# NTSB WPR09FA027: Cessna P206, N2570X, Estacada, OR, October 29, 2008

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: October 28, 2008, 19:00 local (Oct 29, 2008, 02:00 UTC)
- Place: Estacada, OR
- Coordinates: 45.308055, -122.318611 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=45.3081&lon=-122.3186&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report November 9, 2009
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Administration, Teledyne Continental Motors, Cessna Aircraft
- NTSB case key (mKey): 69371
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA027
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69371/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69371
- Page: https://openairdocs.org/ntsb/WPR09FA027

## Probable cause

The pilot's failure to maintain clearance from trees while on approach to land at night. Contributing to the accident was the electrical system failure and the pilot's diverted attention.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2073304), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md)
- [Electrical power system: electrical pwr sys wiring](https://openairdocs.org/ntsb-findings/01022497): Aircraft › Aircraft systems · Not specified (probable cause); cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-findings/01022497/cases.md?model=2073304), [All aircraft, 44 cases](https://openairdocs.org/ntsb-findings/01022497/cases.md)
- [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=2073304), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md)
- [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2073304), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md)
- [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna P206, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2073304), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P206, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073304), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332); cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-events/332/sequence.md?model=2073304), [All aircraft, 182 cases](https://openairdocs.org/ntsb-events/332/sequence.md)
- [Approach: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Cessna P206, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=2073304), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md)

## Analysis

During a night visual-flight-rules personal flight, the pilot reported to a witness via cellular phone that the airplane's electrical system had failed and requested that the witness turn on the runway lights. The witness stated that he observed the airplane flying over the airport on a westerly heading with no lights on. As the airplane passed over the runway and initiated a left turn, the witness lost visual contact with the airplane. Shortly thereafter, the witness heard the sound of impact. On-scene examination of the wreckage and ground scars showed that the airplane impacted trees on final approach about 1,000 feet short of the runway's approach end. Detailed examination of the recovered wreckage revealed that the top ground terminal nut that attached the alternator filter to the ground terminal of the alternator was loose. Evidence of severe wear was noted on the alternator filter attach point and the bottom alternator ground terminal nut. Copper particle splatter was observed around the ground terminal and on the alternator filter which was found to be consistent with electrical arcing. The alternator controller remained attached to the firewall. The tamper-proof seal on the controller was found separated at the seam. The controller cover was removed and a diode was observed separated from the circuit board and found loose within the cover. Evidence of heat damage was observed within the lower inboard corner of the printed circuit board where the diode was installed. No additional anomalies were noted with the engine that would have precluded normal operation and production of power. The pilot had undergone a minor surgical procedure two weeks prior to the accident, and was prescribed a medication known to cause impairment. Toxicology testing was consistent with the medication having been taken within 24 hours of the accident; however, the investigation could not definitively establish that the pilot was impaired.

## Factual narrative

HISTORY OF FLIGHT On October 28, 2008, about 1900 Pacific daylight time, a Cessna P206, N2570X, was substantially damaged when it impacted terrain while maneuvering near the Valley View Airport (5S9), Estacada, Oregon. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and his passenger were killed. Night visual meteorological conditions prevailed and no flight plan was filed for the cross-country personal flight. The flight originated from the Lexington Airport (9S9) Lexington, Oregon about 1745. According to a witness located at 5S9, the pilot called him using a cell phone about 1845 stating that the airplane had lost all electrical power. The pilot asked the witness to turn on the runway lights so he could locate the airport and land. A few minutes later, the pilot called the witness again requesting that he “flash” the runway lights to assist him in locating the airport and asked if the witness could hear the airplane. The witness stated that he went outside of his residence along with his wife and attempted to locate the airplane. A few seconds later, he observed an airplane flying overhead on a westerly heading with no lights at an estimated altitude of about 800 feet above ground level. As the airplane passed over the runway, the witness observed it initiate a left turn before losing sight of the airplane. Shortly after, the witness heard the sound of impact and called 911. PERSONNEL INFORMATION The pilot, age 54, was issued a private pilot certificate with an airplane single-engine land rating on June 25, 2008. A third-class airman medical certificate was issued to the pilot on April 3, 2007, with the limitation of “not valid for any class after.” Review of the pilot’s personal logbook revealed that as of the most recent entry dated September 28, 2008, he had accumulated 190.6 total hours of flight time, of which 1.2 hours were in the previous 30 days and 43.7 hours within the previous 90 days of the accident. The pilot had accumulated a total of 139.2 hours in the accident make/model airplane. AIRCRAFT INFORMATION The six-seat, high-wing, fixed-gear Cessna P206 airplane, serial number (S/N) P206-0070, was manufactured in 1964. It was powered by a Continental IO-520-A engine, serial number 111111-A-5, rated at 285 horse power driving a McCauley E2A43C7-3-NO two bladed constant speed propeller. According to Federal Aviation Administration (FAA) registration records, the airplane was registered to the pilot on August 22, 2007. Review of copies of maintenance logbook records revealed an annual inspection was completed on December 21, 2007, at a recorded tachometer reading of 332.5 hours, airframe total time of 6,241.3 hours, and engine time since major overhaul of 1,080.12 hours. One entry dated July 28, 2008, stated that a tach time of 401.0 hours, "removed alternator PF DOFF10300JR, SN UNK, and installed OH ALT same PN with SN H092958, installednew voltage reg. adjusted belt tension and ops checked system and found ok." At the time of the accident, the airplane had accumulated 122.5 hours since the time of the inspection. METEOROLOGICAL INFORMATION A review of recorded data from the automated weather observation station, located at the Portland Troutdale Airport, about 15 miles north of the accident site revealed at 1853 weather conditions were wind calm, visibility 10 statute miles, clear sky, temperature 11 degrees Celsius, dew point 8 degrees Celsius, and an altimeter setting of 30.21 inches of Mercury. According to the US Naval Observatory, sunset was at 1800, end of civil twilight was at 1831, and moonset was at 1756. AIRPORT INFORMATION The Valley View Airport (5S9) is an unattended airport that is operating under class G airspace. The recorded field elevation for 5S9 is 735 feet mean sea level. The airport features a single asphalt runway, 3,780-foot long and 32-feet wide, oriented on headings of 160 and 340 degrees respectively. The runway is equipped with runway edge lights, which were located along the middle 2,240 feet of the runway, which were operated by personnel on the ground. No runway visual slope indicators were installed. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the airplane had struck trees and subsequently impacted the ground 0.26 miles south of 5S9. Wreckage debris and several broken tree limbs were scattered about 54 feet along an approximate 070-degrees magnetic heading from the first topped tree. The airplane came to rest inverted within thick vegetation. The left wing and right wing attach points were separated but remained attached to the fuselage via the control cables and were located adjacent to the fuselage. All primary flight control surfaces and major components of the airplane were located within the debris field. The engine and engine mounts were separated from the engine firewall. A strong fuel odor was noted at the accident site. A local resident near the accident site reported that they located a portion of the outboard left wing tip and damaged trees approximately 300 to 400 feet directly south of the accident site about one month after the accident. Flight control continuity was established from the cockpit controls to all primary flight controls. The rudder control cables were separated in the cockpit just above the rudder bellcrank and exhibited "broomstraw" signatures. The flap actuator was measured and was consistent with the flaps being in the "UP" position. The right wing fiberglass fuel tank was shattered. The right wing fuel screen was free of debris. The left fuel tank was intact; however, the left wing fuel lines were breeched at the wing root. The left wing fuel screen was free of debris. The fuel selector was observed set to the right fuel tank. No shoulder harnesses were present. Both lap belts were buckled and were cut by first responders. The airframe and engine were recovered to a securelocation for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The Clackamas County Medical Examiner’s office conducted an autopsy on the pilot on October 29, 2008. The Medical Examiner determined the cause of death to be "head injuries." The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested with positive results for 0.2 (ug/ml, ug/g) of diazepam detected within the blood, unspecified amounts of ibuprofren and naproxen detected within the blood, 0.318 (ug/ml, ug/g) of nordiazepam detected in the blood, 0.152 (ug/ml, ug/g) of nordiazepam detected in the urine, unspecified amounts of oxazepam detected in the blood and urine, 0.018 ug/ml, ug/g) of temazepam detected in the blood, and 0.352 ug/ml, ug/g) of temazepam detected in the urine. A family member indicated that the pilot had undergone a minor surgical procedure on October 14, 2008, and following the surgery was experiencing ongoing muscle spasms, for which he had been prescribed diazepam 10mg, three times a day. TESTS AND RESEARCH On November 6, 2008, the wreckage was examined at the facilities of Specialty Aircraft, Redmond, Oregon. Examination of the engine revealed that the engine was separated from the airframe. The top spark plugs, vacuum pump, alternator, fuel pump, and propeller were removed. All cylinders remained attached to the crankcase. The cylinders were examined internally using a lighted borescope and exhibited normal operational signatures. The engine crankshaft was rotated by hand using a hand tool at the upper right hand accessory drive pad. Thumb compression was obtained on all six cylinders and valve train continuity was established throughout the engine. During rotation of the crankshaft, the left and right magnetos produced spark on all ignition harness leads. The propeller (McCauley E2A34C 7 3-NO, S/N: 737176) was intact and remained attached to the engine. Both propeller blades were loose within the propeller hub. The spinner was impact damaged. The number one propeller blade was bent aft at mid-span with trailing edge damage at mid-span and about 8 inches inboard from the blade tip. Slight chordwise scratching was observed on the outboard 8 inches of the propeller blade. The number two blade was twisted from mid-span to the blade tip. A portion of the propeller blade tip was separated. The remainder of the propeller blade was bent forward. Chordwise scratching was observed mid-span. The alternator remained attached to the engine. All of the associated alternator wiring was separated from the alternator. The alternator was removed and visually examined. The nut that secures the electrical wiring connector to the ground terminal nut was found loose and backed off slightly. The wiring connector and alternator filter were attached to the negative terminal but moved up and down on the terminal freely. Numerous copperparticles were observed in the vicinity of the ground terminal. The alternator filter and wiring connector were removed and examined. The alternator filter exhibited severe wear on the bottom side with evidence of electrical arching on the top side. A significant amount of copper splatter was observed on the cylinder portion of the filter. The wiring connector was found severely worn. The ground terminal exhibited some wear at the top portion of the terminal. The nut that secured the terminal to the alternator housing was secure and severely worn. No additional anomalies were noted with the engine that would have precluded normal operation and production of power. Examination of the airframe verified continuity from the master switch and associated wiring to the 50 amp circuit breaker, battery relay, and alternator controller. The diode on the master switch terminals was found separated. The alternator controller remained attached to the firewall. The tamperproof seal on the controller was found separated at the seam. The controller cover was removed and a diode was observed separated from the circuit board and found loose within the cover. Evidence of heat damage was observed within the lower inboard corner of the printed circuit board where the diode was installed. On December 11, 2008, the alternator was examined and tested using an alternator test bench. The alternator functioned normally with no anomalies noted. ADDITIONAL INFORMATION A Garmin GPSMap 396 portable GPS unit was found within the wreckage and sent to the NTSB Vehicle Recorder Laboratory for data extraction. Track logs from the date of the accident were extracted from the unit. The track log started about 8 miles northwest of the accident site and continued on a southwesterly heading until about 2 miles southwest of 5S9, when a left turn to a northeasterly heading was observed. About 2 minutes later, the GPS data depicted a left turn to a southwesterly heading. The track continued to the south southwest for about 9 minutes before a right turn to a westerly heading was made. About 3 minutes later, the data showed a 180-degree left turn to an east northeasterly heading. The track continued mostly on a northeasterly heading for about 12 minutes before turning left to a northerly heading, about 0.3 mile east of 5S9. The track continued north for about 1 minute, followed by a left 180-degree turn to a southerly heading, about 0.5 mile west of 5S9. About 1 minute later, the data showed a left turn to an easterly heading was initiated. The last point depicted on the GPS track log was located about .16 mile west of the accident site.

## Aircraft

- Registration: [N2570X](https://openairdocs.org/deregistered/N2570X-2013-06-18), registration cancelled 2013-06-18, S/N P206-0070, built 1964 (OpenAirDocs)
- Reported make and model: CESSNA P206
- Registry model: [Cessna P206](https://openairdocs.org/model/cessna-p206) (registry code 2073304) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: P206-0070
- Airframe hours: 6241
- Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Mark S Greenup
- Registered owner: Mark S Greenup
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, December 21, 2007, 124 hours before
- Departed: 9S9, Lexington, OR
- Destination: 5S9, Estacada, OR
- Flight plan: Unknown
- Airport: 5S9, Valley View Airport, runway 34, 3,780 × 32 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 54; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review July 25, 2008; seat: left; toxicology performed; flight hours: 191 total, 43 in the last 90 days, 1 in the last 30 days

## Weather

- Conditions: Visual (VMC), Night
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 52 °F, dew point 46 °F
- Altimeter: 30.20 inHg
- Observed at: TTD, 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 (OpenAirDocs).

- [Accident 20081029850099A](https://openairdocs.org/incident/20081029850099A), Oct 29, 2008: Cessna P206, Estacada, OR, Destroyed, 2 fatal. (-23) The pilot departed lexington, OR enroute to Estacada, OR (5S9). Pilot called the Estacada airport manager on cell phone and asked him to turn the runway…

## Docket (21 files)

The files NTSB released with the investigation on July 2, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69371. 31.6 MB in all.

- GPS 17 - Factual Report of Group Chairman (item 1, .PDF, 964 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40310151&FileExtension=.PDF&FileName=GPS%2017%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF
- Medical Records Information (item 2, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312403&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF
- Witness Statements (item 3, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314227&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF
- Record of Conversation - Pilot's Daughter (item 4, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314228&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot%27s%20Daughter-Master.PDF
- Aircraft Maintenance Logbook Entries (item 5, .PDF, 449 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314229&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Logbook%20Entries-Redacted.PDF
- Airport Information (Courtesy of Airnav.Com) (item 6, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314230&FileExtension=.PDF&FileName=Airport%20Information%20(Courtesy%20of%20Airnav.Com)-Master.PDF
- Reports from Parties to the Investigation - Teledyne Continental Motors (item 7, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314231&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Teledyne%20Continental%20Motors-Redacted.PDF
- Zeftronics Report (item 8, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314232&FileExtension=.PDF&FileName=Zeftronics%20Report-Master.PDF
- Reports from Parties to the Investigation - Cessna Aircraft Company (item 9, .PDF, 726 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314243&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Cessna%20Aircraft%20Company-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314233&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314234&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Toxicological Report (item 12, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315633&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF
- Photo 1: View of the main wreckage. (item 13, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314244&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20the%20main%20wreckage.-Master.PDF
- Photo 2: View of the alternator. (item 14, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314245&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20the%20alternator.-Master.PDF
- Photo 3: Side view of the alternator. (item 15, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314246&FileExtension=.PDF&FileName=Photo%203%3A%20Side%20view%20of%20the%20alternator.-Master.PDF
- Photo 4: View of the alternator ground terminal and filter. (item 16, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314247&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20the%20alternator%20ground%20terminal%20and%20filter.-Master.PDF
- Photo 5: View of the alternator controller circuit board. (item 17, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314248&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20the%20alternator%20controller%20circuit%20board.-Master.PDF
- Photo 6: View of the alternator. (item 18, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314249&FileExtension=.PDF&FileName=Photo%206%3A%20View%20of%20the%20alternator.-Master.PDF
- Photo 7: View of the top side of the alternator filter. (item 19, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314251&FileExtension=.PDF&FileName=Photo%207%3A%20View%20of%20the%20top%20side%20of%20the%20alternator%20filter.-Master.PDF
- Photo 8: View of the bottom side of the alternator filter. (item 20, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314252&FileExtension=.PDF&FileName=Photo%208%3A%20View%20of%20the%20bottom%20side%20of%20the%20alternator%20filter.-Master.PDF
- Photo 9: View of the alternator ground terminal. (item 21, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314253&FileExtension=.PDF&FileName=Photo%209%3A%20View%20of%20the%20alternator%20ground%20terminal.-Master.PDF

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.

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