NTSB Factual Report

HISTORY OF FLIGHT

On September 5, 2015, about 1408 mountain daylight time a Cessna 310H, N1099Q, impacted mountainous terrain near Silverton, Colorado. 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 pilot's daughter stated that the airplane was kept at L35 during the summer and afterward at Barstow-Daggett Airport (DAG), Daggett, California. She said that her father departed from L35 on September 5, 2015, about 0615 PDT, and arrived at DAG about 0630 PDT to pick up the passengers. He was then going to fly to Amarillo, Texas, following Interstate 40, where they were going to have dinner and then return the same day. She said that her father did not call her after he refueled and departed Flagstaff and that she called for help on September 6 because she had not heard from him. She said that there was another pilot aboard and that they had a GPS. She said that her father did not know anyone in Colorado or Montana.

A part-time Unicom operator at L35 said that the pilot talked about conducting the flight about 1 week before the accident. The pilot asked "a lot of different pilots to go along as copilot" and asked him to go on the flight. The Unicom operator did not know what time the pilot departed on September 5, but "it was pretty early in the morning" when the pilot left to pick up passengers. The Unicom operator stated that the pilot purchased the airplane "not too long ago," that the airplane radios were "very old," and that the "instruments were not all that good."

The pilot's initial contact with an air traffic control (ATC) facility on the day of the accident occurred during a visual approach to FLG. A rerecording of provided radio transmissions between the pilot and an FLG air traffic controller between 1011 and 1038 follows:

N1099Q: "Flagstaff traffic this is Piper Comanche N1099Z I'm sorry quebec we're approximately thirty miles miles west of the field anybody know what how the weather is down there you socked in there cause we are flying over the top here."

FLG tower: "Comanche 1099Q flagstaff tower we are open. The uh the ATIS is also broadcasting we're 900 broken, 1,600 broken, 2,400 overcast, visibility 10."

N1099Q: "Oh thank you I just turned the ATIS then. I appreciate it thank you Flagstaff."

N1099Q: "Flagstaff tower 1099Q about to land we are we are approximately 10 miles west of the airport."

FLG tower: "Comanche uh 99Q flagstaff tower the uh we're IFR at the airport 900 broken 1600 broken visibility 10."

1099Q: "We are now approximately 8,000 feet we have visibility looks like greater than 10 miles."

FLG tower: "Comanche 99Q I concur with the visibility uh are you requesting something special."

FLG tower: "Comanche 99Q the field is now VFR the uh ceiling is well I have a scattered layer of 1,200 ceiling 1,600 report a right base for runway 21."

N1099Q: "Report right base for runway 21 will do quebec."

FLG tower: "Comanche 99Q uh verify you have information charlie."

N1099Q: "Copy that we have we got a little bit of a … here."

FLG tower: "Comanche 99Q roger the wind is 220 at 8 temperature 16 density altitude is 8,400 dew point 13 and the altimeter 30.26."

N1099Q: "30.36 thank you."

FLG tower: "altimeter 30.26 26."

N1099Q: "Flagstaff tower this is quebec were gonna report left base runway 21 I just want to confirm that quebec."

FLG tower: "Comanche 99Q are you set up for a right base or a left base you're coming from the west you said."

N1099Q: "Oh its showing left base on my uh GPS left traffic on runway 21."

FLG tower: "Comanche 99Q uh we can make whichever way you want I just need to know which direction you're coming from."

N1099: "Well we're comin we're we're coming from 270 right now."

FLG tower: "From 270 you should be west of the…airport where was the destination you left from."

N1099Q: "Well we can report let's see the winds are from uh what."

FLG tower: "Comanche 99Q the wind is 240 at 6 just report base."

N1099Q: "Well… we're…right now…"

FLG tower: "Comanche 99Q that came in broken and unreliable."

N1099Q: "The winds are 210."

FLG tower: "Wind 210 at 8."

FLG tower: "Comanche 99Q how far from the airport are you."

N1099Q: "We're downwind 21 left we're settin up for uh base for 21 left."

FLG tower: "Okay we only have runway 21 okay I see you now you are on a left downwind runway 21 cleared to land wind 210 at 8."

FLG tower: "Comanche 99Q runway 21 cleared to land."

N1099Q: "…the end of the runway now…on the downwind we'll make base to final."

FLG tower: "Comanche 99Q runway 21 cleared to land."

N1099Q: "Cleared to land runway 21."

FLG tower: "N99Q are you going to uh wiseman aviation the FBO."

N1099Q: "Yes we want to gas up can we exit."

FLG tower: "N99Q continue on the runway turn right alpha seven self-serve fuel will be towards the base of the rotating beacon if you want the uh FBO it's a green building near the uh rotating beacon."

N1099Q: "Okay I see the rotating beacon I guess we can make a right taxi here."

FLG tower: "N99Q you make right turn alpha seven that will get you more direct."

N1099Q: "Gotcha alpha seven."

N1099Q: "Flagstaff…down and clear of runway taxi to fuel pump."

N1099Q: "Yep."

N1099Q: "Quebec gettin ready to touchdown here runway 21 here flagstaff."

A fixed-base operator (FBO) employee at FLG stated that, during the airplane's taxi to the fuel pumps, the airplane almost hit an "Eclipse jet," and he thought it was going to hit golf carts that were near the FBO building. When the airplane arrived, it taxied close enough to the self-serve fuel pumps that it "knocked" a ladder with one of its propellers. He said that the pilot was not "observant about his surroundings." The airplane had white "house letters" painted on its side similar to those on fighter or Air Force aircraft. The house letters had "pilot" followed by a name, which he could not remember seeing, and "copilot" followed by "God." The airplane "looked clean.". The employee stated that the pilot told him that he hoped there were no more clouds, there was no more weather, and that he wanted 75 gallons of fuel for the airplane. The pilot pointed east and added that it should be 2 more hours to their destination. The employee thought the destination was Amarillo but was certain that it was in Texas.

The FBO employee said he showed the pilot how to use the fuel pump. The pilot gave the fuel order and payed for the fuel with cash. A passenger helped fuel the airplane at the self-serve fuel pump; he added about 15 gallons of fuel to the left and right wing fuel tanks (auxiliary fuel tanks) and put the fuel caps back on. The wing tip fuel tanks (main fuel tanks) were topped off.

The FBO employee stated that another passenger said that he bought a "brand new GPS" and could not get "ADAS[Automated Weather Observing System Data Acquisition System]" to work and thought he also said, "oh well we'll figure it out later."

At 1054, the pilot called Lockheed Martin Flight Services (LMFS) while at FLG and requested an abbreviated weather briefing for a visual flight rules flight from FLG to Amarillo, Texas. The pilot told the weather briefer that the Amarillo, Texas, airport identifier was "L51"; this was not the correct identifier for Tradewind Airport. The correct identifier was TDW; the L51 airport identifier was assigned to Heller Farm Airport, Winifred, Montana. Despite providing the weather briefer with the wrong airport identifier, the briefer did provide information for the flight to Amarillo. The pilot received the latest weather information in the briefing, which included Airmen's Meteorological Information for mountain obscuration, convective outlooks (the briefer mentioned that there was no convective activity yet but told the pilot to stay updated via Flight Watch), the terminal aerodrome forecast for Rick Husband Amarillo International Airport, Amarillo, Texas, the Meteorological Terminal Aviation Routine Weather Report for Tucumcari Municipal Airport, Tucumcari, New Mexico, and the winds aloft at 9,000 and 12,000 ft between the departure and destination airports. No record was found indicating that the accident pilot received or retrieved any other weather information before or during the flight.

The FBO employee at FLG stated that, after the airplane was fueled, it taxied past the FLG ATC tower without making any radio communications with ATC. The airplane taxied onto a runway while an "air shuttle" was landing, and the air shuttle (SkyWest 2992) had to abort its landing. The pilot then turned the radio on and taxied off the runway and onto a taxiway near the air carrier ramp. A FLG airport rescue and firefighting (ARFF) employee drove to the airplane to talk to the pilot. The ARFF personnel told the left front pilot seat occupant that he had to move the airplane because it was blocking an air carrier ramp entrance. The employee said that FLG ATC had a "lengthy conversation" with the pilot after he had taxied the airplane off the runway and was told to call the FLG ATC tower. The employee said that he overheard on the FLG ATC frequency the air shuttle pilot asking about the airplane, and FLG ATC responded by saying it was "a case of situational awareness."

According to an Air Traffic Mandatory Occurrence Report, SkyWest 2992, CRJ2/L, was on the instrument landing system (ILS) runway 21 approach and was cleared to land on runway 21. The accident airplane was observed northbound on taxiway A without authorization from the FLG tower. N1099Q turned right onto the connecting taxiway A2 continuing toward runway 21. At that time, the tower controller issued go-around instructions to SkyWest 2992 on about 1 1/2 mile final and coordinated missed approach instructions with Phoenix Approach. The accident airplane continued onto runway 21 and initiated the takeoff roll and then established communication with the tower. The tower controller instructed the accident pilot to cancel takeoff and exit the runway. SkyWest 2992 was vectored back to the ILS approach course and landed without further incident.

The FLG ATC tower controller stated that, during his telephone conversation with the accident pilot following the runway incursion, the pilot "kind of missed the point," "came up with excuses" for the runway incursion, and did not know there was another airplane "out there" during the runway incursion. The controller stated that, when he told the pilot that there was an airliner on final, and it was at that point that the pilot "realized the gravity of the situation." The pilot then said that he had been flying for 50 years and nothing like this happened before. The controller said it "seemed" that the pilot "really didn't register" what had happened. The controller added that he did not remember having to repeat questions that he asked the pilot. The pilot did not seem upset nor did the pilot ask questions in response to the questions asked by the controller. The controller said that, during the second takeoff attempt, the accident airplane settled onto the runway after it had lifted off and then climbed out with a left turn.

The ARFF employee stated that the accident airplane taxied from the FBO to taxiway A2, held at A2, and then taxied onto an active runway with a commercial regional airplane on short final without any radio contact to ATC. The employee said that the accident pilot transmitted that he did not have the airplane's radio turned on or "something to that effect" and stated that they were going to take off. The employee said that the radio transmissions from the accident pilot were "screwy" and "lacked organization and context, and was not current."The employee said that it seemed like the pilot had spent a lot of time around uncontrolled airports. The employee said that during the airplane's second takeoff attempt, the airplane remained low over runway 21 for a long time and that, about 1,000 ft from the departure end of the runway, the airplane pulled up, "not steep," and entered a left turn to the east and headed northeast.

The flight was not receiving ATC services and was not assigned a transponder squawk code. The airplane used a squawk code of 1200 based upon ATC recordings and the arrival/departure times to and from FLG. The radar track of an airplane with a squawk code correlating to those times was plotted to provide an overview of the flight and is shown in figure 1.

Figure 1. A radar plot of an airplane flight track consistent with the accident airplane. The plot shows a turn toward the north.

PERSONNEL INFORMATION

Pilot/Airplane Owner Information

The pilot, age 71, held a private pilot certificate with a single-engine land airplane rating. The pilot's most recent FAA third-class airman medical certificate was issued December 17, 2013, with the limitation that he must wear corrective lenses for near and distant vision. At that time, the pilot reported a total flight time of 1,000 hours, 200 hours of which were in last 6 months. There was no military record received showing that the pilot had any flight experience in military airplanes.

The pilot's daughter stated that her father flew F-4 Phantoms. An L35 employee reported that he believed that the pilot said he flew F-4 Phantoms in the military and transitioned to helicopters and was injured in Vietnam. A Department of Defense (DOD)/Uniformed Services identification card that belonged to the pilot was recovered from the accident site. The card showed that he served in the US Marine Corps at grade "E3," which according to DOD's Enlisted Rank Insignias was a grade of Lance Corporal.

The L35 employee said the pilot told him the he was a doctor and "had an MD." He stated that he researched the things told to him by the pilot, and none of it was true. He said the pilot had "some speech issues" and that he had a "high pitched garbled voice." He said that pilot could not "keep a fluent conversation" without having an "issue with talking." He said that the pilot's aircraft radio transmissions were "very short," which "concerned" him and L35 staff. He said "there were a lot of circumstances that concerned people about his [the pilot's] flying."

A review of the pilot's FAA airman record revealed that, on July 18, 2009, the pilot failed the practical portion of the examination in his first attempt for a private pilot certificate with a single-engine land airplane rating. Upon reexamination for the certificate/rating, he was to be reexamined on the following: IX. Basic Instrument Maneuvers, V. Performance Maneuver, and VII. Navigation. At the time of the examination, the pilot reported a total time of 301 hours and a total instruction time received of 52 hours. On September 21, 2009, the pilot successfully passed his second attempt and was issued a private pilot certificate with a single-engine land rating. At the time of reexamination, the pilot reported a total time of 305 hours and a total instruction time received of 55 hours. No record was found indicating that the pilot had been issued a multiengine airplane rating or that he had flown military aircraft..

The pilot's logbook, which was recovered from the accident site by first responders, had flight entries beginning July 7, 2007, and ending August 15, 2015. The logbook showed that the pilot's total flight time in single and multiengine airplanes was 801.9 hours, 255.6 hours of which were in single-engine airplanes and 217.7 hours of which were in multiengine airplanes. The first logbook page entry of a multiengine airplane flight time was dated January

NTSB Probable Cause

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.