NTSB Factual Report

HISTORY OF FLIGHT

On September 23, 2009, at 2025 central daylight time (CDT), a Cessna T210N , N9734Y, impacted trees and an unoccupied home while attempting a go-around at Hilltop Lakes Airport (0TE4), Hilltop Lakes, Texas. The airplane was registered to Moe Transportation, Inc. of South Burlington, Vermont, and was operated by a private individual. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane was destroyed, and the pilot was fatally injured. No other persons were injured. Dark night visual meteorological conditions prevailed and a VFR flight plan had not been filed. The flight had originated from Shreveport Downtown Airport (DTN), Shreveport, Louisiana, at 1911, en route to 0TE4.

The pilot’s first flight of the day departed Burlington International Airport (BTV) Burlington, Vermont, at 0830 eastern daylight time. He refueled the airplane at Flemingsburg-Mason Airport (FGX), Flemingsburg, Kentucky, and departed at 1512 eastern daylight time. The pilot had another refueling stop at DTN before departing for 0TE4.

The runway lights at the 0TE4 airport had been inoperative following a recent lightning strike and the pilot was not aware of the inoperative lights. Several witnesses were listening on the 0TE4 Unicom frequency of 122.750 megahertz when they heard someone repeatedly “clicking five clicks” consistent with a pilot trying to activate the pilot control runway lighting. One witness received a static filled in-flight cellular telephone call from the pilot. He told the pilot to attempt contact on the Unicom radio. Several witnesses heard the pilot’s radio call on their radio scanners, but could not reply. A witness who was able to transmit on the Unicom frequency told the pilot that the runway lighting was inoperative. Another witness had positioned his car with the headlamps illuminating the runway and the pilot acknowledged seeing the flashing car lights on the runway. The pilot stated he was going to attempt a landing on runway 34 by using the landing lights on the airplane to illuminate the runway edge reflectors. The pilot was west of the 0TE4 airport when he flew eastbound over the airport and entered a right turn for a landing on runway 34. Several witnesses said the pilot was not aligned with runway 34 and appeared to be too high to land. The witnesses said the airplane was approximately 50 to 150 feet above ground level when the pilot transmitted on the Unicom frequency that he was starting a go-around. The witnesses said the airplane almost immediately started a descent, struck trees on the right side of the runway, and impacted an unoccupied home. There was an immediate post-impact fire.

PERSONNEL INFORMATION

The pilot, age 57, held a private pilot certificate with an airplane single-engine land rating, and an instrument airplane rating. The pilot was issued a restricted third-class medical certificate on April 16, 2008. The pilot completed a biennial flight review (BFR) on July 28, 2008.

One pilot logbook was available during the investigation. The first entry in that logbook was made on July 22, 2008, and the last entry was made on June 4, 2009. The logbook did not list cumulative totals for night experience or instrument experience. At the time of the accident, the pilot had an estimated total of 1,276 hours of pilot experience with an estimated total of 475 hours in the same make and model airplane.

The pilot’s logbook, aircraft maintenance logbooks, and other records revealed that the pilot had previously landed at the 0TE4 airport a total of five times. The first three landings were cross country flights from Burlington, Vermont, with en route fuel stops. The pilot’s logbook showed that he made three previous night landings at the 0TE4 airport. The first night landing was on August 1, 2008, and the last was on January 12, 2009. For those previous night landings at the 0TE4 airport, the weather conditions were clear skies and runway lighting was available. For the last two night landings there was visible moonlight. The pilot’s logbook showed that his most recent landing at the 0TE4 airport was a daytime flight on February 3, 2009, when the weather conditions were clear skies.

AIRCRAFT INFORMATION

N9734Y, serial number (S/N) 210645883, a model T210N, was manufactured by the Cessna Aircraft Company in 1981. It was a high-wing, single engine land airplane. The airplane was originally delivered with a Continental TSIO-520-R6A engine, S/N 522344 rated at 310 horsepower. At the time of the accident, it was powered by a Continental TSIO-520-PcR (6) engine, S/N 278573-R, rated at 310 horsepower, driving a McCauley 3-blade, constant speed, aluminum alloy propeller. It was equipped with retractable landing gear. In addition, the airplane was equipped with a Garmin GNS 430 navigation and communications unit, a JP Instruments EDM-700 engine analyzer, and a Cessna 400B IFCS autopilot. The airplane was issued a standard airworthiness certificate on December 3, 1981, in the normal category. The airplane was registered to the owner on May 26, 2006.

The aircraft maintenance records available during the investigation showed that the most recent annual inspection was completed on June 1, 2009, at a tachometer time and aircraft total time of 3,280.4 hours, and an engine total time of 1,193.6 hours. The last maintenance log entry was on August 4, 2009, at a tachometer time of 3,300.3 hours. Examination of data from airplane tracking websites and other records showed that the airplane flew six flights after August 4, 2009, totaling approximately 12 hours.

At the time of the accident, the airplane had an estimated total time of 3,312 hours, and an estimated engine total time of 1,225 hours.

METEOROLOGICAL INFORMATION

Three witnesses at the accident scene were instrument rated professional pilots. One witness estimated the visibility was 3 to 5 miles in drizzle or light rain with overcast clouds. The second witness estimated the visibility was less than 5 miles in light drizzle with a ceiling of 2,000 feet. The third witness estimated the visibility was 5 miles in light rain with a ceiling at 500 to 1,000 feet.

At 2053, the automated weather observing system at Easterwood Field Airport (CLL), 30 miles southwest, reported winds from 010 degrees at 10 knots, visibility of 5 miles in rain, overcast clouds at 3,600 feet, temperature 61 degrees Fahrenheit, dew point 54 degrees Fahrenheit, with an altimeter setting of 30.16 inches of Mercury. U. S. Naval Observatory records show that sun set occurred at 1920 and the end of civil twilight occurred at 1944. There was a waxing crescent moon with 27 percent of the moon’s visible disk illuminated. Moon transit occurred at 1725 and moon set occurred at 2228.

AIRPORT INFORMATION

The Airport/ Facility Directory, Southwest U. S., listed the 0TE4 airport as a private airfield use with prior permission required for landing. Runway 16/34 was listed as 3,000 feet long and 40 feet wide. The runway surface was composed of asphalt. No runway lighting was listed, but there was a note that the runway was outlined with reflectors.

The airport operator’s website showed that runway 16/34 had runway lighting, which could be pilot controlled on the Unicom frequency of 122.750 megahertz. The runway lighting system had been inoperative for several weeks due to a lightning strike.

A notice to airmen (NOTAM) was not published for the outage of the 0TE4 airport lighting system, nor was one required for the private airport.

WRECKAGE AND IMPACT INFORMATION

Investigators from the Safety Board, Cessna Aircraft Company (Cessna), and Teledyne Continental Motors (TCM), examined the wreckage at the accident scene on September 24 and 25, 2009.

The accident site was located in a rural residential neighborhood adjacent to 0TE4. The streets surrounding the accident site were not equipped with street lights. The main wreckage was located near the center of an unoccupied single story home, which had been destroyed by the post impact fire. The first point of impact was a damaged pine tree approximately 40 feet tall. Lodged on the top of the pine tree was the airplane’s right horizontal stabilizer. The debris path was approximately 320 feet long on a bearing of 360 degrees. The outboard portion of the right wing, the right aileron, the left aileron, and a portion of the left wing had separated from the airplane and were found in the debris path leading to the main wreckage. The aileron cables on the outboard portions of the wings were connected to their bellcranks, and the separated ends of the cables exhibited fracture surfaces consistent with tension overload.

The flap and elevator trim actuators, landing gear, engine, propeller, and several avionics boxes were found in the debris of the main wreckage. The flap motor had separated from the jack screw. The jack screw extension measured 3.75 inches, which corresponds to a flap setting between 0 and 5 degrees. The elevator trim actuator measured 1.4 inches, which corresponds to approximately 6 degree tab down. Several seat components, three latched seat belt buckles, and one unlatched seat belt end were found in the wreckage. The elevators and rudder were not observed. Several primary flight control cables were found in the wreckage, but continuity and identification could not be determined. No avionics components with non-volatile memory were recovered from the wreckage. All portions of the wreckage recovered from inside the home exhibited extensive thermal damage. No pre-impact anomalies were observed that would have precluded normal operations.

PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on September 26, 2009 by the Southwestern Institute of Forensic Sciences, Dallas, Texas. The autopsy findings reported the cause of death as "acute traumatic injuries sustained in a plane crash".

Toxicological analysis was performed on specimens from the pilot by the Federal Aviation Administration (FAA), Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma. The toxicology report stated: tests for CARBON MONOXIDE were not performed; tests for CYANIDE were not performed; NO ETHANOL detected in Muscle; NO ETHANOL detected in Brain; and NO DRUGS detected in Liver.

TESTS AND RESEARCH

Investigators from the Safety Board, Cessna, and TCM examined the engine at the facilities of Air Salvage of Dallas, Lancaster, Texas, on October 15, 2009.

The engine exhibited impact and thermal damage. All of the accessories except the turbocharger and the propeller governor were separated. All of the cylinder heads exhibited impact and thermal damage. The rear portion of both crankcase halves had been thermally damaged and the crankshaft and camshaft were exposed. The turbocharger was attached and partially melted. The propeller remained attached and was partly melted. The intake and exhaust pipes were mostly separated.

The crankshaft was intact and in place. All of the connecting rods were in place and would not move. The counter weights were in place and would not move. The camshaft was intact and examined. The pistons were in place and partially melted. Seven of the 12 spark plugs were recovered and examined. The starter drive shaft was recovered and examined. The partially melted turbocharger was in place and examined. The propeller remained attached and was examined. Blade one was melted to the shank. Blade two was bent 40 degrees toward the non-cambered side and the blade tip was melted. Blade three was bent 70 degrees toward the non-cambered side and the tip was melted. No pre-impact anomalies of the engine were observed.

ADDITIONAL INFORMATION

Spatial disorientation

According to the FAA “Instrument Flying Handbook”, FAA-H-8083-15A, chapter 1, Human Factors, lists some of the illusions leading to spatial disorientation as follows:

“Somatogravic illusion - A rapid acceleration…..can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low, or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the aircraft into a nose up, or stall attitude.

Elevator illusion - An abrupt upward vertical acceleration, as can occur in a helicopter or an updraft, can shift vision downwards (visual scene moves upwards) through excessive stimulation of the sensory organs for gravity and linear acceleration, creating the illusion of being in a climb. The disoriented pilot may push the aircraft into a nose low attitude.”

The FAA “Airplane Flying Handbook”, FAA-H-8083-3A, chapter 10, states the following about night flying and its affect on spatial orientation:

"Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning...Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane...Under no circumstances should a VFR night-flight be made during poor or marginal weather conditions unless both the pilot and aircraft are certificated and equipped for flight under…IFR...”

According to the FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

According to FAA Order JO 7930.2, Instructions that NOTAMs are issued only for public use airports, and are not issued for private use airports is found in paragraph 2-2-1a. “NOTAM D. Information that meets the criteria of this order and requires wide dissemination via telecommunication and pertains to en route navigational aids, civil public-use airports listed in the AFD, facilities, services, and procedures”. Additionally, the front cover of the airport facility directory (AFD) has a note that the directory contains NOTAMs only for public airports, seaplane bases and heliports, and military facilities. NOTAMs are listed for selected private use facilities only when specifically requested by the Department of Defense.

NTSB Probable Cause

The loss of control of the airplane in dark night light conditions due to the pilot’s spatial disorientation.