# NTSB WPR19FA250: Cessna 210, N94262, Henefer, UT, September 4, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 4, 2019, 15:21 local (21:21 UTC) - Place: Henefer, UT - Coordinates: 41.015277, -111.58083 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.0153&lon=-111.5808&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Textron Aviation, Federal Aviation Administration, Continental Aerospace Technologies - NTSB case key (mKey): 100196 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA250 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100196/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100196 - Page: https://openairdocs.org/ntsb/WPR19FA250 ## Probable cause The pilots’ decision to enter a canyon at low altitude, which resulted in controlled flight into terrain while attempting to exit the canyon. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Ability to respond/compensate; cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=2073448), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 210L, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073448), [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 210L, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2073448), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=2073448), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Cessna 210L, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2073448), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The two commercial pilots were conducting a familiarization aerial pipeline flight for one of the pilots, who was newly hired by the operator. Data from an onboard GPS unit indicated that the airplane was completing a 180° turn in a canyon. The last recorded data showed the airplane at a GPS altitude about 5,998 ft; company tracking data showed the airplane about .7 mile closer to the accident site at an altitude of 6,208 ft mean sea level. Postaccident examination of the airframe and engine revealed no evidence of pre-impact mechanical malfunctions or failures that would have precluded normal operation. No significant weather or turbulence was reported or forecast in the area, and the density altitude at the time of the accident exceeded 9,700 ft. Based on the available information, it is likely that the pilots maneuvered the airplane into a canyon at low altitude and were attempting to perform a climbing turn to exit the canyon when the airplane impacted terrain. ## Factual narrative The high-wing airplane was built in 1975. It was powered by a 375-horsepower Continental IO-520-L reciprocating engine driving a three-bladed, composite, constant-speed propeller. According to information provided by the operator, the airplane’s most recent annual inspection was completed on January 2, 2019. A 500-hour company inspection was completed on August 26, 2019. At the time of this inspection, the airplane had accumulated a total of 13,727.6 hours of operation. On September 4, 2019, about 1521 mountain daylight time, a Cessna 210L airplane, N94262, was substantially damaged when it was involved in an accident near Henefer, Utah. The two commercial pilots were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. The operator reported that the pilot was giving a pipeline patrol orientation flight to a new-hire pilot. According to the operator, the pilot was familiar with the area of the accident site and had routinely flown there to conduct aerial pipeline inspections. When the pilots did not return as planned, a Federal Aviation Administration (FAA) Alert Notice (ALNOT) was issued, and the wreckage was located the following morning in a mountain canyon about 5 miles west of Henefer, Utah. Company-provided flight tracking data (Spidertracks) indicated that the airplane departed from Evanston-Utica County Airport (EVW), Evanston, Wyoming, about 1455 and proceeded roughly southwest, flying much of the flight over a valley at or near the altitude of surrounding terrain. The airplane turned west, then southeast into a canyon. At 1521, the last recorded data point indicated that the altitude was 6,208 ft mean sea level (msl), the direction of flight was 122°, and the airspeed was 126 mph. An onboard GPS unit also contained data from the accident flight, which closely matched the Spidertracks data; however, the GPS data showed a 135° left turn near the end of the data that was not recorded by Spidertracks. The last recorded GPS point was at 1521:14, and showed the airplane at 5,998 ft msl, at a ground speed of about 120 mph. The last recorded Spidertracks data point was about 0.7 mile southeast of the last recorded GPS point. Tracking data revealed that the airplane flew below the company minimum altitude of 500 ft above ground level (agl) during the pipeline patrol portion of the flight, several times to altitudes as low as about 300 ft agl. During the last portion of the flight, the airplane was at or above the minimum altitude of 500 ft agl specified in the company’s operations manual. The Utah Department of Health Office of the Medical Examiner, Taylorsville, Utah, conducted autopsies on the pilots. The medical examiner determined that the cause of deaths were blunt force injuries. The FAA's Forensic Sciences Laboratory performed toxicological testing on the pilots. For the pilot, testing was negative for carbon monoxide and volatiles and tested for drugs, except forphentermine. Phentermine is prescription anti-obesity medication used for a limited period to speed weight loss in overweight individuals who are exercising and eating a low-calorie diet. Potential adverse side effects include heart palpitations, elevated blood pressure, and restlessness. This medication may be misused for performance enhancement and relief of fatigue and has abuse potential. Phentermine is in a class of medications called anorectics, and its use by pilots is not recommended. Testing for the recently hired pilot was negative for carbon monoxide, volatiles, and tested-for drugs except for a small amount of ethanol in cavity blood and urine, but not vitreous, consistent with post-mortem production. At 1448, the weather observation facility at Hill Air Force Base, Utah, located about 20 miles west northwest of the accident site, reported wind from 310° at 4 knots, 10 statute miles visibility, few clouds at 8,000 ft, temperature 32ºC, dew point 5ºC, and an altimeter setting of 30.12 inches of mercury. No significant weather or mountain wave conditions were reported or forecast in the accident area, and no AIRMETS, SIGMETS, or CWAs were valid in the area at the time of the accident. The surface wind speed was estimated to be about 10 to 15 knots. Given the atmospheric conditions on the day of the accident, the density altitude at the accident location was calculated to be about 9,778 ft. The pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. The pilot was issued an FAA first-class airman medical certificate on June 19, 2019, with a limitation for corrective lenses. On the application for that medical certificate, the pilot reported 1,404 total hours of flight experience and 562 hours in the previous six months. The pilot’s logbook was not located during the investigation. The new-hire pilot held a commercial pilot certificate with airplane single-engine land and instrument ratings. The pilot was issued a FAA second-class airman medical certificate on November 1, 2018, with no limitations, at which time he reported 350 total hours of flight experience and 100 hours in the previous six months. All major structural components of the airplane were located at the accident site. The site was located on a canyon hillside at an elevation about 6,553 ft msl, about 150 ft below the top of a ridgeline and surrounded by mountainous terrain. The initial impact point, identified by a large area of disturbed terrain, was located about 30 ft before the main wreckage. The disturbance measured about 22 ft long by 9 ft wide. Small fragments of the airplane and propeller blade tips were found at the initial impact point. The fuselage came to rest upright on a magnetic heading of about 345°. The flaps and landing gear were retracted. Some residual fuel was observed in the fuel tanks and a strong odor of fuel was present. The airplane’s bank indicator showed the airplanein about a 35° left bank. The three-bladed propeller had separated from the crankshaft and was located about 10 ft from the main wreckage with all blade tips observed separated. One blade was loose at the hub. Chordwise scratches and gouges were observed. The two remaining blades were bent forward about 6 inches from the tip and exhibited light scratching. The airframe and engine were examined at a nearby facility. Continuity of the flight controls was established. The crankshaft was rotated by hand and rotational continuity was established throughout the engine and valve train to all cylinders. A borescope inspection of the cylinders revealed normal operating signatures. The examination revealed no evidence of pre-impact mechanical anomalies or malfunctions that would have precluded normal operation. ## Aircraft - Registration: [N94262](https://openairdocs.org/deregistered/N94262-2021-04-05), registration cancelled 2021-04-05, S/N 21060568, built 1974 (OpenAirDocs) - Reported make and model: Cessna 210 (L) - Registry model: [Cessna 210L](https://openairdocs.org/model/cessna-210l) (registry code 2073448) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21060568 - Year built: 1974 - Airframe hours: 13727.6 - Engines: Continental IO 520 SERIES 375 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Hawker Helicopters LLC - Registered owner: Scott John D - Airworthiness certificate: Standard, Normal - Last inspection: Unknown, August 26, 2019 - Departed: EVW, Evanston, WY - Equipment: Satellite tracking device, Onboard weather, Handheld GPS, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review September 25, 2019; seat: right; toxicology performed; flight hours: 1,404 total - Pilot; age 32; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2; last flight review November 21, 2018; seat: left; toxicology performed; flight hours: 350 total ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 41 °F - Altimeter: 30.12 inHg - Observed at: KHIF, 19 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 20190904012479A](https://openairdocs.org/incident/20190904012479A), Sep 4, 2019: Cessna 210L, Henefer, UT, Destroyed, 2 fatal. Aircraft was flying pipeline observation when it appears that the aircraft flew into a box canyon. The aircraft impacted the ground at a high velocity just… ## Docket (20 files) The files NTSB released with the investigation on June 17, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100196. 35.8 MB in all. - GPS specialist's factual report (item 1, PDF, 5 pages, 4 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12271246&FileExtension=pdf&FileName=WPR19FA250_GPS_Factual_final_final-Rel.pdf - GPS factual - attachment 1 (accident tracklog data) (item 2, CSV, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12185980&FileExtension=csv&FileName=WPR19FA250_Acc_Flt_MDT-Rel.csv - Onboard image recorder specialist's factual report (item 3, PDF, 3 pages, 2 photos, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12186552&FileExtension=pdf&FileName=WPR19FA250%20Onboard%20Image%20Recorder%20Factual%20-%20final-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 4, PDF, 11 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12375776&FileExtension=pdf&FileName=NTSB%20Form%206120_1_Redacted-Rel.pdf - Weather information (item 5, PDF, 1 page, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12375432&FileExtension=pdf&FileName=WPR19FA250%20WX_Redacted-Rel.pdf - Weather information attachment (item 6, GIF, 19.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12376326&FileExtension=gif&FileName=animation_2001to2201utcVISSAT_CODNEXLAB-GOES-East-subregional-Cen_Rockies-02-22_01Z-20190904_map-id_-25-1n-10-100-Rel.gif - Weather sounding image (item 7, PDF, 1 page, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12376010&FileExtension=pdf&FileName=0000utcSLCsoundingimage-Rel.pdf - Record of conversations (item 8, PDF, 2 pages, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12375796&FileExtension=pdf&FileName=WPR19FA250%20Record%20of%20Conversation-Rel.pdf - Record of conversation (co-owner) (item 9, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12381430&FileExtension=pdf&FileName=Record%20of%20Conversation%20-%20Co%20Owner-Rel.pdf - Accident site summary (item 10, PDF, 6 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12381118&FileExtension=pdf&FileName=WPR19FA250%20On%20Site%20Examination-Rel.pdf - Accident pictures (item 11, PDF, 2 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12463687&FileExtension=pdf&FileName=WPR19FA250%20Accident%20Pictures-Rel.pdf - Airframe and engine examination report (item 12, PDF, 6 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12381741&FileExtension=pdf&FileName=WPR19F250%20Airframe%20and%20Engine%20Examination-Rel.pdf - Record of email (item 13, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12376394&FileExtension=pdf&FileName=WPR19FA250%20Record%20of%20Email-Rel.pdf - Record of email 2 (item 14, PDF, 1 page, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12463732&FileExtension=pdf&FileName=WPR19FA250%20Record%20of%20Email%202-Rel.pdf - N94262 afternoon flight track (operator provided) (item 15, PDF, 1 page, 538 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12385981&FileExtension=pdf&FileName=N94262%20Afternoon%20Track-Rel.pdf - Statement of party representatives to NTSB investigation (item 16, PDF, 2 pages, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12375106&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - FAA certificate of waiver or authorization (item 17, PDF, 7 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12375442&FileExtension=pdf&FileName=Low%20Altitude%20Waiver%202019-2021_Redacted-Rel.pdf - Operator flight track information (item 18, PDF, 1 page, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12381165&FileExtension=pdf&FileName=Hawkeye%20Documentation_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12373241&FileExtension=pdf&FileName=Wrecakge%20Release%20Form_Redacted-Rel.pdf - Toxicological report (item 20, PDF, 2 pages, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12379827&FileExtension=pdf&FileName=Toxicology%20Test%20Pilot_Redacted-Rel.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.