NTSB Factual Report

HISTORY OF FLIGHT

On April 27, 2014, about 1606 Pacific daylight time, a Cessna 210E, N4962U, and a Hawker Sea Fury TMK 20, N20SF, collided in flight near Richmond, California. Sanders Aircraft, Inc., was operating both airplanes under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The private pilot in the Cessna sustained fatal injuries; the commercial pilot and one passenger in the Sea Fury were not injured. The Cessna was destroyed during the accident sequence, and the Sea Fury sustained substantial damage to the empennage. Both cross-country personal flights departed Half Moon Bay, California; the Sea Fury departed about 1530, and the Cessna departed about 1538. Both airplanes were en route to Eagle's Nest Airport, Ione, California. Visual meteorological conditions prevailed, and no flight plans had been filed.

The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) interviewed the Sea Fury pilot, and the operator submitted a Pilot/Operator accident report, NTSB form 6120.1. The Sea Fury pilot and the Cessna pilot had flown their airplanes to Half Moon Bay to display them at an open house for the airport. The two pilots briefed the flight home, and determined their route of flight. The Sea Fury departed, flew overhead the airport, and rendezvoused with a Beechcraft A36 Bonanza for a photo shoot over the Golden Gate Bridge in San Francisco, California. They flew several 360-degree patterns over the bridge, and the pilot observed the Cessna during one of his turns, and noted that it was on the briefed course. He completed the photo work, and set his course for the return to Ione.

The Sea Fury pilot made radio contact with the Cessna pilot on a common, previously briefed frequency, and the Cessna pilot responded with his position. The Sea Fury pilot made visual contact with the Cessna, which was forward and to the left of his position, and the Cessna pilot responded that he had visual contact of the Sea Fury. The operator reported that the Cessna's airspeed was approximately 150 knots, and the airplane was under 3,000 feet msl. The Sea Fury's airspeed was approximately 200 knots, and the airplane was under 3,000 feet msl. The Sea Fury pilot stated that he would pass the Cessna low and to the left.

Approaching from well behind, the Sea Fury pilot advised the Cessna pilot that the Sea Fury was low and to the left. The Cessna pilot acknowledged visual contact again, and broadcasted that he wanted to take a picture. The Sea Fury pilot replied that there would probably not be time due to the speed differential. The Sea Fury pilot observed the trajectory and flight profile of the Cessna abruptly change to a left roll so that he could see the top of the Cessna's wing. The Sea Fury pilot attempted to evade by pitching his airplane nose down; however, he felt and heard a thump, and realized that the two airplanes had collided. He pulled up and looked over his shoulder; he observed the Cessna inverted and going down. He squawked code 7700 on the transponder, and due to communications issues, reported the mid-air and position of the Cessna to air traffic control via relay by another aircraft.

The Sea Fury pilot concentrated on flying his airplane. He initiated a climb, and conducted a controllability check; he determined that he could control the airplane in the current configuration. He wanted to avoid populated areas, so he continued toward his home airport. He contacted company personnel, who decided to fly another company airplane to meet him, and examine the Sea Fury's condition. The Sea Fury pilot lowered the landing gear, and did a controllability check, which included turns. He lowered the flaps, and repeated the testing. He reduced airspeed to a landing compatible speed of 130 mph, and checked controllability again; he determined that he had adequate control to land. He had to abort the first landing attempt at his home airport due to emergency equipment on the runway; he made a full stop landing on runway 19 on the second attempt.

PERSONNEL INFORMATION

Cessna 210 Pilot

The operator reported that the 33-year-old pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot held a third-class medical certificate that was issued on February 28, 2012, with no limitations or waivers. The pilot also had an airframe and powerplant mechanic's certificate.

The operator reported that the pilot had a total flight time of 285 hours. He logged 6 hours in the last 90 days, and 2 in the previous 30 days. He had an estimated 37 hours in this make and model. He completed a flight review on July 26, 2012.

Sea Fury Pilot

The 52-year-old pilot reported that he held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. He held a second-class medical certificate issued on April 16, 2014, with the limitation that he must have reading glasses. He had an airframe and powerplant mechanic's certificate.

The operator reported a total flight experience of 5,646 hours, and a total of 143 flight hours in the accident airplane make and model. He completed a flight review on October 1, 2012.

AIRCRAFT INFORMATION

Cessna 210E

The airplane had a high wing with a single-engine; it was serial number 21058662. The operator reported that the airplane had a total airframe time of 6,384 hours at the most recent annual inspection dated September 10, 2013.

The engine was a Continental Motors Inc. (CMI) IO-520A, serial number 112377R. The operator reported that the time since major overhaul was 468 hours.

Sea Fury

The airplane had a low wing with a single engine; it was serial number ES9505. The operator reported that the airplane had a total airframe time of 6,378 hours at the most recent annual inspection dated August 1, 2013.

The engine was a Pratt & Witney R4360, serial number PS15867A. The operator reported that the time since major overhaul was 85.2 hours.

METEOROLOGICAL INFORMATION

An aviation routine weather report (METAR) for Oakland (KOAK), California, (elevation 9 feet, 11 nautical miles (nm) southeast of the accident site) was issued at 1553 PDT. It stated: wind from 260 degrees at 15 knots; visibility 10 miles; few clouds at 1,700 feet; temperature 17/63 degrees C/F; dew point 8/46 degrees C/F; altimeter 30.09 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Detailed reports on follow-up examinations of both airplanes are part of the public docket for this accident, and can be accessed by the Accident Docket link on the ntsb.gov home page.

Cessna 210

The Cessna 210 came to rest in about 10 feet of water in San Pablo Bay near Richmond, and the wreckage was retrieved on April 30. The recovered wreckage consisted of the fuselage and the engine. Neither wing was recovered. The propeller separated from the crankshaft, and was not located.

Sea Fury

The Sea Fury landed at its home base.

The Sea Fury was silver with dark blue and red accents. The Cessna had blue wingtips; it also had blue paint on the leading edge of both wings, on top of the cowling, and along the sides of the fuselage.

The IIC and an inspector from the Federal Aviation Administration examined the Sea Fury. The top remaining portion of the vertical stabilizer was crushed aft and down with blue paint transfer marks on the aft portion of the remaining metal. The operator reported that the missing vertical stabilizer section was about 12 inches long. The rudder had crush damage. The right elevator separated outboard of the middle hinge; about 2 feet of the elevator was missing. About 3 feet of the outboard section of the right horizontal stabilizer was missing. The outboard fracture surface was jagged and angular, and the upper surface had crushed inboard in an accordion fashion. Investigators observed blue paint transfer marks and scratches on the upper skin surface and within the folds of the metal. The scratches were a few degrees (outboard to inboard) from alignment with the longitudinal axis of the airframe.

The bottom of the right horizontal stabilizer had two slash cuts that were similar in shape to a propeller blade; the cuts were almost perpendicular to the chord line. The marks were 10 inches apart from trailing edge to trailing edge, and 4 inches wide near their end point (tip). The metal was pushed up into the horizontal stabilizer cavity, and had black paint transfer on the metal surfaces. The forward cut was through both the bottom and top skins, and the edges of the cut in the top skin were curled up.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted by Contra Costa County Office of the Sheriff- Coroner. The cause of death was reported as multiple blunt force injuries.

Toxicological tests on specimens recovered from the Cessna 210 pilot were performed by the FAA Civil Aerospace Medical Institute Forensic Toxicology Research Team. Analysis of the specimens for the pilot contained no findings for volatiles or tested drugs. They did not perform tests for carbon monoxide or cyanide.

TESTS AND RESEARCH

Investigators examined the recovered wreckage of the Cessna 210 at Plain Parts, Sacramento, California, on May 6, 2014. A full report is contained within the public docket for this accident, and is accessible via the Accident Docket link on the ntsb.gov home page.

Airframe

Only the inboard portion of the left wing spar was recovered, and continuity could not be established for the ailerons. Continuity was established for the elevators and rudder.

The airframe manufacturer's investigator determined that the landing gear was in the up position. The flap actuator was not recovered; the indicator was full down, but the handle was in a neutral position. The investigator determined that the elevator trim was in the neutral position.

Engine

The engine separated during the accident sequence. The front and left side of the engine sustained the most damage; cylinder number six's front fins were crushed aft, the exhaust valve spring was missing, the exhaust valve was bent aft, and the associated portion of the rocker shaft was missing. The fracture surface on the remaining portion of rocker shaft was jagged and angular. The intake push rod for cylinder number five was severely bent.

The crankshaft was manually rotated with a drive bar on the propeller mounting bolts. The crankshaft rotated with some resistance; and the valves for cylinders one, two, three, and four moved approximately the same amount of lift. The gears in the accessory case turned freely. Thumb compression was obtained on cylinders one, two, three, and four.

The spark plug electrodes corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. Several plugs were caked with mud.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

The propeller flange was bent adjacent to the serial number, and the crankshaft cracked aft of the flange on the opposite side.

The gascolator screen was clean; there was some contamination in the bowl, and white, bubbly discoloration was evident. The engine driven fuel pump drive gear was undamaged, and the pump rotated freely. The throttle body screen was clean. The mixture shaft rotated freely from stop to stop; the throttle shaft rotated freely. The metering unit of the throttle body separated; but it was located in the wreckage, and remained attached to the mixture control cable. The manifold valve was not recovered.

The oil pump had light scoring on the internal walls; no deformation was observed on the gears.

ADDITIONAL INFORMATION

Cessna 210 GPS Data Extraction

A Garmin GPSMAP 496 battery powered portable unit was recovered from the wreckage. The unit sustained crush and water damage, but the NTSB Recorders Laboratory used forensic equipment to successfully extract data from the nonvolatile memory chip. A complete report is part of the public docket for this accident. The IIC converted all times to PDT. The Garmin GPSMAP 496 was WAAS enabled, which can increase the accuracy of the GPS data by using ground stations to correct the signal; however, the recorded data lacked information regarding satellite signal quality and ground station utilization, therefore the accuracy of the data could not be validated.

The accident event was identified from the recording date and with the airplane on the ground at Half Moon Bay at a starting time of 1538:34. The last couple of minutes of data points indicated a northeasterly track at GPS derived groundspeeds around 150 knots. At 1558:14, the airplane began to descend with varied groundspeeds, and the final data point at 1558:22 was 212 knots at 854 feet.

Radar Track

A review of recorded data was completed, and plotted on a Google Earth map display. The radar data and plots of two tracks with a secondary beacon code of 1200 (visual flight rules) are in the public docket for this accident. The target for one track switched to code 7700.

All altitudes are the transponder mode C reported altitudes. FAA Advisory Circular AC 43-6C discusses altitude reporting equipment and transponder system maintenance and inspection practices. Paragraph 9.c. (2) states that an altimeter should display an altitude within 20 feet of a calibrated reference altimeter set to 29.92 inches of mercury. Paragraph 9.d states that the altitude reporting equipment associated with a radar beacon transponder should transmit data within 125 feet of the indicated datum of the altimeter normally used to maintain flight altitude.

At 1556:39, a target (arbitrarily identified in this report as target 1) was in the middle of San Raphael Bay and left of Red Rock Island at 1,800 feet; it maintained 1,800 feet until 1557.21. The target maintained 1,900 feet from 1557:25 until 1558:02. Another target (arbitrarily identified in this report as target 2) was south of Red Rock Island, and heading to the right side of San Raphael Bay at 1,500 feet. At 1557:11, target 2 was to the right side of San Raphael Bay and right of Red Rock Island at 1,300 feet.

At 1557:39, target 2 was maintaining 1,300 feet, and approaching the path of target 1. Target 2 appeared to cross the path of target 1 at 1557:44 at 1,300 feet and south of The Brothers Island off Point San Pablo. It appeared to be left of target 1's path at 1557:48 at 1,400 feet.

The targets began to merge; at 1557:53, there were targets at 1,900 and 1,400 feet. At 1557:58, there were targets at 1,900 and 1,500 feet. A target at 1558:02 was at 1,900 feet; a target at 1558:07 was at 1,700 feet; and a target at 1558:11 was at 1,800 feet. A target at 1558:16 was at 2,000 feet, this target appeared to descend to 1,800 feet as it continued northeast bound, and changed to a secondary beacon code of 7700.

NTSB Probable Cause

Both pilots’ failure to maintain adequate clearance from each other during cruise flight while in visual contact with each other. Contributing to the accident was the unexpected abrupt maneuver made by the pilot.