NTSB Factual Report

HISTORY OF FLIGHT

On April 28, 1999, about 1323 eastern daylight time, a Cessna 210L, N3458H, registered to a private individual, collided with trees then the ground while descending for a forced landing over a residential area shortly after takeoff from the Vero Beach Municipal Airport, Vero Beach, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was destroyed and the commercial-rated pilot, and three passengers were fatally injured. The flight originated about 3 minutes earlier.

According to a transcription of communications with the Vero Beach Air Traffic Control Tower, at 1314.54, the pilot contacted ground control and requested taxi clearance. The ground controller cleared the pilot to taxi to runway 29L, and while taxiing, the pilot inadvertently taxied onto a runway. The pilot then taxied the airplane off the runway and at 1320.22, the pilot advised the local controller that the flight was ready to depart runway 29L, and requested a left turn out eastbound. The local controller cleared the flight for takeoff with a left downwind departure eastbound; the airplane departed under the provisions of visual flight rules (VFR). The pilot contacted the local controller 5 seconds later using the last 3 of the registration number of the airplane and at 1322.35, the local controller responded and stated "centurian five eight hotel you're not having any kind of problem"; there was no recorded response from the pilot. The local controller later reported that after takeoff, he observed that the airplane was "...not gaining any altitude." At 1322.44, the local controller contacted the airplane and the pilot responded "yeah five eight hotel ah were not getting good power I'm gonna have to come back in." The local controller advised the pilot "ok just continue that left turn to the downwind and ah you're number two follow or you can have runway four if you like it"; again, there was no response from the pilot. At 1323.02, the local controller contacted the airplane and reported "runway four cleared to land if you want the runway four." There was no recorded response from the pilot.

According to the controller who was working the flight data/clearance delivery position, he observed the airplane after takeoff and later reported, "I watched N3458H low level off of the departure end of runway 29L. The aircraft stayed low and turned south and then east and then descended below the trees." According to the controller who was working the ground control position, "I saw N3458H depart runway 29L and climb to approximately 500 feet. The aircraft then began to descend and turn to the south. The aircraft descended below the trees near the approach end of runway 4."

A-pilot rated witness and his wife who were located near the accident site reported seeing the airplane after takeoff. The wife reported seeing the airplane flying "very low" in a nose high attitude. She observed that the propeller was rotating and the airplane continued over a residential area then disappeared from view. The pilot-rated witness reported "We saw a Cessna 210 turning back toward the approach end of runway 4 at Vero Beach. I told my wife that the aircraft would never make it because the tail was so low in 'flight attitude'. We stopped our car and held up traffic in the intersection until we saw the smoke go up...." The airplane collided with trees, then the ground and came to rest upright. A postcrash fire was extinguished by fire rescue.

PERSONNEL INFORMATION

Review of the pilot's third pilot logbook which begins with an entry dated December 18, 1986, and ends with an entry dated March 4, 1999, revealed a carried forward total time of 1,424.8 hours. All logged flights were in the accident make and model airplane; the logbook indicates that he had accumulated a total flight time of 827.3 hours. Additional information pertaining to the pilot is contained on page 3 of the Factual Report-Aviation.

Information pertaining to the passengers is contained in Supplement S.

AIRCRAFT INFORMATION

Review of the aircraft maintenance records revealed that the airplane was inspected last in accordance with an annual inspection that was signed off on April 10, 1999. The throttle cable was replaced during the annual inspection. This was due to a complaint of the pilot that the throttle cable was stiff, which was confirmed by maintenance personnel. The airplane had accumulated 1.6 hours total time since the inspection, as determined by the tachometer.

According to the mechanic who replaced the throttle cable, after installation, he installed the attach hardware but did not immediately install the cotter pin where the throttle control connects to the throttle control arm in the engine compartment. With the assistance of another mechanic who had inspection authorization with the FAA certified repair station, the travel of the throttle was inspected in the engine compartment, while the mechanic who replaced the cable, manipulated the throttle control in the cockpit. The mechanic who assisted by observing the throttle travel in the engine compartment stated that when he saw the rod end assembly on the throttle control arm, a cotter pin was not installed. He reported that he verified full travel and advised the mechanic to safety the bolt and castellated nut assembly, but he did not re-inspect the throttle control rod end assembly to verify that it had been secured with a cotter pin. He signed the final inspection block for that job block. The mechanic who replaced the throttle cable reported that he installed a cotter pin he personally obtained from the parts supply room. He reported using a corrosion resistant steel type cotter pin with the part number MS24665-153. The installation instructions calls for a carbon steel cotter pin part number MS24665-132. Both cotter pins are 1/16 inch in diameter; the difference is length and material.

Review of a document provided by the repair station indicates that during the annual inspection, four MS24665-153 cotter pins were billed to the annual inspection.

The airplane was registered in the pilot's name on July 30, 1979.

METEOROLOGICAL INFORMATION

A weather observation taken at the Vero Beach Municipal Airport at 1329 eastern daylight time, indicated the wind was from 210 degrees at 3 knots, 5 statute miles visibility with light rain, few clouds at 800 feet, broken clouds at 2000 feet, overcast clouds at 10,000 feet, temperature 69.8 degrees F, dew point 67.2 degrees F, and barometric setting of 29.95 inHg.

COMMUNICATIONS

The pilot was in radio contact with the Vero Beach Air Traffic Control Tower (ATCT) and a transcript of communications is an attachment to this report.

WRECKAGE AND IMPACT INFORMATION

The crash site which occurred in a residential area was located at N 27 degrees 38.64 and W 080 degrees 26.12 which is .59 nautical mile from the approach end of runway 04. The approach end of runway 04 is located at N 27 degrees 39.00 and W 080 degrees 25.59. The wreckage path was oriented on a southeasterly heading and distances were measured from the first component on the ground which was determined to be the outboard section of the left aileron. It was found approximately 21 feet to the left of the centerline of the wreckage path and about 9 feet before the first tree contact. The first tree contact was noted about 35 feet above ground level (agl), approximately 30 feet to the left of the wreckage path. Located on the ground 10 feet past and slightly to the right of that tree were the left wingtip and outboard section of the leading edge of the left wing. A second tree contact also to the left of the centerline of the wreckage path was noted 20 feet past the first tree impact. That contact was determined to be located approximately 18 feet agl. Burn damage to the tree bark was noted above the point of contact. Located 23 feet from the second tree contact and approximately 20 feet to the right of the centerline of the wreckage path of the airplane was tree contact in branches. Left wing leading edge skin with an approximate 1 foot segment of the fuel tank was noted on the centerline of the wreckage path about 16 feet past the second tree contact. A ground scar on the centerline of the wreckage path was noted 29 feet past the second tree impact location. Additionally, the left door, left wing fuel tank segment, left inboard flap, and a section of the leading edge of the left wing with an attached pitot tube was located slightly to the left of the centerline of the wreckage path about 46 feet past the second tree contact location. Continuing along the wreckage path was a ground scar followed by contact with a power line pole about 3 feet 8 inches from the base located about 2.5 feet to the right of the centerline of the wreckage path and contact with a tree 3 feet 10 inches from the base; the tree was located to the left of the centerline of the wreckage path. Located on the ground 2 feet aft of the power line pole contact was the outboard segment of the right wing with attached aileron. The power line pole contact occurred 52 feet past the second tree contact location. The trees and the components on the ground adjacent to the tree exhibited fire damage. The main wreckage which consisted of the fuselage and engine/propeller assembly came to rest on a magnetic heading of 120 degrees, 100 feet from the first separated component found on the ground. A wreckage diagram is an attachment to this report.

Fire consumed mostly the upper portion of the fuselage from the cockpit to the area of the emergency locator transmitter, and also to the remaining section of the right wing. Baggage was noted to be positioned on top of the rear seat back which was resting on the seat bottom. The baggage was weighed as found (wet) and determined to weigh 240 pounds. The landing gear and flaps were determined to be retracted. The elevator and rudder flight control cables were confirmed from each control surface to the cockpit control. The aileron cables exhibited evidence of overload failure. All four engine mount pads were broken and the engine was found forward and to the right of the normally installed position. The engine came to rest rotated nearly 90 degrees to the right of its normally installed position. The propeller governor cable was noted to be tightly stretched. The mixture control arm was broken at the throttle body assembly; the mixture control cable was connected to the mixture control arm and the attach hardware was in place. The throttle control cable was not connected to the throttle control arm; the attach hardware was not located. The throttle control arm was not broken and there was no evidence of gross elongation of the hole in the throttle control arm. The throttle control was found in the idle position at the throttle body assembly and the ball in the throttle control rod end was noted to move freely; the throttle control rod end was not broken. Examination of the cockpit revealed that the mixture and propeller controls were full forward but the throttle control was extended aft 3 inches. The fuel selector was positioned to the "right" tank position and no obstructions were noted from the fuel line on the right side of fuselage near the forward door post forward through the selector valve then forward to the gascolator. The engine which remained partially secured in part by the propeller governor control cable and a steel braided line, was removed for further examination and an attempted engine run. The airplane was recovered for further examination.

Examination of the airbox assembly of the engine when viewed from the rear looking forward revealed evidence of downward crushing on the aft portion of the airbox to the left of the throttle body assembly. Slight scoring measuring approximately 11/32 inch in length was observed on the aft right lower section of the damaged airbox. The score line followed the arc of the centerline of the bolt hole for the throttle control arm; no bolt head indentation was noted in the aluminum material of the airbox assembly. An edge was noted on the upper portion of the scored line on the airbox assembly. This position corresponded with the throttle control arm at or near full "open." No damage was noted to the upper forward edge of the throttle control arm. According to Cessna personnel, with proper installation of the throttle control to the throttle control arm, there is no contact by any portion of the bolt head to the airbox assembly.

In preparation for the attempted engine run, a hole in the right aft intake pipe from the throttle control housing was covered with tape and other holes in the induction pipes caused during the impact sequence, were also covered with tape. The hole in the aft portion of the induction pipe was the location of the fitting for the attach point of the manifold pressure gauge line. The damaged oil sump and oil pickup tube were replaced, and the mixture control was placed in the full rich position. The broken high rpm fitting and the broken inlet fitting of the engine driven fuel pump were removed and replaced. A test propeller was installed and the engine was started and found to operate normally using the engine-driven fuel pump. The magnetos were checked with no discrepancies noted.

Further examination of the airplane revealed a semicircular depression in the right wing 5 feet 10 inches inboard of the wingtip. The left horizontal stabilizer and elevator were fractured 3 feet 4 inches and 2 feet 7 inches outboard of the fuselage, respectively. The right horizontal and elevator remained attached but the leading edge of the horizontal stabilizer exhibited chordwise crushing and was displaced upwards and aft. The vertical stabilizer and rudder were also attached to the airframe. A semicircular indentation was noted in the left wing at approximately wing station 189.

Examination of the propeller revealed all blades were free to rotate in the hub with the leading edge of the propeller blade marked as "C", twisted towards low pitch and a slight aft bend beginning near the propeller hub. The second blade marked as "B" exhibited leading edge twisting towards low pitch, slight chordwise scratches, and an aft bend of 70 degrees about 12 inches from the blade tip. The third blade marked "A" exhibited leading edge twisting towards low pitch and an aft bend of approximately 90 degrees beginning 10 inches from the propeller hub. Chordwise scratches were noted beginning 8 inches from the hub and continue to about 1.5 feet from the blade tip.

MEDICAL AND PATHOLOGICAL INFORMATION

Postmortem examinations of the pilot and middle left seat occupant were performed by Frederick P. Hobin, M.D., Pathologist, District Nineteen Medical Examiner, Fort Pierce, Florida. The cause of death for the pilot was listed as deceleration rupture of the aorta with internal hemorrhage. The cause of death of the middle left seat occupant was listed as burn injury as a result of a post crash fire. Toxicological testing on specimens of the pilot was performed by the FAA Toxicology and Accident Research Laboratory (CAMI) and Wuesthoff Reference Laboratory. The results of the testing by CAMI was negative for carbon monoxide, cyanide, and volatiles. The results was positive in the blood and urine for Ranitidine. The results of testing by Wuesthoff was positive for carbon monoxide (1.3 percent), caffeine, nicotine, nicotine metabolite, ranitidine, and ranitidine metabolite. Toxicological testing of specimens of the middle left seat occupant was also performed by Wuesthoff. The results were positive for carbon monoxide (5.3 percent saturation). Medication (Ranitidine 150 mg) prescribed for the pilot, was located in baggage contained in the wreckage.

Postmortem examinations of the front right seat and middle right seat occupant were performed by Charles A. Diggs, M.D., Associate Medical Examiner District Nineteen, Fort Pierce, Florida. The cause of death for the front right sea

NTSB Probable Cause

A loss of engine power due to a disconnected throttle/power lever, cable. Also causal was the failure of the mechanic to install a cotter pin in the throttle control cable attach hardware at the throttle control arm, and failure of the company quality control inspector to verify after the job was completed that a cotter pin was installed, which resulted in disconnection of the throttle control cable from the throttle control arm after takeoff allowing the throttle control to move from the full open position. A related factor was the unsuitable terrain encountered by the pilot during the forced landing.