NTSB Factual Report

HISTORY OF FLIGHT

On August 14, 1999, at 1308 Eastern Daylight Time, a Cessna P210N, N24CD, was destroyed when it impacted terrain in Worcester, Vermont, after takeoff from Morrisville-Stowe State Airport (MVL), Stowe, Vermont, about 1300. The certificated private pilot and both passengers were fatally injured. Instrument meteorological conditions prevailed for the planned flight to Capital City Airport, Harrisburg, Pennsylvania. An instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 CFR Part 91.

The Airport Manager stated:

"On August 14, 1999 at approximately 1:00pm. I witnessed Cessna 210 N24CD depart from the Morrisville-Stowe State Airport. The ceilings were low at the time around 800 to 1000 feet, as I recall. There was some distant thunder to the south and the winds were out of the northwest at 15 to 20 knots. We had fueled the aircraft previously on August 8, when they arrived, with 40 gal. of 100LL. I saw [the family] briefly in the terminal building before they left. They used the facilities and the candy machine and [the pilot] told his wife and child to hurry because they had a void time...I was in the office at the time they departed and was surprised and concerned when I suddenly noticed that they were departing on runway 19 with a 15 to 20 knot tailwind. The airplane took a substantial amount of runway to rotate and then climbed very slowly. I watched the aircraft climb very slowly straight out until they disappeared in the overcast at about 800 to 1000 feet AGL. About 10 minutes later I received a call from Boston Center. They told me they had received one radio call from them, but they never showed up on radar..."

A review of an excerpt from a Federal Aviation Administration (FAA) transcript revealed:

1305:56 (N24CD) center two four charlie climbing

1306:09 (controller) two four charlie delta report reaching uh---six thousand

1306:20 (N24CD) two four charlie did not cop---copy altitude

1307:59 (N24CD) boston center two four charlie delta do you copy

1308:03 (controller) two four charlie delta climb and maintain six thousand report reaching six thousand

1308:07 (N24CD) boston center you're cutting up

1308:17 (controller) nuv two four charlie delta say again please

Air Traffic Control (ATC) did not receive any more transmissions from N24CD. Additionally, ATC never obtained radar contact with the assigned transponder code for N24CD. An emergency locator transmitter signal was received about 1308.

The accident occurred during the hours of daylight; approximately 44 degrees, 25.83 minutes north latitude, and 72 degrees, 36.76 minutes west longitude.

PILOT INFORMATION

The pilot held a private pilot certificate; with ratings for single engine land and instrument airplane.

His most recent FAA third class medical certificate was issued on October 8, 1998. At that time, he reported a total flight experience of 600 hours.

The pilot's logbook was not recovered. Using FAA records, maintenance records, and a flight instructor's estimate, the pilot's total flight experience at the time of the accident was estimated to be approximately 840 hours. About 40-80 of those hours were in actual instrument meteorological conditions.

AIRCRAFT INFORMATION

The airplane's last annual inspection was performed on March 29, 1999.

According to the airport manager, the airplane departed with full fuel, three occupants, baggage, and a dog. A Cessna P210N manual contained maximum rate of climb information. According to the information; at 4,000 pounds, at sea level, at a temperature of 20 degrees Celsius, the airplane would climb at 910 feet per minute.

METEOROLOGICAL INFORMATION

The pilot obtained three weather briefings from the Burlington Flight Service Station via telephone. He received a full briefing at 0724, and two updated briefings at 1131 and 1235. During the full briefing, the briefer stated: "...well ah thunderstorms ah possible on your route um well pretty much anytime particularly over southern portion of your route ah right now..."

During the first updated briefing, the briefer asked if the pilot's airplane was equipped with a stormscope or weather radar. The pilot stated that he had both.

During the second updated briefing, the briefer stated: "uh well there's almost a whole line ah stretching oh it looks like ah down in the ah binghamton elmira area right up through ah central ah or northcentral vermont to maine right now...." The briefer again asked if the pilot had a stormscope. The pilot stated that he did.

In addition to the airport manager's recollection of distant thunder to the south of MVL, a detective for the Vermont State Police stated that a severe weather warning was in effect, for thunderstorms, at the time and place of the accident. He added that several witnesses reported hearing thunder about 1308.

NEXRAD radar imageries were provided by the National Weather Service. According to the imageries, medium to strong intensity echo returns were present to the south of MVL, in the vicinity of the accident site, at 1246, 1300, and 1319.

MVL was approximately 8 miles north (020 degrees) of the accident site. The reported weather at MVL, at 1254, was: wind calm; visibility 3 miles, mist; sky condition broken 2,000, broken 4,900; temperature 70 degrees Fahrenheit (F); dewpoint 66 degrees F; altimeter 29.82 inches Hg.

Edward F. Knapp State Airport (MPV), Montpelier, Vermont was located approximately 15 miles south of the accident site. The reported weather at MPV, at 1251 was: wind 310 degrees at 9 knots; visibility 1.25 miles, heavy rain and mist; sky condition scattered 300, overcast 1,300; temperature 66 degrees F; dewpoint 66 degrees F; altimeter 29.85 inches Hg.

AIDS TO NAVIGATION

According to a FAA Inspector, the current Jeppesen Airway Manual contained the correct departure procedure for Runway 19 at MVL. It stated: "...Rwy 19, climbing right turn direct JRV NDB and climb in hold (northeast, left turns, 230 [degrees] inbound) to 3500' before proceeding on course."

A Jeppesen Airway Manual was found at the accident site. However, witness statements and ATC information indicated that the pilot did not fly the published departure procedure for Runway 19, nor was he required to.

The FAA Inspector added that after the accident, someone at the FAA noticed that the text departure procedure for Runway 19 at MVL was not listed in the National Ocean Service (NOS) U.S. Terminal Procedures. The FAA then added the procedure to the publication. The Inspector was advised that no NOS U.S. Terminal Publications were found at the accident site, only the Jeppesen Airway Manual.

A former flight instructor stated that the pilot was instrument proficient, but may not have been proficient at departure procedures and mountainous operations.

AERODROME INFORMATION

Morrisville-Stowe State Airport was located in valley at a field elevation of 732 feet above mean sea level. Mount Worcester was approximately 8 miles to the south. Mount Mansfield was approximately 8 miles to the west. Lower terrain was present to the north and east of the airport. The airport was served by Runway 1/19.

WRECKAGE INFORMATION

The wreckage was examined at the accident site on August 16, 1999, and although a large portion was consumed by fire, all major components of the airplane were accounted for at the scene. It was oriented to a 190-degree heading, approximately 3,200 feet above mean-sea-level, on Mount Worcester. The wreckage was about 200 feet from the summit, on the south side of the mountain. There were several tree scars near the wreckage, oriented to a southerly heading. Some of the branches were cut clean, at an approximate 45-degree angle. The wreckage and surrounding area were charred.

The right wing sustained impact damage to the leading edge. The flap was separated about mid-span, crushed, and deflected upward. The aileron was intact, and deflected upward. The right wing spar separated approximately 1 foot from the wing root. A right wingtip fuel tank was discovered in the vicinity of the wing, it was crushed and charred.

The left wing was resting on a tree. It was intact, charred, and twisted. The flap was observed separated from the wing, and the aileron was deflected upward. The leading edge was crushed.

The empennage was observed folded, charred, and twisted. The vertical and horizontal stabilizers were separated from the empennage. The right horizontal stabilizer was buckled and charred, and the left horizontal stabilizer was crushed, buckled, and charred. The rudder was destroyed.

The cockpit, and a large section of fuselage, were completely destroyed by fire. Only four flight instruments were recovered.

Due to impact and fire damage, flight control continuity could not established, and the crankshaft of the engine could not be rotated. A jackscrew measurement corresponded to a retracted flap position. The only trim that was not destroyed was the elevator trim, which was observed to be in a nose down trim setting.

The top spark plugs were removed and observed to be clean, and light brown to gray in color. Oil was present on the number one, number three, and number five spark plugs. The fuel pump was observed to be fire damaged; however, the coupling was intact. The fuel control unit filter was clean. The fuel injection manifold screen was charred, but absent of debris. One of the three propeller blades exhibited "s-bending".

Several days after the on-site examination, a detective from the Vermont State Police discovered a section of the tailcone on the other side (north) of the mountain. The tailcone was approximately 20 feet from the summit. According to the detective, the tailcone was crushed, and corresponding tree scars were observed. The detective believed that the airplane initially struck trees on the north side of the mountain, and momentum carried it to the south side, to where it came to rest.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Vermont State Department of Health Office of Chief Medical Examiner, on August 16, 1999.

Toxicological testing was conducted at the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, on September 10, 1999.

ADDITIONAL INFORMATION

The wreckage was released on August 17, 1999, and a copy of the release form was left at the Stowe Police Department, Stowe, Vermont.

NTSB Probable Cause

The pilot's inadequate in-flight planning/decision, his failure to follow the published instrument departure procedure for the particular runway, and his continued flight into known adverse weather. A factor was thunderstorms.