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Fri, Apr 21, 2017

NTSB Releases Probable Cause Report From Cessna 310 Accident In Colorado

Says Pilot Was Acting Erratically During Fuel Stop Prior To Accident Which Fatally Injured Four

The NTSB has released its probable cause report from an accident which occurred on September 5, 2015 which resulted in the fatal injury of the pilot and three passengers on board the Cessna 310, and the board found many inconsistencies with the pilot/owner's claimed experience.

According to the report, the airplane impacted mountainous terrain near Silverton, CO. The private pilot, a pilot-rated passenger, and two passengers were fatally injured. The airplane was destroyed by impact forces. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations Part 91 a personal flight. Instrument meteorological conditions (IMC) prevailed at the time of the accident, and no flight plan had been filed. The pilot was not using air traffic control (ATC) services. 

The flight departed from Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, about 1150 and was destined for Tradewind Airport (TDW), Amarillo, Texas. A fuel receipt from the Big Bear City Airport (L35), Big Bear, California, showed that 20.04 gallons of fuel was purchased for the airplane on September 4, 2015.

The airplane owner, who was a noninstrument-rated private pilot and did not hold a multiengine airplane rating, was conducting a visual flight rules (VFR), personal cross-country flight in the multiengine airplane. Before the accident flight, the pilot flew the airplane to an intermediate airport to refuel. A review of air traffic control (ATC) radio transmissions between the pilot and an air traffic controller between 0911 and 0938 showed that, during the approach for landing, the pilot misidentified in every transmission the make and model airplane he was flying, referring to his airplane as a Piper Comanche instead of a Cessna 310. Further, he did not provide correct responses to the controller's instructions (for example, he reported he was set up for the left base leg instead of right base leg as instructed), and he provided inaccurate information about the airplane's position, including its distance and direction from the airport. A witness stated that, after the airplane landed and while it was taxiing, it almost hit another airplane and golf carts, and it was taxied close enough to the fuel pumps that it "knocked" a ladder with one of its propellers. The witness said that the pilot was not "observant about his surroundings." While at the intermediate airport, the pilot requested an abbreviated weather briefing for a VFR flight from that airport to the destination airport. However, the pilot incorrectly identified the destination airport as "L51," which was depicted on the VFR sectional chart for the Amarillo area but referred to the maximum runway length available at the destination airport not the airport itself. L51 was an airport identifier assigned to an airport in another state and located north of the accident location and in a direction consistent with the airplane's direction of travel at the time of the accident.

During the departure for the accident flight, the pilot taxied to and attempted to take off from an active runway without any radio communications with or clearance from ATC, which resulted in a runway incursion of an air carrier flight on final approach for landing to the runway. The air carrier initiated a missed approach and landed without further incident. The controller reported that the runway incursion was due to the accident pilot's loss of "situational awareness." Radar data showed that, after the airplane departed, it turned northward and away from a course to the intended destination airport. The northward turn and track was consistent with a course to an airport in another state. According to meteorological information, as the flight progressed northward, it likely encountered instrument meteorological conditions (IMC) while flying into rain showers. The wreckage was found in rising mountainous terrain, and the accident wreckage distribution was consistent with a low-angle, high-speed impact. Given that postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation, it is likely that the noninstrument-rated pilot did not see the rising mountainous terrain given the IMC and flew directly into it.

The pilot had told person(s) that he flew F-4 Phantoms, but a military identification card showed that the pilot was a retired Marine lance corporal. Although the pilot's logbook showed that he had accumulated 150 hours of multiengine airplane flight time, there was no record of the actual flights showing the accumulation of 150 multiengine airplane hours or any record that he had flown military aircraft. The logbook did not show that the pilot had received any flight training in the accident airplane. The logbooks also showed that he had flown numerous flights in the airplane with passengers without proper certification and that he had not had a recent flight review as required by Federal Aviation Regulations (FARs). The pilot's logbook showed that he had once made low-altitude (10 ft above the ground) passes over a parade in the same airplane. The airplane had not received an annual inspection for continued airworthiness as required by FARs. The pilot's noncompliance with FARs and the logbook entries indicate that he had a history of poor decision-making and piloting errors, which was reflected in his behavior and actions while landing at the intermediate airport and during the taxi and takeoff phases of the accident flight.

Although the pilot had a number of medical problems that potentially could have interfered with his ability to safely operate the airplane, including spinal cord injuries, diabetes, and psychiatric issues, and was taking medications to treat them, these conditions and medications likely would not have interfered with his navigational skills and his ability to communicate on the radio or affected his decision-making. Although the available medical information was limited by the degree of damage to the body, there was no evidence of a medical condition or effects of a medication that contributed to this accident. Although ethanol was detected in the pilot's tissues, it likely resulted from postmortem production.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The noninstrument-rated pilot's improper judgment and his failure to maintain situational awareness, which resulted in the flight's encounter with instrument meteorological conditions and controlled flight into terrain during cruise flight.

(Source: NTSB. Images included in NTSB report)

FMI: Report


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