NTSB Factual Report

History of Flight

On April 11, 1997, at 2005 central daylight time (CDT), a Cessna T210N, N5310A, was destroyed when it impacted the terrain one half mile north of the Rolla National Airport, Vichy, Missouri. The private pilot and one passenger received fatal injuries, and one passenger received serious injuries. The 14 CFR Part 91 flight departed Butler County Airport (BTP), Butler, Pennsylvania, en route to the Rolla National Airport. Instrument meteorological conditions prevailed and the aircraft was cleared for an instrument approach to the airport. The aircraft was executing a missed approach when it impacted the terrain.

The pilot had refueled the aircraft earlier in the day at Butler County Airport. The fuel tanks had been topped off with 59 gallons of fuel. The pilot filed an instrument flight plan with 6,000 feet mean sea level (msl) as the cruise altitude. At 1652 eastern daylight time, the pilot departed Butler County Airport and contacted the Pittsburgh Departure Radar and requested an IFR clearance to Vichy, Missouri.

The flight was without incident until about an hour after takeoff. At that time the aircraft's transponder became inoperative which required the pilot to make periodic position reports to the air traffic controllers (ATC).

The pilot was unable to fly the filed intended route of flight due to weather conditions near Terre Haute, Indiana, and St. Louis, Missouri, and the inoperative transponder. ATC was able to monitor the aircraft's progress throughout the en route portion of the flight by use of pilot position reports and occasional "primary" radar hits on the aircraft.

The passenger reported that the pilot had indicated that there was enough fuel to land at Vichy, Missouri, when the aircraft had passed the half way point in the flight.

The aircraft's position at 1942 CDT was about 55 nautical miles east of the Vichy VOR on the V234 VOR airway at 6,000 feet msl. The pilot was instructed to continue to follow V234 and report 25 DME east of the Vichy VOR.

At 1944 CDT, the pilot requested a weather update for the current weather at Rolla National Airport. The pilot was informed that the weather, which had been recorded 30 minutes prior, was: one quarter mile visibility in fog, 200 foot overcast, with surface winds at 350 degrees at 6 miles per hour. (The instrument approach minimums for the VOR RWY 22 approach were 1500 feet Minimum Descent Altitude with a 400 foot ceiling and 3/4 mile prevailing visibility.)

At 1948 CDT, the pilot responded that his present weather conditions were VFR and that he planned to continue to the Rolla National Airport. The pilot requested to fly the VOR Runway 22 approach to the Rolla National Airport.

At 1950 CDT, the aircraft was at 37 DME east of Vichy VOR. The pilot was cleared to descend to 3,000 feet msl at the pilot's discretion, and to maintain 3,000 feet msl until the initial approach fix and established on the approach, and was cleared for the VOR Runway 22 approach.

At 1953 CDT, the pilot requested the barometric setting for Vichy and was informed that the altimeter was 29.74.

At 2001 CDT, ATC advised the pilot to cancel his IFR flight plan with Columbia Flight Service or on the current radio frequency after he had landed at Rolla National Airport. If a missed approach was required, the missed approach frequency was 133.4.

At 2002 CDT, the pilot reported that he was established on the approach. No further transmissions were made by the pilot.

The passenger reported the following information concerning the instrument approach:

"...there was fog over the airport and we could see lights straight down. Jim [the pilot] said we were right over the airport, but conditions were too close to land, and he would have to go somewhere else. I looked around Jim, and the altimeter read 1300 feet. Jim pushed the power up and turned north. The next thing I heard was a crunching noise, and then I don't remember anything until I woke up, about three hours later."

At 2007 CDT, the ATC controller tried to contact the aircraft but received no reply.

The Columbia Flight Service initiated a search for the aircraft. The Flight Service telephoned an aviation flight dispatcher who worked at the Rolla National Airport for Baron Aviation. The flight dispatcher reported that she had seen the runway lights illuminate and heard an aircraft make an approach earlier. A search was made of the airport ramp but the aircraft was not located.

Another witness who lived at the airport reported that he had heard a very low flying airplane fly by, and then heard a "loud thud sound." The witness reported that he may have heard a slight hesitation in the aircraft's engine power, and then the "...power came back momentarily..." and "...then the sound of the crash."

A ground search was made for the aircraft. It was located about 1/2 mile north of the airport in a wooded pasture about three hours later. Dense fog and the dark night had made the search difficult, and the Emergency Locator Transmitter (ELT) was not producing a signal. When the search team discovered the aircraft, they found that the pilot and front seat passenger had perished, but the passenger in the back seat had survived.

Personnel Information

The pilot had a private pilot's certificate with an instrument rating. He had a total of about 1,330 total flight hours with about 69 hours in make and model. He had logged 338 hours of actual instrument time, 35 hours of simulated instrument time, and about 89 hours of night time.

The pilot's current logbook did not indicate a current Biennial Flight Review (BFR). The last BFR was recorded in the logbook was on June 8, 1992. The logbook and aircraft time sheets indicated that the pilot had flown about 140 hours in the last year and had flown in instrument conditions.

The pilot had a current third class medical.

Aircraft Information

The airplane was a Cessna T210N, Centurion, with a Continental 310 horsepower engine. It was owned and operated by Scott Charters, which was owned by the pilot. The last annual inspection was performed on August 8, 1996. The total airframe hours were 2,930 hours. The total engine time was about 98 hours since major overhaul.

Meteorological Conditions

The weather at 1953 central daylight time at Rolla National Airport, Vichy, Missouri, was recorded as:

3/4 of a mile visibility in fog, 100 foot overcast ceiling, temperature 46 degrees Fahrenheit, 46 degree Dew Point, Altimeter 29.77, Wind 330 degrees at 8 knots.

The weather reported to the pilot when the aircraft was about 37 miles east of Vichy was:

1/4 mile visibility in fog, 200 foot overcast, wind 350 degrees at 6 mph.

The flight dispatcher who was on duty that night for Baron Aviation at the Rolla National Airport, reported that she was a trained weather observer. She reported that at the time that the airplane made the approach, the horizontal visibility was not more that 1/16th of a mile due to fog.

Aids to Navigation

The pilot flew the straight-in approach to the VOR Runway 22 approach to the Rolla National Airport. The airport elevation is 1,148 feet msl. The Minimum Descent Altitude for the VOR Rwy 22 approach was 1,500 feet msl, and the minimum prevailing visibility was 3/4 mile. The approach minimums for weather were a 400 foot ceiling and 3/4 statute mile visibility. (See attachment)

The Federal Aviaiton Administration (FAA) conducted a flight check of the VOR Runway 22 approach on April 12, 1997. The fight check determined that the approach was within normal parameters.

Wreckage and Impact Information

The accident site was located about 1/2 mile north of the Rolla National Airport. The elevation at the site was about 1,125 feet msl.

The wreckage path was on a heading of approximately 335 degrees. The wreckage path indicated that the airplane first hit the top of some trees which were about 45 feet in height. Pieces of the right wing were found about 65 feet after the first tree strike. The aircraft flew over a 80 foot area where the woods had been cleared for a gas pipeline. The aircraft impacted more trees on the other side of the clearing, where pieces of the right wing were found at about the 135 foot mark in the wreckage path. Two pine trees were knocked down by the aircraft impact. The left wing separated from the fuselage and was propped up in a tree at about the 230 foot mark in the wreckage path. The main wreckage was found about 260 feet from the initial tree impact. The aircraft was on its left side and the left wing had separated at the wing root. The outboard 1/2 of the right wing had separated from impact. The left horizontal stabilizer and elevator had separated from the empenage and were found at the 235 foot mark in the wreckage path. The engine was ripped from the engine mounts and was about 40 feet from the main wreckage on a heading of 300 degrees.

Both wing fuel tanks were ruptured.

The aircraft controls were checked for continuity. All controls exhibited continuity of the controls or exhibited overload failures of the control cables.

The flap jack screw's exposed threads were measured. The measurement equated to a full flap down position.

The landing gear were in the down position at impact.

The engine inspection and teardown revealed that there were no anomalies with the engine.

The propeller inspection and teardown revealed blade damage which included all three blades twisted toward low pitch/high power. All three blade tips were twisted off. All three blades exhibited leading edge gouges and chordwise scoring.

The electric altimeter was indicating 1200 feet msl at the accident site on April 12, 1997, one day after the accident. The altimeter was inspected and its calibration examined. It revealed no anomalies.

The gyros from the attitude gyro and HSI were examined. Neither the gyros or gyro housings exhibited scoring.

Medical and Pathological Information

An autopsy was performed on the pilot at the Fountain Mortuary Service on April 15, 1997.

A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The report indicated the following results:

The results of the toxicology examination were negative.

Search and Rescue

The search of the aircraft was hindered by the dense fog and dark night. The emergency locator transmitter (ELT) was not transmitting a signal. The ELT's antennae connector to the battery was found loose.

Tests and Research

The Cessna Model T210N Pilot's Operating Handbook indicates the following procedure for Balked Landings:

1. Power -- 36.5 INCHES Hg and 2700 RPM. 2. Wing Flaps -- RETRACT to 20 degrees (immediately). 3. Climb Speed -- 70 KIAS (until obstacles are cleared). 4. Wing Flaps -- RETRACT SLOWLY (after reaching safe altitude and 75 KIAS. 5. Cowl Flaps -- OPEN.

The Pilot's Operating Handbook provides the following narrative description of a Balked Landing:

"In a balked landing (go-around) climb, the wing flap setting should be reduced to 20 degrees immediately after full power is applied. After all obstacles are cleared and a safe altitude are obtained, the wing flaps should be retracted."

Additional Information

Parties to the investigation included Cessna Aircraft Company, Teledyne Continental Motors, McCauley Propellers, Allied Signal, and the Federal Aviation Administration.

The aircraft wreckage was released to the American Eagle Insurance Company.

NTSB Probable Cause

failure of the pilot to properly follow the missed approach procedure and maintain the minimum descent altitude (MDA) during night/IFR flight. Factors relating to the accident included: darkness, low ceiling, fog, and failure of the pilot to properly configure the airplane for the go-around (improper use of full flaps and gear retraction not performed).