NTSB Factual Report

HISTORY OF FLIGHT

On November 15, 1996, at 0436 central standard time (cst), a Cessna T210N, N5083C, operated by Prompt Air, Inc., of Chicago, Illinois, piloted by a commercial pilot, was destroyed when it collided with the terrain approximately one mile from the runway 02 threshold, at the Springfield Regional Airport, Springfield, Missouri. The airplane was on final approach, after being cleared for the ILS runway 02 approach by Kansas City Center. The pilot sustained fatal injuries in the accident. The 14 CFR Part 135 flight was operating on an IFR flight plan. Weather in the vicinity of the accident was reported as Instrument Meteorological Conditions (IMC). The flight departed Cahokia, Illinois, at 0310 cst.

The pilot was on his last flight leg for that evening carrying cancelled bank checks. The baggage handler, who loaded the airplane before the pilot departed for Springfield, said that the pilot "looked very tired and fatigued." The pilot had commenced his workday at approximately 1800 cst the day before the accident.

At approximately 0440 cst, a Greene County Sheriff's Department Officer discovered N5083C on fire near the approach end to runway 02 at Springfield Regional Airport.

PERSONNEL INFORMATION

The pilot was born April 9, 1969. He was the holder of a commercial certificate with single/multi engine land ratings. He also held a first class medical issued on April 4, 1996. A review of the pilot's last logbook revealed his most recent biennial flight review was on April 30, 1996. He had accumulated a total of 1,886 hours of flight time, 453 of which were in Cessna T210N airplanes.

AIRCRAFT INFORMATION

The airplane was a Cessna T210N, serial number 21063700, N5083C. The airplane had accumulated 3,107 hours time in service at the time of the accident. The engine had 3,107 hours total time with 508 hours since its last overhaul. The most recent inspection was conducted on November 12, 1996, 10 hours prior to the accident.

METEOROLOGICAL INFORMATION

A handwritten note was discovered at the accident site, which appeared to be a weather report copied from a weather terminal. On the note was written the Springfield Regional Airport weather on November 15, 1996, at sometime before departure from Cahokia, Illinois. Recorded was a 200 feet overcast with one-half mile visibility in fog, and winds reported at 150 degrees at 18 knots with gust to 23 knots. The forecast weather valid sometime before departure until 1000 cst on November 15, 1996 was reported as 200 feet overcast with one-quarter mile visibility in fog, and winds reported at 160 degrees at 15 knots with gusts to 25 knots.

COMMUNICATIONS

At 0416 cst Kansas City Center transmitted to the pilot "the new Springfield weather just came out uh has still has two hundred feet overcast visibility uh one and one-quarter mile now and uh mist wind one five zero at one niner gusting to two four altimeter uh is uh three zero two four". The pilot acknowledged "three zero two four prompt air five fifty". The last transmission from Kansas City Center at 0430 cst was "prompt air five fifty show you intercepting the localizer about uh two miles south of coole radar service terminated return to this frequency cancel your ifr on the ground at springfield." The pilot acknowledged this transmission. The transcript between Kansas City Center and N5083C is enclosed with this report.

AERODROME INFORMATION

The airport is open 24 hours a day with the control tower closed between 2330 until 0530. Kansas City Center controls the airspace when the tower is closed. The airport only has one available ILS approach, which is to runway 02.

WRECKAGE AND IMPACT INFORMATION

The NTSB on-scene investigation began at 1530 on November 15, 1996. The main wreckage was located on the side of a railroad track embankment where a post-crash fire had ensued. The airplane wreckage path followed a magnetic heading of 031 degrees, and covered a distance of approximately 183 feet. The main wreckage was 379 feet to the right of centerline of runway 02 and .97 mile away (016 degrees) from the runway threshold.

First located in the wreckage path were three ground scars spaced at 5 feet from left to right and 3 feet between scars perpendicular to the flight path. The ground scars continued for 133 feet. At 25 feet from the first ground scar, a ground imprint resembling the left main gear was also discovered.

The lower nose gear section was found 33 feet further along the flight path from the first ground scar. At 75 feet from the first ground scar, the upper nose gear strut was discovered. Fragments of the red navigation lens were located 59 feet from the first ground scars. Cockpit items, including the left door, were scattered up to the main wreckage which was located at the railroad embankment (150 feet from the first impact scars).

N5083C's wings, engine, and most of the forward fuselage were contained in one location. The horizontal stabilizer was discovered inverted laying under the main fuselage. The entire wing section, except the outer right wing portion, was found on top of the main cabin area with approximately 10 degrees of flap extension. On the remaining belly section burnt cancelled checks were found. The right outer wing section was found near the main wreckage and was not involved in the post-crash fire. The left main gear was found in the retracted position. The right main landing gear was torn out of the attachment points and located near the main wreckage. The gear selector was found in the down position. The Kollsman window on the altimeter was set at 30.50 inches. All cockpit instruments were destroyed by the post-crash fire.

The propeller assembly was still attached to the engine. Only two propeller blades were attached to the hub. One of the propeller blades was separated from the hub. This blade was found partially under the engine. This blade also had full spanwise twisting. The second blade had full span chordwise scratching on the forward surface and was bent aft its entire length. The third blade was bent aft its entire length and had full span wise scratches on the forward surface.

Control continuity was confirmed at all terminal ends of the flight controls.

On November 16, 1996, the airplane was moved to a hangar for further examination of the airframe and engine. The right main landing gear was fractured and was separated from the airframe. The left main landing gear was found to have collapsed about 25 feet past the initial ground scars. This is consistent with ground scars and a worn left gear down-lock. This wear was evident when a comparison of the down-lock dimensions revealed the right down-lock is one-quarter inch longer than the left. The engine turned by way of the crankshaft and continuity was established through all pistons, valve train and the accessory section. The wet engine driven vacuum pump was intact and appeared undamaged. The electrical standby vacuum pump was intact and operated with no discrepancies. Both magnetos were fire damaged. The spark plugs were of two different types with varying spark plug gaps. Upon inspection of the number two exhaust manifold, approximately a one and one-half inch crack was found in the exhaust riser at the cabin heat muff junction. This crack was surrounded by a gray/light chocolate colored residue.

A complete engine teardown was conducted on May 1, 1997, at Loss Management Services, Inc., located in St. Peters, Missouri. The following discrepancies were noted: fuel injector nozzle number one (size 14C) was removed for inspection and was found to be loose (wobbled with fingers) prior to its removal. The cylinders were removed for inspection. All cylinders, except number two (steel), were Cermicrome. Note: according to the engine log, cylinder number three was replaced on 11/12/96. The exhaust pipe was loose on cylinder number three and approximately 1/8 inch gap was noted between the cylinder and the pipe flange. Stud thread marks were present on the side of the one of the flange mounting holes. The top aft exhaust pipe mounting studs were loose on cylinder number five. Scuffing was noted on the topside of cylinder walls number one and number five. Cylinder number six had a shiny spot on the wall, which looked like the Cermicrome finish had been worn away, exposing the original chrome finish (a cracked appearance). The piston skirts on one side of pistons number one, two, three, and five were scored. Piston number four had two scratches across the oil scraper ring area, on the aft side.

MEDICAL AND PATHOLOGICAL INFORMATION

A post mortem examination of the pilot was conducted on November 16, 1996 at Cox South, 940 Boonville, Springfield, Missouri. No pre-existent anomalies were noted which would have affected pilot performance.

The pilot's toxicological analysis was performed by the FAA's Civil Medical Institute in Oklahoma City, Oklahoma. The toxicological examination of specimens from the pilot were negative for the drugs screened and ethanol.

ADDITIONAL DATA

Parties to the investigation were the Federal Aviation Administration, Teledyne Continental Motors, and Cessna Aircraft Company.

Following the on-scene portion of the investigation, the wreckage was released to Prompt Air, Inc. Director of Operations, on November 19, 1996.

NTSB Probable Cause

the pilot's failure to set the altimeter to the current setting given by the controller resulting in the aircraft altimeter reading 260 feet higher than the actual aircraft altitude. Factors involved were pilot fatigue, weather conditions at approach minimums, and a tailwind.