Excerpts: Pilot (item 8, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304499&FileExtension=.PDF&FileName=Logbook%20Excerpts%3A%20Pilot-Redacted.PDF - Logbook Excerpts: Pilot/Passenger (item 9, .PDF, 851 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304179&FileExtension=.PDF&FileName=Logbook%20Excerpts%3A%20Pilot%2FPassenger-Redacted.PDF - Record of Conversation: Grand Rapids Technologies Inc. (item 10, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304183&FileExtension=.PDF&FileName=Record%20of%20Conversation%3A%20Grand%20Rapids%20Technologies%20Inc.-Master.PDF - Toxicological Report: Lloyd (item 11, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306488&FileExtension=.PDF&FileName=Toxicological%20Report%3A%20Lloyd-Redacted.PDF - Toxicological Report: Cartwright (item 12, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306489&FileExtension=.PDF&FileName=Toxicological%20Report%3A%20Cartwright-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40304392&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: Engine Crank/Prop Flange (item 14, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306704&FileExtension=.PDF&FileName=Photo%201%3A%20Engine%20Crank%2FProp%20Flange-Master.PDF - Photo 2: Engine (item 15, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306705&FileExtension=.PDF&FileName=Photo%202%3A%20Engine-Master.PDF - Photo 3: Cut Branches (item 16, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306707&FileExtension=.PDF&FileName=Photo%203%3A%20Cut%20Branches-Master.PDF - Photo 4: Main Wreckage (item 17, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306708&FileExtension=.PDF&FileName=Photo%204%3A%20Main%20Wreckage-Master.PDF - Photo 5: Propeller (item 18, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306709&FileExtension=.PDF&FileName=Photo%205%3A%20Propeller-Master.PDF - Photo 6: Wreckage Path (item 19, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306710&FileExtension=.PDF&FileName=Photo%206%3A%20Wreckage%20Path-Master.PDF - Photo 7: Main Cabin (item 20, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388495&FileExtension=.PDF&FileName=Photo%207%3A%20Main%20Cabin-Master.PDF - Photo 8: Debris Field (item 21, .PDF, 887 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388496&FileExtension=.PDF&FileName=Photo%208%3A%20Debris%20Field-Master.PDF From the NTSB's public API. 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