SEA97FA005

NTSB accident investigation · Cessna T210M · Everett, WA · October 8, 1996

Accident · FatalField investigationFinal report
Date
October 8, 1996, 08:45 local (15:45 UTC)
Place
Everett, WA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N761TQCessna T210M
Weather
Instrument (IMC) · Day
Status
Completed · report March 31, 1998
Report
Approved by Office Director
FAA report
19961008031219A
Case key
42483

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The pilot's impairment of judgment and performance due to the recent excessive use of potent prescription drugs, the pilot's descent below the published decision height, and the pilot's failure to execute a missed approach. Factors contributing to the accident were the adverse meteorological conditions which were below the published required visibility, runway visual range, and ceiling minima due to fog.

Analysis

The 75-year-old private pilot acknowledged all ATC vectors and instructions after receiving a clearance to perform an instrument approach, but he did not operate the airplane in accordance with the vectors. The airplane flew through the ILS localizer course during the initial vectoring, and ATC canceled the pilot's clearance to continue the approach. ATC began to re-vector the airplane for another attempt. Again the pilot did not operate the airplane in accordance with the ATC vectors. He was cleared for the approach and began to descend about 1,000 feet per minute at 150 knots. The airplane struck a power line about 1,400 feet from the runway threshold, impacted terrain and was destroyed. The weather conditions were below the published approach visibility minimums. The pilot's medical certificate and the airplane's annual inspection were expired at the time of the accident. The toxicological analysis revealed that the pilot was under the influence of a potent prescription narcotic at the time of the approach. The pilot had a history of severe cardiovascular disease.

Factual narrative

The factual narrative1,287 words

History of flight

On October 8, 1996, at 0845 Pacific daylight time, N761TQ, a Cessna T210M, operated by the owner/pilot, collided with wires, poles, trees, and terrain and was destroyed while on an instrument landing system (ILS) approach to Runway 16R at Paine Field in Everett, Washington. The instrument-rated private pilot, the sole occupant, was fatally injured. Instrument meteorological conditions prevailed and no flight plan had been filed. The personal flight departed from Buena, Washington, and was destined for Everett. The flight was conducted under 14 CFR 91.

According to voice recordings and radar data (attached) from the Federal Aviation Administration (FAA) Air Route Traffic Control Center (ARTCC) in Seattle, Washington, the pilot requested an instrument clearance to Paine Field at 0810 while airborne at 4,000 feet above mean sea level (msl). The ARTCC granted the clearance and began to vector the airplane for the ILS Runway 16R approach.

At 0830:54, the pilot was instructed to turn to a heading of 330 degrees; the pilot acknowledged and the airplane gradually turned to 348 degrees while its ground speed decreased from 140 knots to 130 knots in 2 minutes.

At 0832:56, the pilot was instructed to turn to a heading of 250 degrees; the pilot acknowledged and the airplane gradually turned to 289 degrees while its ground speed decreased from 130 knots to 113 knots in 2 minutes.

At 0834:51, the pilot was instructed to turn to a heading of 180 degrees and was cleared for the approach; the pilot acknowledged and the airplane gradually turned to 272 degrees while its ground speed increased from 113 knots to 126 knots in 1 minute.

At 0835:47, the pilot was told "you've gone through the localizer..." and was instructed to turn to a heading of 130 to reintercept; the pilot acknowledged and gradually turned to 242 degrees in about 30 seconds.

At 0836:18, the controller told the pilot that the pilot's approach clearance was canceled, and the controller instructed the pilot to turn to a heading of 070 degrees to begin vectoring for another approach; the pilot acknowledged and the airplane gradually turned to 177 degrees while its ground speed decreased from 123 knots to 93 knots in 45 seconds.

At 0837:04, the pilot was instructed to turn to a heading of 030 degrees; the pilot acknowledged and the airplane gradually turned to 123 degrees while its ground speed decreased from 93 knots to 73 knots in 1 minutes.

At 0838:09, the pilot was instructed to turn to a heading of 350 degrees; the pilot acknowledged and the airplane gradually turned to 039 degrees while its ground speed increased from 73 knots to 96 knots in 102 seconds.

At 0841:00, the pilot was instructed to turn to a heading of 180 degrees and was cleared for another approach; the pilot acknowledged and the airplane gradually turned to 241 degrees while its ground speed increased from 94 knots to 137 knots, then decreased to 115 knots in 2 minutes. The airplane's altitude remained about 2,900 feet msl during all of the vectoring.

At 0842:05, the controller instructed the pilot to contact the Paine Field Air Traffic Control (ATC) Tower; the pilot acknowledged. The airplane's heading changed from 244 degrees to 203 degrees while its ground speed increased from 116 knots to 129 knots with no change in altitude.

The pilot subsequently contacted the tower controller, and the controller cleared the pilot to land on runway 16R. About one minute later, the controller told the pilot that the runway visual range for runway 16R was 1,000 feet. The pilot acknowledged; this was his last transmission. No distress calls were made by the pilot during the entire accident flight.

At 0843:17, the airplane began to descend out of 2,900 feet msl. From the beginning of the descent until the accident, the airplane descended about 1,000 feet per minute while its ground speed increased from 127 knots to 151 knots and its heading changed from 203 degrees to 184 degrees. The last recorded radar hit occurred at 0845:17; the airplane was about 400 feet above the ground, 1 mile from runway 16R, and traveling at 151 knots at the time of the last radar hit.

Ground witnesses reported hearing and seeing the airplane flying "low" through "thick fog" and impacting a utility pole. One witness stated that he heard the engine "rev up" just prior to impact. The airplane then struck trees and came to rest inverted about 800 feet from the approach threshold of runway 16R.

The accident occurred during daylight conditions at the following coordinates: North 47 degrees, 54 minutes; West 122 degrees, 16 minutes.

Aircraft information

The accident airplane, a Cessna model T210M, was manufactured in 1978 and was powered by a single 310-horsepower Continental turbocharged, propeller-driven engine. The airplane was registered to, and operated privately by, the accident pilot since 1978.

The Safety Board obtained and reviewed the aircraft maintenance records of the airplane. A review of the records (excerpts of copies attached) revealed that the airplane had not received an annual inspection since March 10, 1994, or an IFR certification inspection since January 13, 1993. Entries subsequent to the last annual inspection were found in the logbook; the last entry was dated June 27, 1996, and documented the overhaul of a hydraulic pump. Information from the records and the airplane's tachometer hour meter revealed that the airplane had logged a total of 2,758 hours at the time of the accident, 243 hours since it's last logged inspection, and 980 hours since its engine was rebuilt.

The records also indicated that the engine received an annual inspection on May 8, 1996, with no outstanding discrepancies noted. The engine accumulated an additional 68 hours from the time of this inspection to the accident.

According to a fixed based operator in Yakima, Washington, who had performed the most recent logged inspection on the accident airplane, the pilot routinely operated the airplane in and out of a private dirt strip located near his orchard properties, and the pilot often performed his own maintenance of the accident airplane.

Personnel information

The pilot, age 75, held an FAA Private Pilot certificate with ratings for airplane single-engine land airplanes and instrument airplanes. An examination of the pilot's personal flight log book (excerpts of copies attached) revealed that he had logged a total of 4,191 hours as of January 1, 1993. No subsequent entries were found in the log book. The most recent flight review was dated March 19, 1990.

According to FAA records, the pilot was issued an FAA Third Class Medical Certificate on November 13, 1992. The pilot indicated that he had logged in excess of 4,000 flight hours at the time of the medical application. The medical certificate had expired on December 1, 1994, after the pilot had failed to undergo several specified medical tests required by the FAA.

Information contained in the pilot's medical records indicated that the pilot underwent "an aortocoronary saphenous vein by-pass graft to the left anterior descending coronary artery" on May 13, 1980. He failed to notify the FAA of the surgery and continued to fly under a medical certificate that was valid at the time of the operation. Seven months after the surgery, the FAA suspended the pilot's airman certificate after a "friend of neighbors of [the pilot were] concerned about his piloting his aircraft following open heart surgery...." The pilot subsequently underwent numerous tests and was continually granted medical certificates by the FAA until December 1, 1994.

The medical records also revealed that the pilot had checked "no" under the category of previous "Heart or vascular trouble" at the time of his most recent medical certificate application. Also, the records indicated that the pilot had a "cystoscop

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 objectApproach - faf/outer marker to threshold (ifr)
Object - wire,transmission
Decision height - belowPilot in commandCause
Acft/equip,inadequate compliance determinationPilot in command
Weather condition - fogFactor
Missed approach - not performedPilot in commandCause
Lack of certificationPilot in command
Weather condition - below approach/landing minimumsFactor
Impairment(drugs)Pilot in commandCause

Aircraft

Registration
N761TQ
Reported as
Cessna T210M
Category
Airplane
Serial number
21062508
Airframe hours
2,758
Engine
Continental TSIO-520-R, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Barbee, Lester I.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 10, 1994 · 343 hours before
Departed
Buena, WA
Destination
PAE · Everett, WA
Airport
PAE · Snohomish Co.(Paine Fld), runway 16R, 9,010 × 150 ft

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
75
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Expired
Seat
Left
Toxicology
Performed
Flight hours
4,500 total

Weather

Conditions
Instrument (IMC) · Day
Wind
330° at 8 knots
Visibility
0.5 statute miles
Lowest ceiling
200 ft
Temperature
54 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
PAE, 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.