# NTSB WPR12FA098: Cessna 210, N9619T, Morgan, UT, February 9, 2012

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: February 9, 2012, 13:48 local (20:48 UTC)
- Place: Morgan, UT
- Coordinates: 41.182498, -111.583053
- Nearby events: https://openairdocs.org/map.md?lat=41.1825&lon=-111.5831&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report April 10, 2013
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Cessna Aircraft Company, Federal Aviation Administration
- NTSB case key (mKey): 82861
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12FA098
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82861/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82861
- Page: https://openairdocs.org/ntsb/WPR12FA098

## Probable cause

The non-instrument-rated pilot’s poor planning and continued visual flight rules flight into instrument meteorological conditions and failure to maintain clearance from mountainous terrain.

## Findings

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

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 210, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073402), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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 210, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2073402), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md)
- [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Not specified; cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=2073402), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md)
- [Ceiling/visibility/precip: obscuration](https://openairdocs.org/ntsb-findings/03035030): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/03035030/cases.md?model=2073402), [All aircraft, 45 cases](https://openairdocs.org/ntsb-findings/03035030/cases.md)

## Sequence of events

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

- [Enroute: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 210, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2073402), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md)

## Analysis

During a volunteer flight to pick up a passenger, the non-instrument-rated pilot had to divert to an alternate airport due to low ceilings at his destination. After picking up the passenger and departing, the pilot requested and received a flight-following clearance. Shortly thereafter, he reported that he was going to turn the airplane out of a valley. There was no further communication from the pilot after this transmission. The last radar target depicted the airplane at an elevation of 7,100 feet. The wreckage was located 3.5 miles from the last radar target in treed, mountainous terrain at an elevation of 7,700 feet. A postaccident examination of the wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Weather information current at the time of the flight reported mountain obscuration and precipitation. Review of weather briefing data showed no record of the pilot obtaining a weather briefing prior to departure. Given the forecast and reported weather conditions, it is likely that the pilot encountered instrument meteorological conditions and was unable to see the trees and terrain prior to the collision.

## Factual narrative

HISTORY OF FLIGHT On February 9, 2012, about 1348 mountain standard time, N9619T, a Cessna 210, collided with mountainous terrain about 9 miles east-northeast of Morgan County Airport, Morgan, Utah. The private pilot and passenger sustained fatal injuries during the 14 Code of Federal Regulations Part 91 flight. The airplane was substantially damaged. The flight originated from Morgan and was destined for Converse County Airport, Douglas, Wyoming. The pilot requested and received a flight following clearance. The pilot was conducting a mission for the Wyoming Pilots for Christ. He was volunteering his services to transport the passenger, a nurse, from the Salt Lake City area back to her home. According to Wyoming Pilots for Christ personnel, the pilot had departed Douglas about 1000 MST and intended to land at Salt Lake City International Airport, Salt Lake City, Utah. However, the pilot landed in Morgan due to low ceilings in the area. The passenger then met him at the Morgan airport. PERSONNEL INFORMATION The pilot, age 47, held a private pilot certificate with airplane and single-engine land ratings. He held a third-class medical certificate issued September 27, 2011, with no limitations or waivers. The pilot’s logbook was reviewed and showed about 553 total flight hours. He had flown about 18 hours in the last 90 days and 10 hours in the last 30 days. AIRCRAFT INFORMATION The high wing airplane, SN 57419, had four seats and retractable gear. It was manufactured in 1961. It was powered by a Continental IO-470-E (17) engine. Review of the maintenance records showed an annual inspection was completed on February 10, 2011, at a total time of 3,465 hours. The airplane was equipped with a Garmin 430. AIR TRAFFIC CONTROL INFORMATION An NTSB air traffic control specialist reviewed the air traffic control information pertaining to the flight, as well as the pilot’s flight earlier that day from Sheridan, Wyoming, to Morgan, Utah. Review of the radar track of the pilot’s inbound flight from Sheridan showed radar targets along the mountain range to the east of the pilot’s landing airport. The radar targets showed several course reversals along the mountain range. The track then ended prior to the pilot’s landing in Morgan, likely due to limited radar coverage in the area. Upon departure from Morgan, the pilot requested and received a flight following clearance at 1346 MST, and advised that his destination was Douglas. Shortly thereafter, the pilot reported that he was going to turn the airplane out of a valley. There was no further communication from the pilot. The last radar target was at 1448 at an altitude of 7,100 feet, approximately 3.5 statute miles from the accident site. METEOROLOGICAL INFORMATION An NTSB senior meteorologist completed a weather study. A composite of the NWS Weather Depiction Charts for 1200 (1900Z) and 1500 MST (2200Z) on February 9, 2012, depicted a small area of reported instrument flight rule (IFR) conditions over Idahoimmediately north of the accident site at 1200 MST by a shaded contour, with another area over Colorado to the east-southeast. The areas were enclosed by a larger area of marginal visual flight rule (MVFR) conditions by an unshaded contour which extended over northern Utah and the accident site. At 1355, an aviation routine weather report (METAR) for Hill Air Force Base, located about 17 nautical miles west-southwest of the accident site, reported the following conditions: wind, calm, visibility, 7 statute miles, clouds, few at 2,700 feet, overcast at 3,200 feet, temperature, 3 degrees Centigrade, dew point, 0 degrees Centigrade, altimeter, 30.33 inches of mercury. The subsequent observations indicated a ceiling overcast from 2,100 to 2,600 feet agl or from 6,900 to 7,400 feet msl assuming normal rounding to a hundred feet, and with a period of visibility reduced to 5 miles in mist. The cloud heights would have implied a high likelihood of mountain obscuration conditions over the accident site. At the accident airplanes altitude of 7,700 feet the sounding indicated a temperature of -3º C, a temperature-dew point temperature spread of less than 1 degree C, a relative humidity of 98 percent, and a wind from 275 degrees at 9 knots. The sounding did not indicate a high probability of turbulence due to the light winds and low vertical shear. A probability of icing existed in clouds and in precipitation above 6,000 feet. The GOES-15 infrared band 4 satellite image at 4X magnification for 1415 MST (2215Z) on February 9, 2012, depicted multiple layers of low to mid-level clouds over Utah during the period. No defined cumulonimbus clouds or thunderstorms were identified over the area. The infrared image indicated a radiative cloud top temperature over the accident site at 260 degrees kelvin or -13.16 degrees C, which corresponded to tops near 14,500 feet over the accident site. The GOES-15 visible band 1 image at 1415 MST (2115Z) depicted low stratiform clouds over the area with a second mid-level band of altostratus bordering on the accident site. The image indicates a high probability of mountain obscuration with the low stratiform type clouds over the region. The forecast for northern Utah indicated scattered to broken clouds at 10,000 feet layered to 17,000 feet were expected over the region. The forecast however was amended by AIRMET Sierra update 6 for mountain obscuration due to clouds and precipitation issued at the same period. Review of weather briefing data from Lockheed Martin Flight Service, CSC DUATS, and DTC DUATS, showed no record of the pilot obtaining a weather briefing. WRECKAGE AND IMPACT INFORMATION Initial responders reported that the airplane impacted a northwest-facing, treed slope, at an elevation of approximately 7,700 feet mean sea level. The debris field was approximately 75 feet in length and on a general heading of west-northwest. MEDICAL AND PATHOLOGICAL INFORMATION The Utah Office of the Medical Examiner performed anautopsy on the pilot on February 11, 2012. The manner of death was reported as an accident due to injuries as a result of the accident. The FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, completed forensic toxicology on specimens from the pilot. The report was negative for volatiles, cyanide, and tested drugs. The report stated 10 percent carbon monoxide was detected in the blood. Cotinine and nicotine were also detected. TESTS AND RESEARCH An NTSB investigator, the FAA accident coordinator, and a representative from Cessna Aircraft Company examined the wreckage. Examination of the recovered airframe revealed that it was separated into numerous pieces. The right wing was separated from the fuselage and exhibited crushing damage along the entire span of the leading edge. The right wing lift strut remained attached to the forward spar and a fragmented portion of the fuselage frame. The right flap was in the retracted position. The flap actuator measured 0.15 inches which equated to a retracted position. The aileron remained attached to its respective hinge points. Aileron control cable continuity was established to the wing root. The separations of the control cables at the wing root were consistent with cuts made by recovery personnel. The fuel bladder was fragmented. The fuel cap was secure; however the structure surrounding the fuel cap was separated from the wing. The left wing was separated from the fuselage. The left wing lift strut was separated from the wing and fuselage. The aileron was separated from the wing structure. The flap assembly remained attached to the inboard portion of the left wing. The fuel bladder was fractured. The fuel cap remained attached to the upper wing surface and was in place. The outboard portion of the left wing was not recovered (recovery personnel reported it was in a 70-foot tall tree). The aft portion of the fuselage was separated from the forward portion of the fuselage. The vertical stabilizer and rudder remained attached to their respective mounts. The inboard sections of the horizontal stabilizers remained attached. The elevators were separated from their mounts. The right elevator was fragmented and the trim tab was separated. The elevator trim actuator was fragmented which prevented measurement of the actuator. Flight control cable continuity was established from the elevator and rudder control horns forward to the cuts made by recovery personnel. Control cable continuity was established from the cockpit controls to the area of cuts made by wreckage recovery personnel. Continuity for aileron controls was obtained throughout the aileron control chain to the left and right wing root. The seats and seat tracks were fragmented and separated from the fuselage. The pilot side seat engagement pin was found engaged to a separated portion of seat track. The airspeed indicator was found separated and the airspeed needle was observed stuck at 180 knots. The altimeter setting wasobserved at 30.22. Both doors were separated from the fuselage. The pitot-static system was fragmented. The unobstructed pitot tube was intact and separated from the wing structure. Examination of the Teledyne Continental Motors (TCM) IO-470-E (17) engine, serial number 088778-R, revealed that all six cylinders remained attached to the engine crankcase. All engine accessories remained attached to the engine with the exception of the starter, which was separated from its mount. The exhaust, propeller, and oil filler cap were separated. The oil sump was crushed upwards. The top spark plugs, rocker arm covers, fuel pump, oil pump, left and right magnetos, and throttle body fuel control were removed. The engine crankshaft was rotated by hand using a hand tool attached to an accessory mount pad. Rotational continuity was established throughout the engine and valve train. Thumb compression and suction was obtained on all six cylinders. Both magnetos produced sparks at all posts when manually rotated. The top spark plugs were examined and found to be consistent with worn out normal when compared to the Champion Check-A-Plug comparison card. Light gray coloring was noted within the electrode areas. Examination of the fuel system revealed no contamination or anomalies. The vacuum pump drive shaft rotated freely by hand. The vacuum pump was disassembled and the rotor and vanes were intact and undamaged. The propeller was separated from the engine crankshaft propeller flange. Both propeller blades exhibited aft bending and blade twisting and remained attached to the propeller hub. Both propeller blades exhibited multi directional scratching on the forward face of the blade. No evidence of pre-impact mechanical malfunction was noted during the examination of the recovered wreckage. ORGANIZATIONAL AND MANAGEMENT INFORMATION According to the Pilots for Christ website, “Pilots for Christ International, Inc. is a membership organization that posts public requests, for consideration by our member pilot's and non-pilot's regarding volunteer urgent travel opportunities. The decision to accept and provide travel assistance, by yourself is an individual matter between yourself and the person(s), requesting travel. Pilots for Christ International, Inc. offers communication, (contact, urgency of request and indemnity waiver) assistance, only, between the requester and yourself as a pilot or non-pilot. You must always abide by all Federal, State and local legal requirements for operating your aircraft, and/or automobile. The requirement to meet these licensed operating regulations is strictly your responsibility, and is not the responsibility of Pilots for Christ International, Inc. As a pilot or non-pilot you are not required to be a commercial or professional individual and you are not required to meet the same standards. You are a private individual volunteering your aircraft, and/or automobile and time to help all those in need of urgent transportation, within thescope of your licensed abilities.” ADDITIONAL INFORMATION The Aircraft Owners and Pilots Association has an online course designed to assist volunteer pilots. The course “Public Benefit Flying: Balancing Safety and Compassion”, can be found at www.airsafetyinstitute.org/volunteerpilots.

## Aircraft

- Registration: [N9619T](https://openairdocs.org/deregistered/N9619T-2014-11-24), registration cancelled 2014-11-24, S/N 57419, built 1961 (OpenAirDocs)
- Reported make and model: CESSNA 210
- Registry model: [Cessna 210](https://openairdocs.org/model/cessna-210) (registry code 2073402) (OpenAirDocs)
- Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 57419
- Airframe hours: 3465
- Engines: Continental Motors IO-470-E 260 horsepower reciprocating
- Damage: Substantial damage
- Flight: Other work use, Part 91
- Registered owner: Madewell Inc
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, February 10, 2011, 142 hours before
- Departed: 42U, Morgan, UT
- Destination: DGW, Douglas, WY

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 47; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review June 28, 2010; seat: left; toxicology performed; flight hours: 553 total, 538 in this make and model, 473 as pilot in command, 18 in the last 90 days, 10 in the last 30 days, 2 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Day
- Wind: calm
- Visibility: 7 statute miles
- Lowest ceiling: 3,200 ft overcast
- Temperature: 37 °F, dew point 32 °F
- Altimeter: 30.32 inHg
- Observed at: HIF, 18 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 20120209001749A](https://openairdocs.org/incident/20120209001749A), Feb 9, 2012: Cessna 210, Mountain Green, UT, Substantial damage, 2 fatal. The aircraft left Douglas, Wyoming converse county airport (dgw) on February 9, 2012 at approximately 1000 Mountain standard time (MST) for salt lake city,…

## Other investigations on N9619T (1)

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.

- [NTSB WPR09CA059](https://openairdocs.org/ntsb/WPR09CA059), Dec 17, 2008: Cessna 210 (N9619T), Sheridan, WY, substantial damage. Probable cause: Maintenance personnel's failure to reinstall the left front pilot's seat correctly, which resulted in the pilot's loss of control and subsequent impact with a taxiway sign.

## Docket (24 files)

The files NTSB released with the investigation on February 13, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82861. 53.5 MB in all.

- Meteorology 5 - Weather Study (item 1, .PDF, 406 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40365301&FileExtension=.PDF&FileName=Meteorology%205%20-%20Weather%20Study-Master.PDF
- Weather Briefing Information (item 2, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40387280&FileExtension=.PDF&FileName=Weather%20Briefing%20Information-Redacted.PDF
- Record of Conversation - Pilots for Christ (item 3, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377853&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilots%20for%20Christ-Master.PDF
- ATC Plot Inbound/Outbound Flight (item 4, .PDF, 219 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383948&FileExtension=.PDF&FileName=ATC%20Plot%20Inbound%2FOutbound%20Flight-Master.PDF
- Radar Plot (item 5, .PDF, 601 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383964&FileExtension=.PDF&FileName=Radar%20Plot-Master.PDF
- Pilot Logbook Excerpt (item 6, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40387059&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpt-Redacted.PDF
- Pilots for Christ Webpage Excerpt (item 7, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384913&FileExtension=.PDF&FileName=Pilots%20for%20Christ%20Webpage%20Excerpt-Master.PDF
- Wreckage Examination Report (item 8, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379533&FileExtension=.PDF&FileName=Wreckage%20Examination%20Report-Master.PDF
- Statement of Party Representatives to NTSB Investigation- Cessna (item 9, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377856&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-%20Cessna-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation- Continental Motors (item 10, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384473&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-%20Continental%20Motors-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40387282&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Toxicological Report (item 12, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377852&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF
- Photo 1. Aerial View of Accident Site (Provided by Police) (item 13, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384015&FileExtension=.PDF&FileName=Photo%201.%20Aerial%20View%20of%20Accident%20Site%20(Provided%20by%20Police)-Master.PDF
- Photo 2. Aerial View 2 of Accident Site (Provided by Police) (item 14, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384016&FileExtension=.PDF&FileName=Photo%202.%20Aerial%20View%202%20of%20Accident%20Site%20(Provided%20by%20Police)-Master.PDF
- Photo 3. Area of Accident Site (Provided by Police) (item 15, .PDF, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384450&FileExtension=.PDF&FileName=Photo%203.%20Area%20of%20Accident%20Site%20(Provided%20by%20Police)-Master.PDF
- Photo 4. On Site Photo (Provided by Recovery Company) (item 16, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384451&FileExtension=.PDF&FileName=Photo%204.%20On%20Site%20Photo%20(Provided%20by%20Recovery%20Company)-Master.PDF
- Photo 5. On Site Photo 2 (Provided by Recovery Company) (item 17, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384452&FileExtension=.PDF&FileName=Photo%205.%20On%20Site%20Photo%202%20(Provided%20by%20Recovery%20Company)-Master.PDF
- Photo 6. On Site Photo 3 (Provided by Recovery Company) (item 18, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384453&FileExtension=.PDF&FileName=Photo%206.%20On%20Site%20Photo%203%20(Provided%20by%20Recovery%20Company)-Master.PDF
- Photo 7. Wreckage Exam (item 19, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384455&FileExtension=.PDF&FileName=Photo%207.%20Wreckage%20Exam-Master.PDF
- Photo 8. Vacuum Pump (item 20, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384456&FileExtension=.PDF&FileName=Photo%208.%20Vacuum%20Pump-Master.PDF
- Photo 9. Engine Examination (item 21, .PDF, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384457&FileExtension=.PDF&FileName=Photo%209.%20Engine%20Examination-Master.PDF
- Photo 10. Engine Examination 2 (item 22, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384461&FileExtension=.PDF&FileName=Photo%2010.%20Engine%20Examination%202-Master.PDF
- Photo 11. Propeller (item 23, .PDF, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384470&FileExtension=.PDF&FileName=Photo%2011.%20Propeller-Master.PDF
- Video File 1 - ATC Video (item 24, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384010&FileExtension=.PDF&FileName=Video%20File%201%20-%20ATC%20Video-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.

---
OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.