NTSB Factual Report

HISTORY OF FLIGHT

On December 14, 2003, about 1050 pacific standard time, a Cessna P210N, N4674A, was destroyed when it collided with terrain about 13 miles north of Tonopah, Nevada, during an instrument approach to the Tonopah Airport. The airplane was being operated by the private pilot as an instrument flight rules (IFR) personal cross country flight under Title 14, CFR Part 91, at the time of the accident. The pilot and sole passenger were fatally injured. Instrument meteorological conditions prevailed, and an instrument flight plan was filed. The flight departed Tucson International Airport, Tucson, Arizona, about 0700 en route to Tonopah.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on December 15, an air safety investigator from the Los Angeles, California, NTSB office said the accident airplane was reported overdue by FAA air traffic control (ATC) when the airplane did not arrive at the Tonopah airport after being cleared for the GPS Runway 15 instrument approach to the airport. A search for the airplane was initiated.

On December 17, the wreckage of the airplane was located on a mountainside at an approximate elevation of 7,500 feet, about 13 miles north of Tonopah.

During a telephone conversation with the NTSB IIC on December 17, the Nye County Coroner, Nye County, Nevada, said he had been to the accident site. He said the airplane impacted a high rock face and tumbled to the scree slope below. He said a postcrash fire consumed most of the cabin.

The airplane was being flown by the pilot/owner, accompanied by his wife, from an airport near their residence in Tucson, Arizona, to an airport in Florence, Oregon to visit relatives, with a planned fuel stop in Tonopah, Nevada. The flight was on a visual flight rules (VFR) flight plan. According to FAA ATC records, at 1023, while approaching Tonopah, the pilot reported deteriorating weather conditions, and requested a global positioning system (GPS) instrument approach to the Tonopah airport. The pilot was issued a clearance for the GPS Runway 15 approach at 1041, and told to change to the local advisory frequency. No further communications occurred with the accident airplane.

Due to mountains and high terrain in the area, the approach is not monitored on ATC radar. The pilot was instructed to contact Reno Radio on the ATC frequency after landing at the Tonopah airport. When the pilot did not contact ATC after an appropriate time period, ATC telephoned the airport, and was advised the airplane had not arrived. After further attempts to contact the airplane failed, a search was initiated. The search was conducted by personnel of the Reno, Nevada FSDO and the Nye County Sheriff's Office.

INJURY TO PERSONS

The two occupants of the airplane received fatal injuries.

DAMAGE TO AIRCRAFT

The airplane was destroyed by impact and postcrash fire.

PERSONNEL INFORMATION

The accident airplane was owned and operated by the pilot, and excerpts from the pilot's logbook were provided by the pilot's insurance company. According to a pilot's logbook entry, the pilot received and passed a biennial flight review on April 3, 2002. The pilot was issued an FAA third class medical certificate on November 22, 2003, with the limitation to wear corrective lenses. The pilot held a private pilot certificate with an instrument airplane rating. According to an application for a airman medical examination dated November 25, 2003, the pilot had about 3,500 hours total pilot time, with about 50 hours flown in the previous six months. Logbook entries showed recent actual and simulated instrument flight time including approaches, but the total instrument hours flown could not be ascertained.

AIRCRAFT INFORMATION

The airplane was a model year 1982 Cessna P210N, single-engine, retractable-gear, pressurized airplane. No airplane maintenance logbooks were found. Airplane information was obtained from shop maintenance records. An annual inspection was completed on October 20, 2003. During the inspection the propeller was removed, overhauled, and replaced. The airplane had accumulated 2,406 airframe service hours.

METEOROLOGICAL INFORMATION

The pilot of the accident airplane was self briefed on weather prior to departure via the Direct User Access Terminal System (DUATS). He accessed DUATS 5 times on the day prior to the accident flight, and 3 times on the morning of the flight.

After notifying ATC of deteriorating conditions in-flight, and requesting an instrument approach to Tonopah, ATC provided current weather at Tonopah.

The accident airplane was cleared for the GPS Runway 15 instrument approach to the Tonopah airport at 1042. The special weather observation taken at Tonopah at 1024, reported 10 miles visibility, with a scattered layer of clouds at 1,900', and broken layers of clouds at 7,000' and 8,000'. A special observation taken at 1042, reported visibility of 2 miles in light snow, with few clouds at 2,000', and a broken layer of clouds at 2,800'. A special observation taken at 1049 reported 1 mile visibility in light snow and mist, and a vertical visibility (VV) of 1,700'. The METAR observation at 1056 reported 1 mile visibility in light snow and mist, with a VV of 1,200'. A special observation taken at 1106, reported three-quarter mile visibility in light snow and mist, with a broken layer of clouds at 800', and an overcast layer of clouds at 1,600'. A special observation at 1122 reported one and three-quarter miles visibility in light snow and mist, with a broken cloud layer at 1,400', and an overcast layer at 4,300'. Throughout the period the winds were variable at three to seven knots.

The weather forecast for the area, and valid for the period, included active AIRMET's (Airman’s Meteorological Information) for instrument flight rules (IFR), and mountain obscurations. Specifically, the AIRMET's called for mountains obscured by snow and mist, visibility below three miles, and ceilings below 1,000'.

AIDS TO NAVIGATION

The Tonopah Global Positioning System GPS RWY 15 instrument approach is a non-precision approach with a minimum descent altitude (MDA) of 5820' msl, which is 394' above the airport elevation. The instrument approach is north of Tonopah with a southerly inbound course. The charted initial approach fix (IAF) is "DOBZU", west of "CEDUM", which is the last fix north of the final approach fix (FAF) "BEUTE", which is 5 nm north of "AWNIN", the missed approach point. The approach is bounded on all sides by mountain peaks ranging from 7,000' to 9,000'. A copy of the GPS RWY 15 approach chart is included in the docket for this report.

Radar coverage is not available for the entire approach. According to radar data, the airplane initiated the approach at the appropriate location and altitude, then descended below radar coverage on the approach.

COMMUNICATIONS

According to FAA ATC tapes/transcripts, the pilot communicated with ATC during the VFR portion of the flight, and at 1023 told ATC controllers there was deteriorating weather ahead, and requested an instrument approach to the Tonopah airport. At 1041 the final controller issued the pilot a clearance for the GPS Runway 15 instrument approach to the Tonopah airport, and at 1042 instructed the pilot to change to the local advisory frequency. The final controller also instructed the pilot to "report cancellation or down time" through Reno Radio via the ATC frequency. No further radio transmissions were received from the accident airplane.

WRECKAGE AND IMPACT INFORMATION

The accident site was north of the Tonopah Airport, Tonopah, Nevada. The elevation of the airport is 5,426 feet above sea level. North of Tonopah is the Toiyabe National Forest, which contains three mountain ranges and numerous individual mountain peaks. Peaks range between 7,000 feet and 10,000 feet in elevation. The area is high desert, and vegetation is sparse.

According to a Nye County Sheriff Deputy Coroner who responded to the site to retrieve the victims, the airplane impacted a rock bluff face, and fell to a steep scree slope below.

Due to its location, the airplane wreckage was not examined at the accident site. The wreckage was transported to a maintenance facility at the North Las Vegas Airport, Las Vegas, Nevada. On June 16, the airplane was laid out and examined by the IIC accompanied by representatives from the FAA, engine manufacturer, and the airplane manufacturer. The airplane had come to rest inverted on a scree slope, and the cabin was consumed by a postcrash fire. All the major components were located at the accident site, and all the flight control surfaces were recovered. Both outboard wing sections exhibited span-wise crushing and accordion folding throughout the entire chord depth of the wings, including the ailerons. The inboard sections of the wings, flaps, and cabin roof were mostly intact. A measurement of the flap actuator indicated the flaps were extended between 10-20 degrees. The cabin sides and floor were burned away. The lower nose fairings, including the nose landing gear well, had separated from the fuselage. The nose wheel well was crushed and distorted from external forces, but showed no signs of interior damage from the wheel and landing gear assembly. The nose wheel strut had an overload fracture, and the lower portion of the strut and wheel were separated from the airplane. Both main landing gear exhibited overload fractures of the gear legs near the rotational pivot point of the gear extension mechanism, and the extension mechanism was in the gear extended position. All three propeller blades were recovered. Two of the blades were snapped off chord-wise, about mid span. The fracture surfaces of both blades had over-stress fracture signs. The third blade was intact, and exhibited chord-wise scratches, with extreme gouging of the leading-edge. The engine was examined, and no preaccident mechanical anomalies were noted. The exhaust manifolds exhibited extreme plastic folding and bending.

MEDICAL AND PATHOLOGICAL INFORMATION

Due to the postcrash fire, no pathological or toxicological testing was possible.

ADDITIONAL INFORMATION

During the search for the airplane, personnel from the Nye County Sheriff's Office interviewed witnesses who observed the airplane flying low, in and out of cloud bases. Based on these statements, Sheriff's personnel, in conjunction with FAA personnel from the Reno, Nevada, Flight Standards District Office, prepared a map of the airplane's low altitude path. A copy of the map is attached. The airplane was observed northeast of Tonopah along Highway 82, proceeding westbound, where it intercepted highway 376 northbound. The airplane reversed course south along the highway, and then turned southwest, along the west side of the San Antonio Mountains. Turning south along the mountains, the airplane entered an easterly oriented canyon which terminates at Lime Mountain Peak, elevation 7,102' msl. Prior to Lime Mountain Peak, the airplane turned north into a canyon leading to San Antonio Peak, elevation 7,727' msl. The airplane impacted a steep wall on the south side of San Antonio Peak.

No components or parts were retained by the NTSB. The wreckage has been released to the owner's insurance company.

NTSB Probable Cause

The pilot's failure to follow approved instrument flight procedures, and his failure to maintain clearance from obstacles/terrain, which resulted in an in-flight collision with terrain. Factors associated with the accident are snow and low clouds.