Accident Details
Probable Cause and Findings
the pilot's in-flight loss of control due to spatial disorientation and a likely accumulation of airframe ice that led to a high speed descent and a structural breakup once the aerodynamic forces exceeded the strength limits of the structure. A factor in the accident was the pilot's lack of experience and training in instrument flight conditions.
Aircraft Information
Registered Owner (Historical)
Analysis
1.1 HISTORY OF FLIGHT
On April 7, 2005, at 0903 Pacific daylight time, a Cessna T210L, N8126L, broke up in flight and impacted terrain near Tranquility, California. The airplane was operated by the private pilot under the provisions of 14 CFR Part 91. The pilot and two passengers were fatally injured; the airplane was destroyed. Instrument meteorological conditions prevailed, and a flight plan had not been filed. The flight originated at Healdsburg Municipal Airport, Healdsburg, California, about 0800, with an intended destination of Scottsdale, Arizona.
The pilot and two passengers were traveling to Scottsdale, on a weekend golf trip, where they were to meet up with other members of their party. The pilot received a weather briefing from Oakland Automated Flight Service at 0554. The airplane departed Healdsburg sometime before 0800. The initial radar track was picked up over the San Pablo Bay in the San Francisco area at 0801:30, at 11,600 feet mean sea level (msl). The track continued on a southeasterly course until over Crows Landing, California, where it made a deviation to the south. After the track passed over the San Luis Reservoir it turned left to regain its original southeasterly course. The track ended at 0902:21 in the vicinity of Tranquility. Radar data revealed that the altitude encoding transponder (mode C) reported a change of altitude of 1,000 feet from 12,400 to 13,400 feet msl between the times of 0848 and 0853. The final track segment depicted the airplane level at 13,400 feet msl and traveling in a southeasterly direction when it turned abruptly to the right. The last radar return was recorded at 0902:14, at a position of 36 degrees 37.22 minutes north latitude by 120 degrees 24.12 minutes west longitude, at an altitude of 12,400 feet msl. No record of radio communication between the pilot and air traffic control (ATC) was located by the Federal Aviation Administration (FAA) for the time period surrounding the accident.
1.5 PERSONNEL INFORMATION
A review of FAA airman records from Oklahoma City, Oklahoma, revealed that the pilot held a private pilot certificate with a single engine land rating that was issued on June 3, 1992. The pilot did not hold an instrument rating. The pilot held a third-class medical certificate that was issued on January 1, 2005. No restrictions or limitations were listed on the medical.
The pilot's flight logbook was recovered from the airplane wreckage. Examination of the logbook revealed that the pilot had accumulated 576.2 hours of single engine flight time. His last recorded flight occurred on March 16, 2005, and consisted of an insurance check ride in a PA-32. The entry made prior to that was dated November 18, 2004, where the pilot recorded a 2.8-hour flight in the accident airplane. The endorsement page of the logbook contained one entry, a flight review signed by a certified flight instructor (CFI) on September 14, 2003.
1.6 AIRCRAFT INFORMATION
The airplane was a Cessna T210L, serial number 21060613, single engine, high wing, 6-place airplane. A review of the airplane's logbooks revealed a total airframe time of 3,415.2 hours at the last inspection. An inspection in accordance with the scope and detail of Appendix D of 14 CFR Part 43 (annual/100-hour inspection) was completed on September 24, 2004.
The airplane was powered by a Teledyne Continental TSIO-520-H4 factory remanufactured engine, serial number 217474-R. An examination of the engine logbook revealed that the engine had been installed into the airplane on August 8, 2003. The engine was inspected in accordance with an annual inspection on September 24, 2004, at a total time since maintenance overhaul (TSMO) of 33.6 hours.
The airplane had a factory installed Nav-O-Matic 400A autopilot, which provides altitude hold, heading hold, and VOR tracking. There were no autopilot discrepancies noted in the maintenance records.
The airframe and power plant (A&P) mechanic who performed the annual inspection stated that the airplane's crew oxygen system had not been inspected during the annual and was not in service.
A fuel receipt with the pilot's name on it was obtained from Healdsburg Aviation, Inc. The date and time on the receipt was April 7, 2007, at 06:56:51. The receipt recorded the total amount of fuel purchased was 58.094 gallons.
The airplane's pilot operating handbook states in the limitation section that flight into known icing conditions is prohibited.
1.7 METEOROLOGICAL INFORMATION
1.7.1 Surface Analysis Chart
The southwest section of the National Weather Service (NWS) Surface Analysis Chart for 0800 depicted a high-pressure system with a central pressure of 1027-millibar (mb) over Colorado. To the north, a low-pressure system with a central pressure of 1001-millibars (mb) was located over the Oregon and Nevada border with a cold front extending from the low south to southwestward into Nevada, central and southern California, and into the Pacific Ocean. The accident site was located in the cold air mass behind the position of the surface cold front.
The station models behind the cold front, over central and southern California, indicated broken to overcast sky conditions.
1.7.2 Surface Observations
The area surrounding the accident site was documented utilizing official NWS meteorological aerodrome reports (METARs) and specials (SPECI). The reports are in standard format, provided in plain language. The variation for wind at Fresno is 15 degrees east, and cloud heights are reported above ground level (agl).
Madera Municipal Airport (KMAE), Madera, California
Madera weather observation at 0853, automated, wind from 300 degrees at 8 knots; visibility 10 miles in light rain; ceiling broken at 3,500 feet, broken at 4,100 feet, overcast at 9,500 feet; temperature 12 degrees Celsius (C); dew point 9 degrees C; altimeter 30.02 inHg. Remarks: automated observation system, rain began at 0849; sea level pressure 1016.3-mb; hourly precipitation less than 0.01-inch (trace); temperature 11.7 degrees C; dew point 8.9 degrees C; thunderstorm sensor not operating.
Lemoore Naval Air Station/Reeves Field (KNLC), Lemoore, California
Lemoore Naval Air Station (KNLC) special weather observation at 0845, wind from 330 degrees at 10 knots; visibility 7 miles in light rain; a few clouds at 6,000 feet; ceiling broken at 14,000 feet, overcast at 20,000 feet; temperature 13 degrees C; dew point 7 degrees C; altimeter 30.00 inHg. Remarks: sea level pressure 1016.0-mb.
Lemoore Naval Air Station (KNLC) weather observation at 0855, wind from 330 degrees at 13 knots; visibility 7 miles in light rain; ceiling broken at 5,000 feet, broken at 14,000 feet, overcast at 20,000 feet; temperature 12 degrees C; dew point 9 degrees C; altimeter 30.01 inHg. Remarks: sea level pressure 1016.2-mb; hourly precipitation less than 0.01-inch (trace); temperature 12.2 degrees C; dew point 8.9 degrees C.
Fresno Yosemite International Airport (KFAT), Fresno, California
Fresno weather observation at 0856, wind from 300 degrees true at 10 knots; wind 280 variable 350 degrees; visibility unrestricted at 10 statute miles; scattered clouds at 8,000 feet; ceiling broken at 14,000 feet, overcast at 18,000 feet; temperature 13 degrees C; dew point temperature 7 degrees C; altimeter 30.01 inHg. Remarks: automated observation system, sea level pressure 1015.9-mb; temperature 13.3 degrees C; dew point 7.2 degrees C.
Merced Municipal Airport/Macready Field (KMCE), Merced, California
Merced Municipal Airport special weather observation at 0830, automated, wind from 330 degrees at 8 knots; visibility 3 miles in light rain and mist; a few clouds at 600 feet; ceiling broken at 2,200 feet, overcast at 3,400 feet; temperature 11 degrees C; dew point 9 degrees C; altimeter 30.02 inHg. Remarks: automated observation system, hourly precipitation 0.06-inch; thunderstorm sensor not operating.
Merced Municipal Airport weather observation at 0853, automated, wind from 010 degrees at 6 knots; visibility 4 miles in light rain and mist; a few clouds at 2,400 feet; ceiling broken at 3,000 feet, overcast at 6,000 feet; temperature 11 degrees C; dew point 9 degrees C; altimeter 30.02 inHg. Remarks: automated observation system, sea level pressure 1016.4-mb; hourly precipitation 0.11 inches; temperature 10.6 degrees C; dew point 8.9 degrees C; thunderstorm sensor not operating.
1.7.3 Satellite Information
The GOES-10 (Geostationary Operational Environmental Satellite) infrared image at 0900 (6X magnification), with a standard MB temperature enhancement curve applied to the image to highlight the higher and colder cloud tops associated with deep convection, depicted an area of enhanced cloud cover associated high and cold cloud tops over California (including the accident site). The radiative cloud top temperature over the upset location was determined to be 228.20 degrees Kelvin (K), or -44.95 degrees C, which corresponded to cloud tops near 30,000 feet.
The GOES-10 visible image for 0900 (2X magnification) continued to depict an extensive area of cloud cover over California and the accident site. The cloud features over the upset location showed signs of vertical development consistent with nimbostratus type clouds.
1.7.4 Weather Radar Information
The closest Weather Surveillance Radar-1988, Doppler (WSR-88D) was located at the NWS San Joaquin Valley Office (KHNX) in Hanford, California, approximately 34 miles east of the accident site. The Level II archive data was obtained from the National Climatic Data Center (NCDC) and displayed on a Hewlett-Packard X-Station utilizing the National Transportation Safety Board McIDAS system.
Composite Reflectivity
The KHNX composite reflectivity image completed at 0904 (2X magnification) with the accident airplane's flight track that was obtained from the FAA National Track Analysis Program (NTAP). The image depicts the accident airplane's track...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX05FA132