NTSB Factual Report

HISTORY OF FLIGHT

On January 31, 2014, about 1317 central standard time, a Cessna 210E, N4957U, was destroyed when it impacted terrain during a fire detection flight near Oden, Arkansas. The commercial pilot, the sole occupant, received fatal injuries. The airplane was registered to and operated by the Arkansas Forestry Commission (AFC) as a public-use aircraft. Marginal visual meteorological conditions prevailed in the area near the accident site at the time of the accident. The pilot filed a company visual flight rules flight plan. The airplane departed from the Malvern Municipal Airport (M78), Malvern, Arkansas, at 1240, on a local fire detection flight.

The pilot originally scheduled for the flight needed to cancel due to sickness. The accident pilot was contacted on the morning of the accident and was asked if he wanted to take the flight. He agreed to take the flight, and he arrived at the airport at 1200 to check weather and preflight the airplane.

The pilot departed M78 at 1240 to conduct a fire detection flight of Fire District 2 (D-2) using a predetermined flight route. The pilot reported his flight progress to the dispatch center which provided flight following. The pilot reported entering the eastern boundary of the forest district at 1253. At 1258, he reported checkpoint 2, which is located at Mt. Ida, Arkansas. The pilot turned north toward checkpoint 1, located 32 nm to the north at Danville, Arkansas. At 1303, the pilot reported to the dispatch center that he was 20 nm from checkpoint 1 and he was turning back due to low ceilings. At 1311, the pilot reported that he was 3 nm west of Oden, Arkansas, which is about 16 nm southwest of his last reported position on a magnetic bearing of 244 degrees. There were no further radio transmissions from the pilot. The accident site was located about 13 nm from the last reported position near Oden, Arkansas, on a magnetic bearing of 171 degrees.

There were no witnesses to the accident. When the pilot did not check in with the dispatch center after 30 minutes from his last communication, the dispatch center attempted to contact the pilot. At 1431, the Federal Aviation Administration's (FAA) Flight Service Station was contacted about the overdue airplane and the Air Force Rescue Coordination Center was notified. Ground and aerial searches were made for the missing airplane, but weather conditions over the next 11 days hampered the search effort. The airplane wreckage was located on February 11, 2014.

PERSONNEL INFORMATION

The 33 year-old pilot held a commercial certificate with single-engine land, multi-engine land, and airplane instrument ratings. He was also a certificated flight instructor with single-engine land, multi-engine land, and airplane instrument ratings. The pilot's flight logbook was not obtained during the investigation. On his application for his FAA medical examination on October 30, 2013, the pilot reported that his total flight time was 2,800 hours. The number of flight hours in the make and model of the accident airplane was not determined. He held a first class medical certificate.

The AFC aviation manager reported that the pilot was hired as a full time pilot in 2005 and flew for five years until he took another position with the North Little Rock Police Department. The AFC aviation manager estimated that the pilot flew between 200 to 300 hours a year while working full time. He started flying part time for the AFC in 2013. The pilot was checked out in all of the airplanes that were operated by the AFC and was considered as a very experienced fire surveillance pilot. The AFC did not keep flight records on any of their pilots, so it could not be determined how much flight time the pilot had accumulated, or how much flight time he had flown in the various airplanes operated by the AFC.

The pilot held an instrument airplane rating; however, it was not determined if he was current in his instrument flying. The AFC did not track pilots' instrument currency since fire surveillance flights required that the flight remain in visual flight rule (VFR) conditions only.

AIRCRAFT INFORMATION

The airplane was a single-engine Cessna 210E that was manufactured in 1965. The airplane seated six and had a maximum gross weight of 3,097 lbs. The engine was a 285-horsepower Continental IO-520-A5 engine equipped with a McCauley propeller. The last annual maintenance inspection was conducted on December 18, 2013. The total airframe time at the time of the inspection was 2,870 hours, and the total engine time was 1010.3 hours with 87.3 hours since the last "top" overhaul.

The airplane was equipped to fly in instrument meteorological conditions; however, the AFC fire surveillance missions required that the flights remain in visual meteorological conditions. Therefore, the airplane was not maintained to fly in instrument conditions and was limited to VFR conditions only.

METEOROLOGICAL INFORMATION

The National Weather Service Surface Analysis Chart depicted a frontal boundary that stretched from northern Texas northeastward across northwestern Arkansas and into southern Indiana. A surface low pressure center was located in central Oklahoma. A surface high pressure center was located in eastern Alabama. The accident site was located in a favorable area for clouds given the proximity of the frontal boundary and low pressure center as both of these features could act as lifting mechanisms.

There is no aviation weather reporting station located at M78. The 1153 surface weather observation at the Hot Springs Memorial Field Airport (HOT), Hot Springs, Arkansas, located 35 nm miles on a 082 degrees magnetic bearing from the accident site, at an elevation of 540 feet, was wind 150 degrees at 4 knots; 10 miles visibility; overcast 1,500 feet; temperature 10 degrees Celsius (C); dew point 5 degrees C; altimeter 29.97 inches of mercury.

The 1253 surface weather observation at HOT was wind 180 degrees at 3 knots; 10 miles visibility; overcast 1,700 feet; temperature 12 degrees C; dew point 6 degrees C; altimeter 29.93 inches of mercury.

The 1153 surface weather observation at the Bearce Airport (7M3), Mount Ida, Arkansas, located 15 nm on a 041 degrees magnetic bearing from the accident site, at an elevation of 644 feet, was wind variable at 3 knots; 10 miles visibility; overcast 1,100 feet; temperature 9 degrees C; dew point 6 degrees C; altimeter 29.92 inches of mercury.

The 1253 surface weather observation at 7M3 was 10 miles visibility; overcast 1,200 feet; temperature 10 degrees C; dew point 7 degrees C; altimeter 29.89 inches of mercury.

The 1155 surface weather observation at the Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas, located 21 nm on a 292 degrees magnetic bearing from the accident site, at an elevation of 1,080 feet, was wind light and variable; 7 miles visibility; overcast 500 feet; temperature 11 degrees C; dew point 10 degrees C; altimeter 29.92 inches of mercury.

The 1315 surface weather observation at MEZ was wind 170 degrees at 3 knots; 7 miles visibility; overcast 700 feet; temperature 12 degrees C; dew point 11 degrees C; altimeter 29.89 inches of mercury.

The National Transportation Safety Board weather specialist reported that the sounding wind profile indicated a surface wind from 120 degrees at 2 kts that increased to 27 kts by 2,000 feet above mean seal level (msl) with the wind from the southwest. Given the rapid increase in wind speed with height between the surface and 2,000 feet, low-level wind shear (LLWS) and clear air turbulence would be expected. The wind above 2,000 feet remained out of the southwest to west while increasing in speed to 65 knots by 15,000 feet. Satellite data indicated areas with visible wave clouds oriented east to west near the accident site at the time of the accident. LLWS and clear air turbulence would most likely be concentrated in the areas of the wave clouds.

The AFC aviation manager indicated that the pilot routinely called 1-800-WX-BRIEF for his weather. There is no record that the pilot called 1-800-WX-BRIEF or received information from DUAT/DUATs on the day of the accident. In addition, the AFC indicated that their pilots will occasionally check weather conditions on the WeatherTAP website. The recorded data from the website indicated which WeatherTAP products were viewed by individuals at the AFC before, during, and after the accident time. However, there is no way to know which individuals reviewed the WeatherTAP products during that timeframe, because all the individuals use the same login information for the WeatherTAP products. All of the WeatherTAP products listed were regional or state scale satellite and radar images. The AFC did not use flight risk assessment forms prior to each flight. There is no record of the accident pilot receiving or looking at weather information before the flight.

Two AFC pilots were conducting fire surveillance flights around the time when the accident occurred. One of the pilots departed M78 about 1310 and flew a fire detection flight in north central Arkansas, which is north and west of Little Rock, Arkansas. He reported that the weather was overcast with 5 to 15 mile visibilities. He noted that he observed wave clouds running approximately east to west as he flew to the north. He estimated that the base of the wave clouds were about 2,400 above mean sea level.

The second pilot reported that he departed M78 about 1327 and flew the fire detection route in central Arkansas. At 1520, the dispatch center notified him that they had lost contact with N4957U, and asked him to fly to the last known position. He flew to the Mt. Ida, Pencil Bluff, and Oden areas. He estimated that the cloud ceilings in that area were about 2,000 feet above mean sea level with no restrictions to visibility.

WRECKAGE AND IMPACT INFORMATION

The airplane initially hit the tops of trees near the top of the ridgeline, which had an elevation of 1,473 feet, located in a remote forest with steep, rugged terrain. The outboard 8 foot section of the left wing separated from the airplane with fracture surfaces consistent with overload, and was found near the top of the ridgeline.

The main wreckage was located 0.3 mile south of the ridgeline at an elevation of 686 feet on a 175 degree magnetic bearing. The airplane's engine and propeller, right wing, the remaining section of the left wing, fuselage, and empennage were all located at the main wreckage site which was found on the side of another wooded ridge. A ground fire had consumed much of the nose compartment, instrument panel, cockpit, and cabin. The wings and empennage exhibited aft crushing and buckling which was consistent with a steep, nose down impact with terrain. Control cable continuity was established for the rudder and elevator control surfaces. The aileron control cable was attached at the cockpit yoke and aileron attach points, and all the cable separations were consistent with overload failures. The engine was shipped to the engine manufacturer for a teardown examination.

The propeller remained attached to the engine, but one of the propeller hub sockets was fractured and the propeller blade, blade retention nut, steel blade ferrule, and bearing assembly were not recovered. The fracture surface of propeller hub was consistent with overload. The examination of the recovered propeller blade revealed that it exhibited blade bending and twisting. The leading edge of the blade had gouges and notches along with chordwise scarring of the blade surface.

MEDICAL AND PATHOLOGICAL INFORMATION

The autopsy of the pilot was conducted on February 13, 2014, at the Arkansas State Crime Laboratory in Little Rock, Arkansas. The "cause of death" was noted as "multiple injuries" as a result of an aviation accident. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. The results were negative for ethanol, and the tests for carbon monoxide and cyanide were not performed. The toxicological report indicated that nortriptyline was detected in the liver.

Nortriptyline is a medication used to treat depression and chronic pain marketed as Pamelor. It carries the warning "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). According to the FAA medical certification file, the pilot had chronic knee pain treated with acetaminophen and unspecified non-steroidal anti-inflammatory drugs.

The FAA designated aviation medical examiner (AME) determined the knee pain did not impair the ability of the pilot to safely operate an airplane and issued a medical certificate without limitations. Personal medical records revealed the pilot had chronic knee pain that was treated with tramadol, meloxicam, and an increasing dose of nortriptyline. The autopsy was limited due to extensive injuries but found no evidence of natural disease.

TESTS AND RESEARCH

The engine was examined at Continental Motors on May 6, 2014, under the oversight of the National Transportation Safety Board. The examination of the engine revealed that the engine crankcase and cylinders were intact, but exhibited thermal damage consistent with the ground fire. The power section of the engine, which included the crankshaft, camshaft, connecting rods, and pistons, was intact with no indication of internal heat distress or preexisting mechanical damage. The spark plugs exhibited normal wear signatures. The engine accessories exhibited impact and thermal damage consistent with ground impact and ground fire.

NTSB Probable Cause

The pilot’s improper decision to fly into an area with reported marginal meteorological conditions in an airplane not maintained for instrument flight and his subsequent failure to maintain clearance from trees and terrain.