SEA05FA201

NTSB accident investigation · Cessna P210N · Salmon, ID · September 28, 2005

Accident · FatalField investigationFinal report
Date
September 28, 2005, 17:15 local (23:15 UTC)
Place
Salmon, ID
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N45SECessna P210N
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
FAA FSDO, Cessna Aircraft Company, Rolls-Royce Corporation
FAA report
20050928031519A
Case key
62571

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 obtain airspeed during the initial takeoff climb, which resulted in a stall/mush and subsequent collision with terrain.

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.

Loss of control - in flightTakeoff - initial climb
Airspeed - not obtained/maintainedPilot in commandCause
Stall/mush - encounteredPilot in command
In flight collision with terrain/waterTakeoff - initial climb
Terrain condition - grass

Analysis

The pilot and passenger were returning home after spending several days on an elk hunting trip in the Idaho backcountry. One of them had shot an elk, and they loaded the airplane with the four elk quarters and their personal gear. A witness heard the airplane taking off and it "didn't sound right." He looked towards the 2,000-foot-long grass airstrip and saw the airplane "barely off the ground" heading south. The witness stated that the airplane was "wallowing back and forth, trying to stall out." He further stated that the "motor sounded like a boat cavitating" and "the nose of the airplane was pointed up." The witness watched the airplane as it veered left and impacted the ground tail first. The airplane's nose then "slammed into the ground," and the airplane nosed over and came to rest inverted. A fire erupted, which destroyed the fuselage and the inboard sections of the wings. The accident site was about 1/4 mile from the end of the runway, offset to the left of the runway centerline, and approximately the same elevation as the runway. The site was located on level grass covered terrain. Examination of the airframe and engine revealed no evidence of any abnormalities that would have prevented normal operation. The pilot began flying the airplane, which had been modified by replacement of its original reciprocating engine with a gas turbine engine, about 4 months before the accident and according to his logbook, had accumulated about 22 hours flight time in it. He had about 1,167 hours in other non-modified airplanes of the same make and model. An estimated weight and balance placed the airplane's takeoff weight at 3,729.4 pounds, which was below the maximum gross weight of 4,000 pounds. The estimated center of gravity was 48.57 inches, which was within, but near, the aft limit of 49 inches. A short field landing performance chart indicated that for the approximate accident conditions, the takeoff ground roll would be 1,581 feet and the total distance to clear a 50 foot obstacle would be 2,461 feet. A pilot, who had experience flying the accident airplane, stated the following with respect to its performance: "Weight and balance is very, very critical. With weight aft, you really need to hold the nose down and gain airspeed on takeoff."

Factual narrative

History of flight

On September 28, 2005, about 1715 mountain daylight time, a Cessna P210N, N45SE, impacted terrain during takeoff initial climb from the Flying B Ranch airstrip, located about 38 nautical miles west of Salmon, Idaho. The airplane was destroyed by impact and fire damage, and the two occupants, the private pilot and one passenger, sustained fatal injuries. The airplane was registered to Marlin Ventures LLC of Corte Madera, California, and operated by the pilot. Visual meteorological conditions prevailed and no flight plan was filed for the personal cross country flight. The flight was originating at the time of the accident, and the intended destination was Boise, Idaho.

According to family members, the pilot and passenger had flown the airplane from San Rafael Airport (Smith Ranch) in San Rafael, California, to the Flying B on September 22, 2005. They were met at the Flying B by three other members of their hunting party, who had flown in on a charter flight from McCall, Idaho. The pilot and passenger did not mention having any problems with the airplane during the non-stop flight that lasted about 2.5 to 3 hours. After spending several days hunting elk, on the day of the accident, the pilot and the passenger returned to the airstrip and prepared to fly back to San Rafael with a planned fuel stop in Boise, Idaho. One of them had shot an elk, and they loaded the airplane with the four elk quarters and their personal gear.

An employee of the Flying B Ranch who observed the pilot and passenger loading the airplane reported that the pilot "did check some figures" and told the passenger that they could have "at least 160 pounds of weight in the rear compartment." The passenger commented that the elk "hindquarters would fit and be almost that weight." The passenger loaded "the 2 hind quarters and then put in 2 sleeping bags, a shirt, a pair of pants, a felt hat, and some Styrofoam packing." The employee reported seeing two seats in the rear of the airplane's passenger compartment. In front of these seats, in the middle of the passenger compartment, the pilot and passenger loaded "the 2 front quarters, 2 rifles, 2 duffle bags, 2 scabbards, a back pack (possibly 2), a small saw, saddlebags, and the antlers." Additionally, this area contained "3 shopping bags with merchandise they had just purchased in the store (3 vests, 2 T-shirts, 1 Jacket, and 1 Visor)" and "a container with cleaning supplies to clean windows on the plane." After the accident, the employee talked with another employee, a wrangler, who estimated each hindquarter weighed approximately 75 pounds, each front quarter weighed 70 to 75 pounds, and each duffle bag weighed "75 pounds at the very most."

According to another Flying B Ranch employee who witnessed the accident, he heard the airplane taking off and it "didn't sound right." He looked towards the airstrip and saw the airplane "barely off the ground" heading south. The witness stated that the airplane was "wallowing back and forth, trying to stall out." He further stated that the "motor sounded like a boat cavitating" and "the nose of the airplane was pointed up." The witness watched the airplane as it veered left, crossed the Middle Fork of the Salmon River, and impacted the ground tail first. The airplane's nose then "slammed into the ground," and the airplane nosed over and came to rest inverted. A fire erupted, which consumed the fuselage of the airplane.

Personnel information

The pilot held a private pilot certificate with single- and multi-engine land airplane and instrument airplane ratings. His most recent third class medical was issued on May 5, 2005, with the limitation, must wear corrective lenses for near and distant vision.

According to a "Pilot Record" sheet dated May 20, 2005, completed by the pilot in connection with an application for insurance on the accident airplane, he had accumulated 1,939 hours total flight time of which 1,167 hours were in same make and model as the accident airplane. Copies of the pilot's flight logbooks were provided to the NTSB investigator-in-charge (IIC) by a family member. The most recent logbook covered the time period from April 22, 1994, to September 12, 2005. Review of this logbook revealed no entries indicating a flight into or out of the Flying B Ranch. The last 12 entries in the logbook appeared to record flights in the accident airplane. All of the entries listed the aircraft type as "P210," and one of the entries listed the aircraft identification as "SE." These entries began on June 1, 2005, ended on September 12, 2005, and totaled 21.8 hours.

During an interview conducted by the NTSB IIC, the flight instructor, who gave the pilot flight training in the accident airplane, stated that the pilot received 10 hours ground school and over 15 hours dual instruction in the airplane over a 4 to 5 day period. He further stated that the training "progressed normally." Landings were made at 8 different airports during the training including Reno, Nevada, elevation 4,415 feet, and Bend, Oregon, elevation 3,456 feet. Short field takeoff and landing techniques were covered during the flight training. The instructor described the short field takeoff technique for the airplane as follows: Add 10 degrees to the normal 10-degree flap setting, pull the airplane off at 75 knots (as opposed to rotating at 75 and letting the airplane fly off), climb at Vx (80 knots), raise flaps 10 degrees at a time - usually after raising the landing gear.

The Flying B employee who observed the loading of the airplane stated that the pilot had been coming to the Flying B for 30 years, but had not flown in himself since 2000.

Aircraft information

FAA airworthiness records for the airplane indicated the 1979 Cessna P210N, S/N P21000267, was modified by installation of a Rolls Royce gas turbine engine Model 250-B17F/2, S/N CAE881125, and Hartzell propeller Model HC-B3TF-7A/T9212NK-2, S/N EXA1123, in accordance with STC SA1003NE on March 20, 2000. This modification, known as a "Silver Eagle" conversion, was performed by the STC holder, O & N Aircraft Modifications, Inc., of Factoryville, Pennsylvania. At this time, a new hour meter was installed.

The airplane's maintenance logbooks were not located during the investigation. According to records obtained from the maintenance facility that had been maintaining the airplane since its conversion, the most recent annual inspection was completed in March 2005. At the time of this inspection, the airplane had accumulated 1,004.0 hours since the conversion.

Review of FAA registration records indicated Marlin Ventures LLC purchased the airplane on May 20, 2005. The accident pilot signed the ownership documents as President of Marlin Ventures LLC. The records indicated that as of May 20, 2005, the airplane had accumulated 2,379.0 hours total time and 1,040.1 hours since its conversion.

The weight and balance of the airplane at takeoff was estimated using the following information:

Basic empty weight, 2,541.2 pounds, obtained from aircraft weighing report prepared by O & N Aircraft dated May 4, 2000.

Front seat occupants, 340 pounds (170 pounds each).

Middle seat baggage, 380 pounds, from information provided by Flying B employee who observed loading of airplane.

Rear baggage, 160 pounds, from information provided by Flying B employee who observed loading of airplane.

Fuel in wing tanks, 308.2 pounds (46 gallons times 6.7 pounds/gallon)

The estimated takeoff weight was 3,729.4 pounds, which was below the maximum gross weight of 4,000 pounds. The estimated takeoff moment was 181.116 pound-inches, and the estimated center of gravity was 48.56 inches, which was within the aft limit of 49 inches. (According to the FAA Approved Flight Manual Supplement for STC SA1003NE, the aft center of gravity limit is 49 inches at all weights, and the forward center of gravity

Aircraft

Registration
N45SE
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000267
Airframe hours
1,004
Engine
Rolls-Royce 250-B17F, 450 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2005
Departed
12ID · Salmon, ID
Destination
Boise, ID
Airport
12ID · Flying B Ranch Landing Strip, runway S, 2,000 × 100 ft, grass/turf

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
60
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
June 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
1,939 total · 1,167 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Temperature
68 °F

Docket · 20

The files NTSB released with the investigation on June 21, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.5 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.