NTSB Factual Report

HISTORY OF FLIGHT

On October 5, 2001, at 1440 eastern daylight time, a Cessna 210M, N6053B, was destroyed during an in-flight break-up over Pittsfield, Pennsylvania. The certificated private pilot/owner and the passenger sustained fatal injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that originated at Ohio State University Airport (OSU), Columbus, Ohio. The personal flight was destined for Syracuse Hancock International Airport (SYR), Syracuse, New York, and was conducted under 14 CFR Part 91.

A review of air traffic control (ATC) voice recordings revealed that the pilot made contact with a Cleveland Center (CLE) controller at 14:34:08. The controller acknowledged the radio call, and issued an altimeter setting to the pilot. He subsequently asked, at 14:37:49, "six zero five three bravo, are you still headed to wellsville, or did they turn you someplace?" The pilot responded, "naw, i just went over... i'm going to wellsville now." The controller then stated, at 14:37:57, "roger, you can go direct to syracuse if you like," which the pilot accepted, and at 14:38:02, stated, "roger that. direct to syracuse."

At 14:39:27, the controller asked, "five three bravo, what's your heading now?" However, there was no response.

The controller continued attempts to contact the pilot, and consulted other controllers to see if the airplane's radar target was depicted on their consoles. There were no further transmissions from the airplane.

A review of radar data from the Cleveland Air Route Traffic Control Center (ARTCC) depicted a radar target with the airplane's assigned transponder code. The target was maintaining a northeasterly heading, and mode C altitude indicated 11,000 feet.

The target eventually turned to an easterly direction, then, about 10 miles northeast of the Tidioute VOR, it made a left turn of approximately 90 degrees over a distance of 3/8 of a mile, and duration of 15 seconds. The turn was completed at 1438:29.

The target then turned right, back to the north, but again initiated a turn to the left, to a southwesterly heading.

At 1439:02, the target was at 10,900 feet. About 24 seconds later, the target had descended to 6,900 feet, where transponder returns were lost.

At 1439:38, primary radar returns were received in the vicinity of the accident site, and continued for approximately 90 seconds after the last transponder return.

During a telephone interview, the controller stated that the airplane's course between the Tidioute VOR and the Wellsville VOR was 080 degrees, and the airplane was tracking 40 degrees off course, to the east, prompting the question "...did they turn you someplace?" The controller then offered the pilot a direct course to Syracuse, which the pilot accepted. Another "hard left turn" was observed, and the controller queried the pilot again about his heading, but received no response.

A couple was walking in the woods near the accident site, when they became aware of the airplane. During a subsequent telephone interview, the first witness said:

"... I heard this loud crack. I looked up and I could see the left wing was broken off the airplane, and it was spinning in a counter-clockwise direction."

The witness at first thought it was an aerobatic airplane, but then realized the airplane was in distress. He was certain that the left wing departed the airplane, and that the engine was running continuously until ground impact.

The second witness stated that her boyfriend called her attention to the airplane. The engine was "really loud", and the engine speed and pitch were so high that she thought it was a "four-runner."

According to a third witness, he was inside his home about 1 mile from the crash site when his attention was drawn to the airplane's engine noise. He ran outside and observed the airplane in a spinning, vertical descent.

A fourth witness, who lived about one-half mile from the crash site, stated that he was working in the back of his barn when he heard the airplane. He said it sounded "rough, erratic, and choppy", and "had a real high-pitched whine, kind of a scream. After the high-pitched whine, I heard the crash. When I came out of the barn, I could see a piece of metal kind of pin wheeling down."

A fifth witness, who was a pilot and an airframe and powerplant mechanic, stated he heard the airplane just prior to the crash.

"I heard this hell of a noise. That engine was so far over rpm that it just made a squeal. I didn't see it, and I didn't hear the engine before that. But that engine made such a noise; I mean it was really wound up. You couldn't put a throttle forward far enough to make an engine go like that."

The accident occurred during the hours of daylight, approximately 38 degrees, 59 minutes north latitude, and 078 degrees, 38 minutes west longitude.

PILOT INFORMATION

The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent third class medical certificate was issued on June 4, 2001. The pilot reported 2,000 hours of flight experience on that date.

On an insurance renewal application form dated June 7, 2000, the pilot reported 1,700 hours of total flight experience, and 900 hours in make and model.

AIRCRAFT INFORMATION

The airplane was on an annual inspection program. The most recent annual inspection was completed on October 2, 2001, at 2,543 aircraft hours. Examination of the airplane's maintenance records revealed that a factory re-manufactured engine was installed on August 17, 2000, at 2,404.2 aircraft hours.

METEOROLOGICAL INFORMATION

A review of weather data revealed there was an AIRMET issued at 0945, valid until 1600, for occasional moderate rime or mixed icing in clouds and in precipitation between the freezing level and FL200 along the airplane's route of flight. The freezing level was forecast between 7,000 and 11,000 feet.

An AIRMET for the same time period was issued for occasional moderate turbulence below 10,000 feet, and was in effect for an area that was also along the airplane's route of flight.

At 1450, the weather reported at Jamestown, New York, about 21 miles north of the accident site, was a ceiling of 3,900 feet broken, 4,500 feet overcast, and visibility of 10 miles with wind from 260 degrees at 6 knots. The temperature was 62 degrees F and the dew point was 53 degrees F.

The pilot reported to ATC that he was experiencing icing and turbulence. The controllers offered a change in altitude and the pilot initially declined. Later, the pilot requested a climb to 11,000 feet, and the request was approved. The airplane's assigned altitude was 11,000 feet at the time of the accident.

WRECKAGE INFORMATION

The airplane was examined at the site on October 6, 2001. All major components were accounted for, but the wreckage was distributed over about 1 mile of heavily wooded terrain. The left wing, left horizontal stabilizer, left elevator, and the right outboard elevator and counterweight were separated from the main wreckage.

The main wreckage came to rest at the initial point of ground contact. Tree strikes were noted directly above the wreckage. Angular cut tree limbs were scattered under and around the wreckage.

The cockpit, cabin area, fuselage, and empennage were completely destroyed by fire. All cockpit controls and panel instruments were consumed by fire.

The center of the wing carry-through spar was exposed and laying on the ground above the outline of the main fuselage. The right wing was essentially intact, with the outboard 5 feet of the leading edge crushed aft in compression. The inboard section of the wing where it attached to the fuselage was destroyed by fire.

The engine came to rest inverted, beneath the right wing. The number 2, 4, and 6 cylinders were damaged by impact. The number 1, 3, and 5 cylinders were damaged by fire. The accessory section of the engine displayed extensive fire damage.

The propeller assembly was separated from the engine at the propeller flange, but was found immediately in front of the engine. Two of the three blades were attached to the hub, and one propeller blade was found separated and buried beneath the hub. The attached blades were loose in the hub.

All three blades displayed similar leading edge gouging and chordwise scratching. Two propeller blades displayed twisting, "S-bending," and tip curling.

The left wing, left horizontal stabilizer, left elevator, and the right outboard elevator and counterweight were recovered and repositioned to the main wreckage. All flight control surfaces were accounted for, and all flight control cables that were observed displayed "broomstrawed" ends at the point of separation.

The outboard 5 feet of the left wing, as well as the aileron, had separated from the wing. The left wing spar displayed 45-degree fracture surfaces at the point where the wing spar attached to the main carry-through spar. The spar and spar cap were bent forward and down towards the breaks.

The right horizontal stabilizer was deformed in the negative direction and damaged by fire. The vertical fin lay flat on top of the right horizontal stabilizer, but was still attached by exterior sheet metal. The vertical fin was wrinkled and damaged by fire.

The left horizontal stabilizer was bent and deformed in the negative direction. The breaks displayed 45-degree fracture surfaces. Examination of the left horizontal stabilizer revealed no impact scars or marks.

The rudder cables, elevator cables, elevator trim cables, and electrical wiring routed to the tail section were in a tight spiral wrap for about 14 inches forward of the elevator control bellcrank.

MEDICAL AND PATHOLOGICAL INFORMATION

The Erie County Coroner, Erie, Pennsylvania, performed an autopsy on October 7, 2001.

The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing for the pilot on January 22, 2002. The pilot, who was a retired medical doctor, tested positive for Butalbital, Triprolidine, paroxetine, and quinine. The tests detected 0.241 (ug/ml, ug/g) Butalbital in the muscle, and 0.681 (ug/ml, ug/g) Butalbital in the liver. The Triprolodine, paroxetine, and quinine were detected in the heart and liver.

According to RxList.com, Butalbital (Fioricet) compound was a barbiturate prescribed for the treatment of tension headaches. The most frequently reported adverse reactions for Butalbital were drowsiness, light-headedness, dizziness, sedation, shortness of breath, nausea, vomiting, abdominal pain, and intoxicated feeling.

Paroxetine (Paxil) was an anti-depressant. The most commonly reported adverse reactions for those taking paroxetine for depression included asthenia, sweating, nausea, decreased appetite, sleepiness, dizziness, insomnia, tremor, and nervousness.

The most commonly noted side effects associated with paroxetine included anxiety, sweating, nausea, decreased appetite, sleepiness, dizziness and insomnia. Dry mouth occurred in about 18% of patients taking Paxil.

The most common symptoms of withdrawal from paroxetine were dizziness, tiredness, tingling of the extremities, nausea, vivid dreams, irritability, and poor mood. Other symptoms have included visual disturbances and headaches.

Quinine was used for the prevention or treatment of malaria. The most frequently observed adverse effects were nausea, stomach cramps, dizziness, and ringing in the ears.

Triprolidine was an antihistamine whose pharmaceutical class could cause dizziness, sedation, and hypotension in elderly patients. It was also prescribed as a sleep aid for insomniacs.

On the pilot's last FAA medical application, he stated that he was taking only Hytrin and Vioxx. The application indicated "no" for items 18.a. "Frequent or severe headaches," 18j. "Kidney stone or blood in urine," and 18.m. "Mental disorders of any sort, depression, anxiety, etc." On previous applications dating back to 1995, the pilot answered no to these questions on every application, and declared no use of any medications.

Examination of the pilot's medical records revealed that he had been treated continuously for some or all of those ailments for several years prior to the accident. He had also been treated for severe joint pain (back and hip) and had been prescribed sleep aids for several years as well. The pilot's most recent complaint to his doctor about back pain was documented September 26, 2001.

On September 10, 2001, after returning from a trip to Spain, the pilot sought treatment for headache, fever, nausea, and diarrhea. He told the doctor he felt "very faint," and the doctor noted that the pilot "look[ed] acutely ill." The pilot was diagnosed with viral gastroenteritis.

According to the FAA Guide for Aviation Medical Examiners, a history or presence of any of the following conditions would preclude the issuance of a medical certificate: migraine headaches, migraine equivalent, cluster headaches, chronic tension headache, or conversion headaches.

In addition, the publication stated that, "pain, in some conditions, may be acutely incapacitating. Chronic recurring headaches or pain syndromes often require medications for relief or prophylaxis, and in most instances, the use of such medications is disqualifying because they may interfere with a pilot's alertness and functioning. The examiner may issue a medical certificate to an applicant with a long standing history of headaches if mild, seldom requiring more than simple analgesics, occur infrequently, and are not incapacitating, and are not associated with neurological stigmata."

ADDITIONAL INFORMATION

The engine was examined at Brokenstraw Airport (P15), Pittsfield, Pennsylvania, on October 7, 2001.

Examination revealed that the #2, #4, and #6 cylinders were impact damaged. The top spark plugs to each of those cylinders were broken off, and the areas around the spark plug holes were cracked and displaced. The intake manifold for the #2, #4, and #6 cylinders was broken away from the engine.

The engine could not be rotated by hand. The crankcase through-bolts were loosened, but the crankshaft still could not be rotated. Removal of the #2, #4, and #6 cylinders revealed no internal deficiencies.

The crankcase halves were separated, and the crankshaft was rotated by hand. The #2, #4, and #6 connecting rods rotated smoothly on the journals, and the #1, #3, and #5 pistons moved smoothly in their respective cylinders.

The accessory section of the engine displayed extensive fire damage. The vacuum pump drive was melted, but still attached to the drive splines on the engine, and the impeller in the pump. The vacuum pump was found separated from the engine, and the case was fractured at the mount plate.

The vacuum pump was disassembled and examination revealed that the impeller was intact, and the impeller vanes were free to move in their guides. The melted drive was removed from the pump case, and the impeller rotated freely. The inside face of the drive coupling cover plate displayed rotational scoring.

On October 7, 2001, the wreckage was released to the manager of Brokenstraw Airport.

NTSB Probable Cause

The pilot's loss of control in flight due to spatial disorientation, and his subsequent overstress of the airplane during a recovery attempt. A factor in the accident was the pilot's use of inappropriate medications.