NTSB Factual Report

HISTORY OF FLIGHT

On October 8, 1996, at 0845 Pacific daylight time, N761TQ, a Cessna T210M, operated by the owner/pilot, collided with wires, poles, trees, and terrain and was destroyed while on an instrument landing system (ILS) approach to Runway 16R at Paine Field in Everett, Washington. The instrument-rated private pilot, the sole occupant, was fatally injured. Instrument meteorological conditions prevailed and no flight plan had been filed. The personal flight departed from Buena, Washington, and was destined for Everett. The flight was conducted under 14 CFR 91.

According to voice recordings and radar data (attached) from the Federal Aviation Administration (FAA) Air Route Traffic Control Center (ARTCC) in Seattle, Washington, the pilot requested an instrument clearance to Paine Field at 0810 while airborne at 4,000 feet above mean sea level (msl). The ARTCC granted the clearance and began to vector the airplane for the ILS Runway 16R approach.

At 0830:54, the pilot was instructed to turn to a heading of 330 degrees; the pilot acknowledged and the airplane gradually turned to 348 degrees while its ground speed decreased from 140 knots to 130 knots in 2 minutes.

At 0832:56, the pilot was instructed to turn to a heading of 250 degrees; the pilot acknowledged and the airplane gradually turned to 289 degrees while its ground speed decreased from 130 knots to 113 knots in 2 minutes.

At 0834:51, the pilot was instructed to turn to a heading of 180 degrees and was cleared for the approach; the pilot acknowledged and the airplane gradually turned to 272 degrees while its ground speed increased from 113 knots to 126 knots in 1 minute.

At 0835:47, the pilot was told "you've gone through the localizer..." and was instructed to turn to a heading of 130 to reintercept; the pilot acknowledged and gradually turned to 242 degrees in about 30 seconds.

At 0836:18, the controller told the pilot that the pilot's approach clearance was canceled, and the controller instructed the pilot to turn to a heading of 070 degrees to begin vectoring for another approach; the pilot acknowledged and the airplane gradually turned to 177 degrees while its ground speed decreased from 123 knots to 93 knots in 45 seconds.

At 0837:04, the pilot was instructed to turn to a heading of 030 degrees; the pilot acknowledged and the airplane gradually turned to 123 degrees while its ground speed decreased from 93 knots to 73 knots in 1 minutes.

At 0838:09, the pilot was instructed to turn to a heading of 350 degrees; the pilot acknowledged and the airplane gradually turned to 039 degrees while its ground speed increased from 73 knots to 96 knots in 102 seconds.

At 0841:00, the pilot was instructed to turn to a heading of 180 degrees and was cleared for another approach; the pilot acknowledged and the airplane gradually turned to 241 degrees while its ground speed increased from 94 knots to 137 knots, then decreased to 115 knots in 2 minutes. The airplane's altitude remained about 2,900 feet msl during all of the vectoring.

At 0842:05, the controller instructed the pilot to contact the Paine Field Air Traffic Control (ATC) Tower; the pilot acknowledged. The airplane's heading changed from 244 degrees to 203 degrees while its ground speed increased from 116 knots to 129 knots with no change in altitude.

The pilot subsequently contacted the tower controller, and the controller cleared the pilot to land on runway 16R. About one minute later, the controller told the pilot that the runway visual range for runway 16R was 1,000 feet. The pilot acknowledged; this was his last transmission. No distress calls were made by the pilot during the entire accident flight.

At 0843:17, the airplane began to descend out of 2,900 feet msl. From the beginning of the descent until the accident, the airplane descended about 1,000 feet per minute while its ground speed increased from 127 knots to 151 knots and its heading changed from 203 degrees to 184 degrees. The last recorded radar hit occurred at 0845:17; the airplane was about 400 feet above the ground, 1 mile from runway 16R, and traveling at 151 knots at the time of the last radar hit.

Ground witnesses reported hearing and seeing the airplane flying "low" through "thick fog" and impacting a utility pole. One witness stated that he heard the engine "rev up" just prior to impact. The airplane then struck trees and came to rest inverted about 800 feet from the approach threshold of runway 16R.

The accident occurred during daylight conditions at the following coordinates: North 47 degrees, 54 minutes; West 122 degrees, 16 minutes.

AIRCRAFT INFORMATION

The accident airplane, a Cessna model T210M, was manufactured in 1978 and was powered by a single 310-horsepower Continental turbocharged, propeller-driven engine. The airplane was registered to, and operated privately by, the accident pilot since 1978.

The Safety Board obtained and reviewed the aircraft maintenance records of the airplane. A review of the records (excerpts of copies attached) revealed that the airplane had not received an annual inspection since March 10, 1994, or an IFR certification inspection since January 13, 1993. Entries subsequent to the last annual inspection were found in the logbook; the last entry was dated June 27, 1996, and documented the overhaul of a hydraulic pump. Information from the records and the airplane's tachometer hour meter revealed that the airplane had logged a total of 2,758 hours at the time of the accident, 243 hours since it's last logged inspection, and 980 hours since its engine was rebuilt.

The records also indicated that the engine received an annual inspection on May 8, 1996, with no outstanding discrepancies noted. The engine accumulated an additional 68 hours from the time of this inspection to the accident.

According to a fixed based operator in Yakima, Washington, who had performed the most recent logged inspection on the accident airplane, the pilot routinely operated the airplane in and out of a private dirt strip located near his orchard properties, and the pilot often performed his own maintenance of the accident airplane.

PERSONNEL INFORMATION

The pilot, age 75, held an FAA Private Pilot certificate with ratings for airplane single-engine land airplanes and instrument airplanes. An examination of the pilot's personal flight log book (excerpts of copies attached) revealed that he had logged a total of 4,191 hours as of January 1, 1993. No subsequent entries were found in the log book. The most recent flight review was dated March 19, 1990.

According to FAA records, the pilot was issued an FAA Third Class Medical Certificate on November 13, 1992. The pilot indicated that he had logged in excess of 4,000 flight hours at the time of the medical application. The medical certificate had expired on December 1, 1994, after the pilot had failed to undergo several specified medical tests required by the FAA.

Information contained in the pilot's medical records indicated that the pilot underwent "an aortocoronary saphenous vein by-pass graft to the left anterior descending coronary artery" on May 13, 1980. He failed to notify the FAA of the surgery and continued to fly under a medical certificate that was valid at the time of the operation. Seven months after the surgery, the FAA suspended the pilot's airman certificate after a "friend of neighbors of [the pilot were] concerned about his piloting his aircraft following open heart surgery...." The pilot subsequently underwent numerous tests and was continually granted medical certificates by the FAA until December 1, 1994.

The medical records also revealed that the pilot had checked "no" under the category of previous "Heart or vascular trouble" at the time of his most recent medical certificate application. Also, the records indicated that the pilot had a "cystoscopy for renal tuberculosis" in 1950, and had continually experienced periods of pain and abnormal heart rhythms.

METEOROLOGICAL INFORMATION

The reported official weather conditions at Paine Field about five minutes after the accident were: sky obscured, indefinite cloud ceiling, vertical visibility 200 feet, horizontal visibility 1/2 mile in fog, temperature 54 degrees F, dew point 52 degrees F, altimeter 30.20 inches of mercury.

The Safety Board also reviewed the recorded National Weather Service observations (print-out attached) of an experimental Automated Surface Observation System (ASOS) installed at destination airport for the times surrounding the time of the accident. These observations are not considered official and were recorded for test purposes only. A review of the recorded ASOS observations taken immediately before (at 0827), and immediately after (at 0855) the accident revealed that the cloud ceiling deteriorated from 200 feet overcast to 100 feet overcast, while the visibility remained stable at 1/2-mile in fog.

A review of the ATC voice recordings revealed that the runway visual range for the runway of intended landing was 1,000 feet just prior to the accident.

AERODROME AND GROUND FACILITIES

The Snohomish County Airport (Paine Field) is served by two paved runways and ATC services. The field elevation is 606 feet msl. Runway 16R (the accident approach runway) is 9,010 feet long and 150 feet wide. At the time of the accident, there was a complete ILS approach to runway 16R in service. According to a copy of the terminal approach procedure diagram (attached) found in the wreckage, the touchdown zone elevation of runway 16R is 565 feet msl and the approach course is 159 degrees magnetic.

The complete straight-in ILS approach procedure, utilizing an operable localizer (course guidance) and glide slope (descent guidance), calls for a visibility minima of 2,400 feet of runway visual range or 1/2-mile at the decision height. The decision height is published as 765 feet msl, or 200 feet above the ground. If the runway environment is not visible at the decision height, the published procedure calls for the execution a missed approach procedure involving an immediate, straight-out climb to 1,100 feet msl, then a climbing right turn to a heading of 250 degrees.

The FAA conducted a flight inspection of the ILS runway 3 approach on the day of the accident. No anomolies associated with the approach were reported.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was examined at the accident site by the Safety Board about 2 hours after the accident. The airplane came to rest about 800 feet from the approach threshold of runway 16R. The engine and propeller had separated from the airframe and were found about 40 feet to the south of the main wreckage. No evidence of fire was found throughout the entire impact area.

Additional examination of the area surrounding the main wreckage revealed that an electrical transmission wire had been severed about 600 feet north of the main wreckage. The severed wire was located about 450 feet west of the extended runway centerline, and 1,400 feet from the runway threshold. A sheared electrical power pole, left wing tip, sheered trees, ground crater, and a crushed fenced led from the severed power line to the main wreckage. The magnetic bearing of the wreckage distribution path was measured to be about 140 degrees.

No evidence of an in-flight fire, in-flight explosion, or in-flight structural failure was found. All primary and secondary flight control surfaces were accounted for at the main accident site. No evidence was found to indicate a flight control deficiency.

The engine was moved to a hangar and underwent a detailed inspection; no evidence of any preimpact mechanical deficiencies was noted. The engine rotated freely when the propeller was rotated through 360 degrees; compression was felt on all six cylinders during the propeller rotation. Fuel was found in the gascolator and fuel distribution valve.

The propeller remained attached to the engine and its three blades were examined. Propeller blade no. 1 was found secure in the hub. It was bent aft about 30 degrees beginning from a point located about 6 inches from its shank. Light chordwise scratching was noted along the entire blade span, and a gouge was noted on its leading edge about 1.5 inches from the blade tip. Propeller blade no. 2 was also secure in the hub. It exhibited slight "S" bending along its entire span. Light chordwise scratching and leading edge gouging was found along the outboard 12 inches of the blade. Propeller blade no. 3 was bent aft about 30 degrees and was found loose in the hub. Marks that were similar to the thickness of a power cable were found near the tip of the blade, and the leading edge was torn in two areas near the marks. This blade also exhibited a slight "S" bend beginning about 10 inches from the hub.

TESTS AND RESEARCH

On January 21, 1997, the navigation/communication transceivers from the accident airplane were tested (report attached) under the supervision of the FAA at facilities owned by AlliedSignal Aerospace in Olathe, Kansas. The results of the testing revealed that the primary navigational receiver found to function normally and within specifications; it was in the "on" position and selected to the proper ILS runway 16R approach frequency. The marker beacon receiver was also tested and found to function normally and within specifications.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by Dr. Daniel Selove, M.D., on October 9, 1996, at the Snohomish County Medical Examiner's Office, Everett. According to the report of autopsy, the pilot "... died of multiple visceral lacerations and skeletal fractures due to blunt impact to the head and trunk. The manner of death is accidental."

Specimens taken from the pilot were analyzed by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. According to their report (attached), the following substances were detected:

--- 0.085 (ug/ml, ug/g) Hydrocodone detected in blood --- 0.767 (ug/ml, ug/g) Hydrocodone detected in urine --- 0.057 (ug/ml, ug/g) Dihydrocodeine detected in urine --- 0.158 (ug/ml, ug/g) Hydromorphone detected in urine --- 12.100 (ug/ml, ug/g) Acetaminophen detected in blood --- 39.700 (ug/ml, ug/g) Acetamenophen detected in urine --- Isoniazid detected in urine --- Nadolol detected in blood and urine

The levels of hydrocodone and its metabolites, and acetamenophen is consistent with recent use of a potent narcotic painkiller which would have impaired the pilot's mental and physical performance during the accident flight.

Isoniazid is a drug used exclusively to treat tuberculosis or prevent it in exposed individuals. Nadolol is a long-acting beta-blocker which can be used to treat high blood pressure and abnormal heart rhythms. Nadolol can also be used to reduce the risk of heart attack. The level of these two drugs is also consistent with recent use.

ADDITIONAL INFORMATION

The aircraft wreckage, except for the avionics equipment that was retained for further testing, was released to Ms. Virginia Obert, Zillah, Washington, on October 10, 1996. Ms. Obert was representing the estate of the pilot at the time of the release. The avionics equipment was subsequently released to Ms. Obert on March 10, 1997.

NTSB Probable Cause

The pilot's impairment of judgment and performance due to the recent excessive use of potent prescription drugs, the pilot's descent below the published decision height, and the pilot's failure to execute a missed approach. Factors contributing to the accident were the adverse meteorological conditions which were below the published required visibility, runway visual range, and ceiling minima due to fog.