NYC99FA199

NTSB accident investigation · Cessna P210N · Worcester, VT · August 14, 1999

Accident · FatalField investigationFinal report
Date
August 14, 1999, 13:08 local (17:08 UTC)
Place
Worcester, VT
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N24CDCessna P210N
Weather
Instrument (IMC) · Day
Status
Completed · report June 7, 2000
Report
Approved by Office Director
FAA report
19990814011949A
Case key
47108

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 inadequate in-flight planning/decision, his failure to follow the published instrument departure procedure for the particular runway, and his continued flight into known adverse weather. A factor was thunderstorms.

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 encounter with weatherClimb
Terrain condition - rising
In-flight planning/decision - inadequatePilot in commandCause
Weather condition - thunderstormFactor
Flight into known adverse weather - continuedPilot in commandCause
Ifr procedure - not followedPilot in commandCause
In flight collision with terrain/waterClimb
Terrain condition - mountainous/hilly

Analysis

The pilot received three weather briefings from a flight service station prior to departure. The briefings included forecasts of thunderstorm activity along the planned route of flight, and in the area of the departure airport. The pilot was asked by the weather briefer if the airplane was equipped with weather radar. The pilot stated that he had a stormscope and weather radar. He departed the runway with a 15-20 knot tailwind, did not follow the published instrument departure procedure, and flew south toward mountainous terrain. The wreckage was located about 200 feet from the summit, on the south side of the mountain. Witnesses at the airport and in the vicinity of the accident site report hearing thunder about the time of the accident. Additionally, weather imageries and surface observations confirmed areas of heavy precipitation south of the airport, in the vicinity of the accident site, at the time of the accident. The pilot made four brief transmissions to Air Traffic Control, but was never in radar contact.

Factual narrative

History of flight

On August 14, 1999, at 1308 Eastern Daylight Time, a Cessna P210N, N24CD, was destroyed when it impacted terrain in Worcester, Vermont, after takeoff from Morrisville-Stowe State Airport (MVL), Stowe, Vermont, about 1300. The certificated private pilot and both passengers were fatally injured. Instrument meteorological conditions prevailed for the planned flight to Capital City Airport, Harrisburg, Pennsylvania. An instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 CFR Part 91.

The Airport Manager stated:

"On August 14, 1999 at approximately 1:00pm. I witnessed Cessna 210 N24CD depart from the Morrisville-Stowe State Airport. The ceilings were low at the time around 800 to 1000 feet, as I recall. There was some distant thunder to the south and the winds were out of the northwest at 15 to 20 knots. We had fueled the aircraft previously on August 8, when they arrived, with 40 gal. of 100LL. I saw [the family] briefly in the terminal building before they left. They used the facilities and the candy machine and [the pilot] told his wife and child to hurry because they had a void time...I was in the office at the time they departed and was surprised and concerned when I suddenly noticed that they were departing on runway 19 with a 15 to 20 knot tailwind. The airplane took a substantial amount of runway to rotate and then climbed very slowly. I watched the aircraft climb very slowly straight out until they disappeared in the overcast at about 800 to 1000 feet AGL. About 10 minutes later I received a call from Boston Center. They told me they had received one radio call from them, but they never showed up on radar..."

A review of an excerpt from a Federal Aviation Administration (FAA) transcript revealed:

1305:56 (N24CD) center two four charlie climbing

1306:09 (controller) two four charlie delta report reaching uh---six thousand

1306:20 (N24CD) two four charlie did not cop---copy altitude

1307:59 (N24CD) boston center two four charlie delta do you copy

1308:03 (controller) two four charlie delta climb and maintain six thousand report reaching six thousand

1308:07 (N24CD) boston center you're cutting up

1308:17 (controller) nuv two four charlie delta say again please

Air Traffic Control (ATC) did not receive any more transmissions from N24CD. Additionally, ATC never obtained radar contact with the assigned transponder code for N24CD. An emergency locator transmitter signal was received about 1308.

The accident occurred during the hours of daylight; approximately 44 degrees, 25.83 minutes north latitude, and 72 degrees, 36.76 minutes west longitude.

Personnel information

The pilot held a private pilot certificate; with ratings for single engine land and instrument airplane.

His most recent FAA third class medical certificate was issued on October 8, 1998. At that time, he reported a total flight experience of 600 hours.

The pilot's logbook was not recovered. Using FAA records, maintenance records, and a flight instructor's estimate, the pilot's total flight experience at the time of the accident was estimated to be approximately 840 hours. About 40-80 of those hours were in actual instrument meteorological conditions.

Aircraft information

The airplane's last annual inspection was performed on March 29, 1999.

According to the airport manager, the airplane departed with full fuel, three occupants, baggage, and a dog. A Cessna P210N manual contained maximum rate of climb information. According to the information; at 4,000 pounds, at sea level, at a temperature of 20 degrees Celsius, the airplane would climb at 910 feet per minute.

Meteorological information

The pilot obtained three weather briefings from the Burlington Flight Service Station via telephone. He received a full briefing at 0724, and two updated briefings at 1131 and 1235. During the full briefing, the briefer stated: "...well ah thunderstorms ah possible on your route um well pretty much anytime particularly over southern portion of your route ah right now..."

During the first updated briefing, the briefer asked if the pilot's airplane was equipped with a stormscope or weather radar. The pilot stated that he had both.

During the second updated briefing, the briefer stated: "uh well there's almost a whole line ah stretching oh it looks like ah down in the ah binghamton elmira area right up through ah central ah or northcentral vermont to maine right now...." The briefer again asked if the pilot had a stormscope. The pilot stated that he did.

In addition to the airport manager's recollection of distant thunder to the south of MVL, a detective for the Vermont State Police stated that a severe weather warning was in effect, for thunderstorms, at the time and place of the accident. He added that several witnesses reported hearing thunder about 1308.

NEXRAD radar imageries were provided by the National Weather Service. According to the imageries, medium to strong intensity echo returns were present to the south of MVL, in the vicinity of the accident site, at 1246, 1300, and 1319.

MVL was approximately 8 miles north (020 degrees) of the accident site. The reported weather at MVL, at 1254, was: wind calm; visibility 3 miles, mist; sky condition broken 2,000, broken 4,900; temperature 70 degrees Fahrenheit (F); dewpoint 66 degrees F; altimeter 29.82 inches Hg.

Edward F. Knapp State Airport (MPV), Montpelier, Vermont was located approximately 15 miles south of the accident site. The reported weather at MPV, at 1251 was: wind 310 degrees at 9 knots; visibility 1.25 miles, heavy rain and mist; sky condition scattered 300, overcast 1,300; temperature 66 degrees F; dewpoint 66 degrees F; altimeter 29.85 inches Hg.

Aids to navigation

According to a FAA Inspector, the current Jeppesen Airway Manual contained the correct departure procedure for Runway 19 at MVL. It stated: "...Rwy 19, climbing right turn direct JRV NDB and climb in hold (northeast, left turns, 230 [degrees] inbound) to 3500' before proceeding on course."

A Jeppesen Airway Manual was found at the accident site. However, witness statements and ATC information indicated that the pilot did not fly the published departure procedure for Runway 19, nor was he required to.

The FAA Inspector added that after the accident, someone at the FAA noticed that the text departure procedure for Runway 19 at MVL was not listed in the National Ocean Service (NOS) U.S. Terminal Procedures. The FAA then added the procedure to the publication. The Inspector was advised that no NOS U.S. Terminal Publications were found at the accident site, only the Jeppesen Airway Manual.

A former flight instructor stated that the pilot was instrument proficient, but may not have been proficient at departure procedures and mountainous operations.

Aerodrome information

Morrisville-Stowe State Airport was located in valley at a field elevation of 732 feet above mean sea level. Mount Worcester was approximately 8 miles to the south. Mount Mansfield was approximately 8 miles to the west. Lower terrain was present to the north and east of the airport. The airport was served by Runway 1/19.

Wreckage and impact information

The wreckage was examined at the accident site on August 16, 1999, and although a large portion was consumed by fire, all major components of the airplane were accounted for at the scene. It was oriented to a 190-degree heading, approximately 3,200 feet above mean-sea-level, on Mount Worcester. The wreckage was about 200 feet from the summit, on the south side of the mountain. There were several tree scars near the wreckage, oriented to a southerly heading. Some of the branches were cut clean, at an approximate 45-degree angle. The wreckage and surrounding area were charred.

The right wing sustained impact damage to the leading edge.

Aircraft

Registration
N24CD
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000798
Airframe hours
2,429
Engine
Continental TSIO-520, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Dennis L. Lehman
Registered owner
Lima Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 29, 1999 · 173 hours before
Departed
MVL · Stowe, VT
Destination
CXY · Harrisburg, PA
Flight plan
IFR
Airport
MVL · Morrisville-Stowe State, runway 19, 3,701 × 75 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
43
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
840 total · 700 in this make and model · 780 as pilot in command · 140 in the last 90 days · 45 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
310° at 9 knots
Visibility
1.25 statute miles
Lowest ceiling
1,300 ft overcast
Temperature
66 °F, dew point 66 °F
Altimeter
29.00 inHg
Observed at
MPV, 15 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.