# NTSB NYC94FA166: Cessna 310R, N502SB, Blain, PA, September 3, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 3, 1994, 01:10 local (05:10 UTC) - Place: Blain, PA - Coordinates: 40.329124, -77.510894 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3291&lon=-77.5109&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report August 31, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38688 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94FA166 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38688/pdf - Page: https://openairdocs.org/ntsb/NYC94FA166 ## Probable cause THE PILOT'S IMPAIRMENT OF JUDGMENT AND PERFORMANCE DUE TO DRUGS, FAILURE TO MAINTAIN CONTROL OF THE AIRPLANE, AND EXCEEDING THE DESIGN STRESS LIMITS OF THE AIRPLANE, WHICH RESULTED IN AN IN-FLIGHT BREAKUP OF THE AIRPLANE. A FACTOR RELATED TO THE ACCIDENT WAS: CONDITIONS CONDUCIVE TO FATIGUE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, descent - normal - aircraft control - not maintained, pilot in command (cause) - impairment(drugs), pilot in command (cause) - fatigue(flight and ground schedule), pilot in command (contributing factor) - Airframe/component/system failure/malfunction, descent - uncontrolled - design stress limits of aircraft - exceeded, pilot in command (cause) - horizontal stabilizer - overload - horizontal stabilizer - separation - wing - failure - wing - separation ## Analysis THE AIRPLANE WAS IN A CRUISE DESCENT FROM 9000 TO 7000 FEET AT NIGHT IN VISUAL METEOROLOGICAL CONDITIONS, WHEN, ACCORDING TO RECORDED RADAR DATA, THE ALTITUDE INCREASED 200 FEET AND THEN RADAR CONTACT WAS LOST AT 7800 FEET. WITNESSES SAW THE AIRPLANE IN A STEEP DESCENT AND HEARD A LOUD WHINE. THE AIRPLANE SUSTAINED INFLIGHT AIRFRAME SEPARATION. DEBRIS WAS SCATTERED OVER A DISTANCE OF ABOUT 1500 FT WITH THE HORIZONTAL STABILIZERS AND ELEVATORS FOUND NEAR THE BEGINNING OF THE WRECKAGE PATH, FOLLOWED BY THE FUSELAGE, AND ENDING WITH THE ENGINES AND PROPELLERS. THE LEFT HORIZONTAL STABILIZER HAD FAILED DOWN AND AFT. THE LEFT WING OUTBOARD OF THE LEFT ENGINE HAD FAILED DOWN AND WAS FOUND 600 FT LEFT OF THE DEBRIS TRAIL. WRINKLES IN TWO DIRECTIONS AND POPPED RIVETS WERE FOUND ON BOTH WINGS. TOXICOLOGY TESTS OF THE PILOT'S BLOOD REVEALED 0.002 UG/ML OF TETRAHYDROCANNABINOL (MARIJUANA) AND 0.011 UG/ML TETRAHYDROCANNABINOL CARBOXYLIC ACID. A TEST OF HIS URINE SHOWED 0.305 UG/ML OF TETRAHYDROCANNABINOL CARBOXYLIC ACID. THE PILOT HAD WORKED A FULL-TIME CONSTRUCTION JOB DURING THE DAY, AND HE HAD BEEN AWAKE FOR ABOUT 19 HOURS. ## Factual narrative HISTORY OF FLIGHT On September 3, 1994, at 0110 eastern daylight time, a Cessna 310R, N502SB, owned and operated by SmithKline Beecham Bio Science Labs, and operating as Skibil 910 (SQB 910), struck the ground near Blain, Pennsylvania. The airplane was destroyed, and the pilot and passenger were fatally injured. Visual meteorological conditions prevailed, and the flight was operated on an Instrument Flight Rules (IFR) flight plan under 14 CFR Part 91. The pilot was scheduled to fly seven flights with his first departure at 1830. On the sixth flight, he departed the Allegheny County Airport, West Mifflin, Pennsylvania, at 0031, en route to Pottstown, Pennsylvania, with 200 pounds of cargo onboard. At 0106, control of flight 910 was transferred from the New York Air Route Traffic Control Center, to Harrisburg Approach Control, and it was cleared to descend from 9,000 feet to 7,000 feet. At 0114 the controller received a telephone call from Perry County Dispatch, regarding a possible airplane accident. The controller was unable to regain radio or radar contact with flight 910. Witnesses in the area reported seeing the airplane in a descent, which one witness described as 45 degrees nose down. The airplane's rotating beacon was visible and several witnesses reported hearing a loud whine. Sparks were seen coming from the airplane. The outboard portion of the left wing struck a residence damaging the roof, window, and porch roof. The accident impacted the ground during the hours of darkness about 40 degrees, 20 minutes North, and 77 degrees, 28 minutes West. PERSONNEL INFORMATION The pilot-in-command was the holder of a Commercial Pilot Certificate with airplane single and multi-engine land, and instrument airplane ratings. In addition, he held a 1st class FAA Airman Medical Certificate, with no limitations, issued on February 3, 1994. According to the pilot's logbook, which was current through August 22, 1994, the pilot had a total time of 1897 hours, with 1486 hours in the Cessna 310. His pilot-in-command time was 1817 hours, with 1486 hours in the Cessna 310. According to company records, he was upgraded to captain on April 22, 1994 and had flown 22 flights for a total of 139.6 hours as captain. The passenger possessed a student pilot certificate. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the accident site on September 3, 1994, and later at Capital City Airport, Harrisburg, Pennsylvania. The debris trail was 1509 feet long, on a heading of 355 degrees, starting with pieces of engine cowling doors, followed by elevator, horizontal stabilizer, rudder, and vertical stabilizer parts. The fuselage was 978 feet from the start, and both engines and propellers were 531 feet beyond the fuselage, and located within a 25 foot radius. The left wing, outboard of the left engine, both engines, portions of both tip tanks, both horizontal stabilizers and elevators, and the upper portion of the vertical stabilizer and rudder were separated from the airplane. The top of the fuselage was crushed level with the bottom of the windows. The landing gear was retracted. According to Cessna, measurement of the wing flap extension chain corresponded to 10 degrees of flap extension. The left wing outboard of the left engine was 620 feet from the fuselage on a heading of 270 degrees. The inboard portion of the aileron was present and the push/pull tube between the aileron and aileron bellcrank was connected. The outboard 15 inches of right aileron was separated from the wing and was recovered. Both upper and lower engine cowlings were separated from the wings. The upper cowlings were bent upward and the lower cowlings bent down. The top portion of the firewall for both engines was bent rearward. The engine rails on the left engine were pulled out of the firewall and on the right engine had separated just in front of the firewall. Flight control continuity was established with all control cables intact and attached, except for the left wing aileron cables which were frayed and irregular at the separation point. Wrinkles were found on the top and bottom of both wings which angled from inboard aft to outboard forward, and inboard forward to outboard aft. Accompanying the wrinkles were several popped rivets. Similar wrinkles were found on the left and right elevators. Wrinkles, orientated inboard forward to outboard aft, were found on the right horizontal stabilizer. Damage to the left horizontal stabilizer precluded a determination of wrinkles. The metal on the bottom of both tip tanks had a rippled appearance. According to a Structures Factual Report from Mr. Paul Alexander, Aerospace Engineer, with the Safety Board: ...The left wing had separated just outboard of the engine (inboard of the battery box). Examination of the forward and aft spars disclosed evidence of tensile and compressive overstress on the upper and lower spar caps, respectively, which was consistent with primary failure of this portion of the wing in a negative direction.... ...Examination of the forward and aft spars on the left horizontal stabilizer disclosed evidence of primary failure in the down (negative) and aft direction. The stabilizer skin was torn and ripped severely in several areas...The right horizontal stabilizer assembly was deformed, but less severely damaged than the left side. Its lower surface was deformed in a concave manner along its entire length. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on the pilot by Dr. Malcolm Cowen, M.D. Forensic Pathologist, for Forensic Pathologist Associates, 1024 Highland Ave, Bethlehem, Pennsylvania, on September 4, 1994. Toxicological testing was conducted by the FAA Civil Aeromedical Institute (CAMI), in Oklahoma City, Oklahoma, and SmithKline Beecham in Pottstown. Marihuana was found in the pilot's blood and urine at the following levels: .002 ug/ml Tetrahydrocannabinol in blood .011 ug/ml Tetrahydrocannabinol Carboxylic Acid in blood .304 ug/ml Tetrahydrocannabinol Carboxylic Acid in urine According to the toxicological factual report by Merritt M. Birky, Toxicologist, NTSB, Washington, DC, "...Evaluation of pilot performance on a flight simulator has been evaluated for up to 48 hours after marijuana use. This study showed decrements in pilot performance for up to 24 hours after marijuana use." TESTS AND RESEARCH According to report, No. 95-59, by Mr. James Wildey, Metallurgist, NTSB, Washington, D.C., examination of the lower spar car and a piece of upper spar cap outboard of the wing fracture: ...No evidence of progressive cracking was noted anywhere...Smearing damage was found on the lower spar cap fracture.... Examination of the upper spar cap piece at the wing separation point revealed: ...The majority of the fracture contained crack arrest positions and was on a flat transverse plane, typical of fatigue cracking...The visual and SEM examinations revealed no defects that may have contributed to initiation of the fatigue cracking.... ORGANIZATIONAL AND MANAGEMENT INFORMATION Drug testing was not required for 14 CFR Part 91 operations; however, the employment application signed by the pilot revealed the company had a drug testing program in place. There was no record that the employee was ever tested for drugs. The pilot held certificates that meet FAA requirements for Pilot-In Command; however, the company flight operations manual called for captains to possess an Airline Transport Pilot Certificate. The SmithKline-Beecham Clinical Labs, flight department manager reported he possessed the authority ## Aircraft - Registration: [N502SB](https://openairdocs.org/deregistered/N502SB-1995-02-06), registration cancelled 1995-02-06, S/N 310R0244 (OpenAirDocs) - Reported make and model: CESSNA 310R - Registry model: [Cessna 310R](https://openairdocs.org/model/cessna-310r) (registry code 2074245) (OpenAirDocs) - Category: Airplane - Serial number: 310R0244 - Airframe hours: 10508 - Engines: CONTINENTAL IO-520-M1 285 horsepower reciprocating - Damage: Destroyed - Flight: Executive/Corporate, Part 91 - Registered owner: Smithkline Beecham Bio Labs - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 1993, 1,231 hours before - Departed: AGC, WEST MIFFLIN, PA - Destination: PTW, POTTSTOWN, PA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 1,897 total, 1,486 in this make and model, 1,817 as pilot in command, 97 in the last 90 days, 29 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 54 °F - Altimeter: 30.00 inHg - Observed at: CXY, 31 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 19940903025119A](https://openairdocs.org/incident/19940903025119A), Sep 3, 1994: Cessna 310R, Blaine, PA, Destroyed, 2 fatal. Lost control in a descent. Exceeded vne. Airframe failed. Indicates pilot judgement impaired by drugs and fatigue. 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.