NTSB Factual Report

HISTORY OF FLIGHT

On February 5, 2003, approximately 0850 central standard time (CST), a Cessna T210N single-engine airplane, N4945Y, was destroyed when it experienced an in-flight break up and collision with terrain near Mission, Texas. The airplane was in sales negotiations with a private individual in Mexico, but was registered to the pilot at the time of the accident. The pilot operated the airplane as a Mexican business flight. The U.S. commercial pilot and his two passengers (one of Mexican citizenry and one of U.S.) sustained fatal injuries. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the cross-country flight. The flight originated from Matamoros, Mexico (MMMA), approximately 30 minutes prior to the accident and was destined for Torreon, Mexico (MMTC).

Matamoras is located south of the U.S./Mexican border near Brownsville, Texas. Torreon is approximately 318 nautical miles west of Matamoros. According to personnel familiar with the passengers, the purpose of the flight was to transport the passengers to MMTC for business. It is unknown as to what relationship the pilot had with the passengers, under what regulations the flight was conducted in Mexico, or if any financial transactions had been made to conduct the flight.

Review of air traffic control information provided by the Federal Aviation Administration (FAA) and the Direccion General de Aeronautical Civil (DGAC) revealed the accident airplane departed MMMA approximately 0820 with a clearance via victor airway 42 (V42) to Monterey and V10 to MMTC. The pilot was cleared to 6,000 feet mean sea level (msl) and was informed that he could expect 12,000 feet after Monterey. The flight was assigned a discrete transponder code of 1714 and was cleared for the Matamoros Alpha One departure (standard instrument departure - SID).

The following is a summary of the communications between the pilot and air traffic control. Pertinent radar data gleaned from the Houston Air Route Traffic Control Center will be in parentheses following the communications. It should be noted that the communications transcripts and radar data times are off by up to five minutes at some points, and the time noted in this report is from the U.S. radar data.

At 0829, an air traffic controller asked the pilot what the position of N4549Y was. The pilot responded that they were "10 miles out" and they were "leaving 3,000 feet for 6,000 feet on the 268 radial from Matamoros." The air traffic controller acknowledged the pilot's response and requested that he report 20 miles out. At 0834, the pilot reported that they were at 6,000 feet and 20 miles out. Air traffic control responded by asking the pilot to confirm they were "established on an airway?" The pilot confirmed with an affirmative (during this exchange, the aircraft's mode C depicted the airplane around 5 miles north of V42, between V42 and V2-10, tracking toward the northwest toward the U.S./Mexican border). It should be noted that N4945Y never became established on V42 and instead tracked parallel to the airway approximately three miles north until six minutes into the flight when the airplane began a track toward the northwest.

Approximately 0839, the pilot called Reynosa's approach controller and said, "we are…the airway…we are at…12 miles from your station, level at 6,000 feet on the airway" (at this point on the depicted radar track, the airplane is on V2-10 at 6,000 feet approximately 12 miles southeast of the Reynosa very high omnidiretional range navigational aid - VOR). The Reynosa controller responded by providing an altimeter setting of 29.97 inches of mercury, and by requesting the pilot report 25 miles west of the station. The pilot acknowledged the request. At 08 42, the pilot called Reynosa and indicated they were crossing their station 3 miles west and requested 8,000 feet if available (the radar data depicted the airplane east of the Reynosa VOR. The airplane stayed in the northeast quadrant of the VOR until the last three minutes of the flight when it crossed into the northwest quadrant approximately six miles north of the VOR). The controller asked the pilot to repeat his position. The pilot responded with "we are 3 miles west of the station sir." The controller responded with a "roger" and asked him to hold on.

At 0843, the Reynosa controller contacted another controller from a separate sector regarding N4945Y, and indicated that the pilot had requested 8,000 feet, and the aircraft was three miles west of the station (at this point, the radar data depicted the airplane three miles northeast of the Reynosa VOR. It had completed an s-turn to the south and was flying back toward the northwest). The other controller approved the altitude request. Shortly thereafter, the Reynosa controller asked the other controller what transponder code they had for the airplane. The other controller confirmed that it was 1714. The Reynosa controller asked the other controller if he observed the airplane crossing the U.S./Mexican border, to which the other controller answered in the affirmative and said the pilot was correcting himself. The Reynosa controller said, "Wow," to which the other controller responded, "If he is on 42, he is very off course. He is over your station." The other controller added, "How do you like that? He is about five miles north of your station" and suggested that the Reynosa controller pass the data on to Del Valle. The controllers commented to each other that the airplane was crossing the border into the U.S.

At 0844, the Reynosa controller asked the pilot of N4945Y to confirm his position, to which the pilot responded, "let me see…we are on your radial…we have a problem with my [unintelligible]…let me check with my other radio." The controller asked the pilot if they were utilizing transponder code 1714 to which the pilot responded in the affirmative. The Reynosa controller then asked another person in the tower if he should tell the pilot he was off course. Shortly thereafter, Reynosa contacted Corpus Christi approach control (CRP) to let them know that he had "traffic with problem with the…with the instruments…the squawk code is one seven one four." The CRP controller acknowledged and asked Reynosa what the pilot was doing, to which the Reynosa controller responded, "I don't know." The CRP controller asked Reynosa if the pilot was in danger, to which the Reynosa controller responded, "No, he is off course." As the two controllers discuss the aircraft's status, the CRP controller observed the airplane descending and eventually "disappeared off my scope" (the radar data depicted the airplane initiate a left turn at 6,000 feet, then initiate a right turn while entering a descent. The last five mode C returns, at 9-second intervals, depict the airplane's elevation at 5,900 feet, 5,600 feet, 5,500 feet, 5,100 feet, and 3,900 feet, respectively).

One witness was in her home at the time of the accident and heard an airplane engine. She looked out the window and observed an airplane descending at a 45-degree angle before it impacted the ground. Another witness located outdoors, observed the "tail come apart" while the airplane was "turning". He could not tell whether the wings were still on the airplane at that point.

The aircraft wreckage was located approximately ¼-mile north of the U.S. Mexican border and five miles southwest of the McAllen Miller Airport, McAllen, Texas.

PERSONELL INFORMATION

The pilot (registered owner of the airplane) held a United States (U.S.) Federal Aviation Administration (FAA) commercial pilot certificate that was originally issued on July 27, 1967. He held single- and multi-engine land, and instrument airplane ratings. He held a FAA second-class medical certificate that was issued on July 4, 2002. The medical certificate contained one limitation for vision. On the application for the medical certificate the pilot reported that he had accumulated a total of 21,402 flight hours.

The pilot also held a Mexican DGAC issued private pilot certificate for single- and multi-engine airplanes and instrument airplanes.

The pilot's logbook was not located and his instrument experience or currency could not be established.

Acquaintances of the pilot, along with information obtained during the course of the investigation, indicate that the pilot was an aircraft broker and regularly imported/exported aircraft to/from the U.S./Mexico.

AIRCRAFT INFORMATION

The 1980-model, high-wing, six-place airplane (serial number 210-64052) was equipped with a 300-horsepower TSIO-520-R (9) Continental engine (serial number 293678-R). The airplane was also equipped with a 3-bladed D3A34C402-10 McCauley propeller.

The aircraft maintenance records were found within the burnt remains of the wreckage, but were destroyed by a post-accident fire.

According to aircraft sales information found on the pilot's/owner's letterhead (dated January 13, 2003), the airplane accumulated a total of 920 hours and the engine accumulated a total of 372 hours since its last rebuild (which took place on September 23, 1995, at the manufacturer's facility) and 5 hours since a top overhaul. A statement found on the sales information indicated, "new hoses, mounts & seals, magneto, harness, starter, oil cooler, fuel injection & oil pump zero time since top overhaul."

According to the sales information and the original sales information provided by Cessna Aircraft Company, the airplane was equipped with a Cessna 400B autopilot (type AF-550A), a non-slaved Horizontal Situation Indicator (HSI), and a non-slaved attitude indicator (AI). According to the aircraft information manual, the autopilot is a "two axis automatic flight control system that governs the positions of the ailerons and elevators to provide automatic roll and pitch stability as commanded by the selected mode of operation. The autopilot can be disconnected via various methods, two of which are as follows: the "G" switch will automatically disengage the autopilot anytime the airplane pitches down at more than a normal rate from normal flight attitude. The autopilot will also be automatically disengaged anytime the airplane pitches up or down more than a normal amount from a level flight attitude. In either event, the autopilot disconnect horn will sound and the disconnect warning light will illuminate.

It should be noted that this type of autopilot system is a horizon-based system. Pitch and roll information for the autopilot is fed to the computer via a couple of electrical pick-ups located inside the AI. If the aircraft exceeds a pre-determined pitch attitude or roll, the autopilot will automatically disengage. However, if the aircraft encounters a vacuum system failure or AI failure, and the gyro does not wind down with a major tilt (in either roll or pitch), the autopilot will not disconnect immediately.

According to FAA form 8050-1 (Aircraft Registration Application), the pilot purchased the airplane on January 20, 2003. An aircraft bill of sale form (FAA form 8050-2) indicated that a private individual in Mexico was purchasing the airplane; however, no date was entered on the form with the exception of the year (2003). A letter to the Department of Transportation, dated January 2003, advised that N4945Y had been exported and sold to the private individual noted on FAA form 8050-2. The letter requested that the U.S. registry be cancelled. According to the FAA registration database, on February 11, 2003 (six days after the accident), the accident airplane was deregistered.

According to maintenance personnel who worked at Hunt Pan Am in Brownsville, Texas, the accident airplane had been at their facility just prior to the accident flight for various maintenance items, including the installation of extended range fuel tanks. According to maintenance personnel, the attitude gyro was supposed to be replaced, but the pilot took the airplane before the maintenance was performed.

METEOROLOGICAL INFORMATION

At 0853, the weather observation facility located at the McAllen Miller Airport (MFE), McAllen, Texas, reported the following weather conditions: scattered clouds at 2,400 feet, overcast 3,400 feet, wind from 120 degrees at 6 knots, visibility 10 statute miles, temperature 61 degrees Fahrenheit, dew point 55 degrees Fahrenheit, and an altimeter setting of 29.98 inches of mercury.

Review of the air traffic control transcripts provided by the Mexican DGAC revealed that an unknown controller reported the tops of the clouds at 6,200 feet.

At 0653, the pilot called the San Angelo Flight Service Station (FSS) and indicated he wanted to "check with you for inflight uh, going from Mexico, we're gonna go from Brownsville to Torreon..." The FSS weather briefer asked the pilot how long it would take to get to their destination, to which the pilot said "two hours." The briefer then asked the pilot if he had the "disclaimer for the mess of weather down south?" The pilot responded with, "yes sir." The briefer informed the pilot that there was an advisory out for occasional moderate turbulence below 6,000 feet from the departure area south of the border. The briefer added that there was "nothing significant on the radar" regarding precipitation. The pilot was informed that there was a "low pressure moving through west Texas, weak high pressure through central Texas." He was provided the local weather for Brownsville, which was presented as scattered clouds at 3,200 feet, visibility 10 statute miles, wind out of the east at seven knots, temperature 15 degrees Celsius, altimeter setting of 29.98 inches of mercury.

The briefer reported there was no weather report for Torreon because it was too early; therefore, he provided the pilot with the Monterrey weather which was presented as scattered clouds at 3,000 feet, visibility 10 statute miles, wind out of the west at four knots. The briefer was in the process of researching additional weather near Torreon when the pilot asked if anything was depicted on the "satellite, other than light clouds down in that area." The briefer indicated there might be stratus clouds in the Torreon area with a couple "mid level clouds, but other than that, really nothing that significant."

The briefer provided a forecast for the destination area, which was as follows: until 1100, the winds would be calm, clouds scattered at 10,000 feet, broken clouds at 24,000 feet, visibility greater than six statute miles, with occasional ceilings at 3,000 feet broken until 1000. After 1100 until 2300, the winds were forecast out of the south at 10 knots, visibility greater than six miles, broken clouds at 8,000 feet and 24,000 feet.

The pilot then asked the briefer for a terminal forecast for a return flight to Brownsville, arriving around 1800. The briefer provided the pilot with terminal forecast information for Brownsville. The pilot then asked for winds aloft information and was told that the wind was from 180 degrees at 30 knots at 9,000 feet at the departure area. He was then provided the winds aloft information for Mexico, which were from 230 degrees at 20 knots at 9,000 feet and 270 degrees at 30 knots at 12,000 feet. The pilot was asked if he needed anything else, to which he responded, "Well, I think that's it. You can rest a while now and I'll be checking back with you." That was the end of the weather briefing.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located north of the U.S./Mexican border and was distributed throughout an undeveloped field spotted with sagebrush and small trees. The wreckage path was oriented from the northwest to the southeast. Along the northwest end of the debris path were the right side cabin door, the left inboard wing and flap, the right elevator balance weight, the right horizontal stabilizer, and the left outboard aileron. The southeast end of the debris field consisted of the right outboard wing and aileron, the right outboard elevator, the right wing tip, the left horizontal stabilizer, and the left outboard wing. The following is a listing of the major components and their respective locations (measured with a global posit

NTSB Probable Cause

The pilot's failure to maintain aircraft control, which resulted in his exceeding the airplane's design limitation. Contributing factors were the pilot's decision to fly the airplane with known deficiencies with the attitude indicator, and the failure of the attitude indicator.