WPR11FA430

NTSB accident investigation · Cessna P210 · Tehachapi, CA · September 4, 2011

Accident · FatalField investigationFinal report
Date
September 4, 2011, 11:25 local (18:25 UTC)
Place
Tehachapi, CA
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N7WJCessna P210
Defining event
Maneuvering: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed · report May 22, 2014
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Cessna Aircraft Company, Continental Motors, Inc., Federal Aviation Administration FSDO
FAA report
20110904020219A
Case key
81706

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 pilot’s intentional low-altitude maneuvering and failure to maintain clearance from terrain due to distraction.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Incorrect use/operationCessna P210N: 8 casesAll aircraft: 1,310 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna P210N: 2 casesAll aircraft: 329 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot's friend, who was also a pilot, observed the airplane flying around his home. He noted that the landing gear and flaps were partially down and that he saw the pilot wave his hand out his window. Shortly after, the airplane turned west, and the landing gear began to retract. The friend returned to his previous activities, and, within seconds, he heard a "whump" followed by silence. He moved to a better vantage point and observed smoke in the direction of his last observation of the airplane. A pilot-rated witness at the local airport reported that he was familiar with the surrounding area and noticed that the airplane was flying low and that it then started flying up a valley between two ridgelines, disappeared from his sight behind the nearest one, and, about 20 seconds later, he saw smoke. The airplane collided with trees, and it was destroyed in a postcrash fire. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failure that would have precluded normal operation. The autopsy found no evidence of a recent or acute coronary event or the presence of medications that would have affected the pilot's performance. Further, the witness statements did not suggest acute incapacitation or sudden severe impairment, and evidence suggests the pilot was manipulating the controls just before impact. Thus, it is likely that the pilot was distracted with waving to his friend on the ground and failed to maintain sufficient altitude while maneuvering at low altitude.

Factual narrative

The airplane was a Cessna P210, serial number P21000374. Logbooks were not recovered for the airframe or engine. An insurance application dated November 10, 2010, indicated a tachometer time of 509.0 hours and a Hobbs meter time of 592.2 hours. The oil filter on the airplane had markings dated April 23, 2011, that indicated a tachometer time of 2,411.1 hours and a Hobbs meter time of 1,936.4 hours. The engine was a Continental Motors, Inc. (CMI) TSIO-520-P(5), serial number 278637-R. On September 4, 2011, at 1125 Pacific daylight time, a Cessna P210N, N7WJ, collided with trees near Tehachapi, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The pilot and one passenger sustained fatal injuries; the airplane was destroyed from impact forces and a post-crash fire. The local personal flight departed Cable Airport, Upland, California, at 1023. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot called a friend who had a home near Tehachapi, and indicated that he would fly over the home later that morning on a pleasure flight. A witness at the Mountain Valley Airport in Tehachapi possessed commercial pilot certificates for airplane single-engine and multiengine land, as well as an instrument rating. He was working on a glider rating at Mountain Valley and was familiar with the surrounding area. He noticed an airplane approaching the airport from the southeast on a northwesterly heading. The airplane was low over the wind turbines in the area, and after clearing the ridge line that they were on, began a 360-degree turn in a 45- to 60-degree angle of bank. He noticed that two landing gear were down, and from his vantage point thought that the airplane had a tail wheel. The airplane descended a couple of hundred feet during the turn. He noted that it was below the tree line at that point, and it continued the turn to a southwesterly heading. It started up a valley between two ridgelines and disappeared from his sight behind the nearest one. He stated that he had encountered downdrafts in that area on occasion, and didn't think that this was an area where one should fly low. He estimated that the airplane flew about 500 yards out of his sight; about 20 seconds after it disappeared, he saw white, then gray, then black smoke. The pilot's friend, who is also a pilot, observed the airplane slowly flying around his home, and stated that he recognized it as his friend's airplane. He noted that the landing gear and partial flaps were down, and he observed a hand wave out the pilot's window. Shortly thereafter, the airplane turned to the west, and the gear began to retract. He returned to his previous activities, and within seconds heard a "whump" followed by silence. He moved to a better vantage point and observed smoke in the direction of his last observation of the airplane. A postmortem examination was conducted by the Kern County Coroner; thecause of death was multiple blunt force injuries. The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. The analysis contained no finding for ethanol in urine; they did not perform tests for carbon monoxide or cyanide. The report contained the following findings for tested drugs: Tamsulosin detected in Liver; Terazosin detected in urine, and Terazosin detected in Liver. An automated surface weather observation at Tehachapi Municipal Airport (KTSP (elevation 4,001 feet msl) was issued at 1115 PDT. It indicated wind from 140 degrees at 15 knots gusting to 20 knots, 10 miles or greater visibility, clear sky, temperature at 23 degrees C, dew point 09 degrees C, and an altimeter setting at 30.10 inches of mercury. A review of Federal Aviation Administration (FAA) airman records revealed that the 72-year-old pilot held a private pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. He held a third-class medical certificate issued in July 6, 2010, with the limitation that he must wear corrective lenses for near and distant vision. No personal flight records were located for the pilot. The IIC obtained the aeronautical experience listed in this report from an insurance application dated November 10, 2010. The pilot reported a total time of 2,218 hours with 1,422 hours in the make and model. Investigators from the NTSB, FAA, Cessna, and Continental Motors, Inc. (CMI), examined the wreckage at Aircraft Recovery Service, Littlerock, California, on September 7, 2011. A detailed report is part of the public docket for this accident. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The elevator trim actuator was extended 1.7 inches, which equated to 5 degrees tab up. The elevator trim cable was continuous from the tail to the chain in the cabin. The flap actuator measured 4.7 inches; which indicated that 4.4 inches is the retracted position. The National Transportation Safety Board investigator-in-charge (IIC), an FAA inspector, and investigators from Cessna and CMI examined the wreckage at the accident site. The coordinates of the main wreckage were 35 degrees 04.08 minutes north latitude and 118 degrees 26.007 minutes west longitude. The debris path was along a magnetic heading of 215 degrees. The airplane came to rest upright on a northerly heading; the engine was inverted, and pointing about 90 degrees clockwise from the main wreckage. The first identified point of contact (FIPC) was broken limbs near the top of a 20-foot tree. At the base of the tree were broken limbs and the red and white left wing tip fairing containing a red navigation lens. About 10 feet further into the debris path was a second tree with upper branches broken; near the base of this tree was the outboard rib and about 2 feet of skin from the left wing.Another 10 feet into the debris path was another tree with topped branches. The debris path was about 200 feet long from the FIPC to the main wreckage, and some separated pieces were about 120 feet from the debris path centerline. The next point of contact was the principle impact crater (PIC), which began about 20 feet before the final resting place of the main wreckage. Fire consumed the majority of the airframe skin and structure. Investigators identified remnants of all flight controls and airframe structure.

Aircraft

Registration
N7WJ
Reported as
Cessna P210 (N)
Category
Airplane
Serial number
P21000374
Built
1979
Engine
Continental Motors TSIO-520, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Walter L Johnson Trustee
Registered owner
Walter L Johnson Trustee
Airworthiness certificate
Standard, Normal
Last inspection
April 23, 2011
Departed
CCB · Upland, CA
Destination
CCB · Upland, CA
Flight plan
Unknown
Equipment
Stall warning system, Auto-pilot

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
72
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
November 10, 2012
Seat
Left
Toxicology
Performed
Flight hours
2,248 total · 1,422 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 15 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 48 °F
Altimeter
30.10 inHg
Observed at
KTSP

Docket · 10

The files NTSB released with the investigation on May 15, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.5 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.