DEN07FA165
DEN07FA165

HISTORY OF FLIGHT

On September 24, 2007, at 1024 mountain daylight time, a Cessna T210M single-engine airplane, N732XE, was destroyed when it impacted terrain following a loss of control during landing at Moriarty Airport (0E0), Moriarty, New Mexico. The flight instructor (instructor pilot) sustained serious injuries and the commercial pilot receiving instruction (pilot trainee) sustained fatal injuries. The airplane was registered to and operated by the United States (U.S.) Customs and Border Protection (CBP), Washington, DC. Visual meteorological conditions prevailed, and a company flight plan was filed for the Title 14 Code of Federal Regulations Part 91 instructional flight. The flight departed the Albuquerque International Sunport Airport (ABQ), Albuquerque, New Mexico, at 0934.

Prior to departure, at 0929, the instructor pilot and pilot trainee contacted ABQ approach and requested a heading of 060 degrees and an altitude of 9,500 feet mean sea level (msl). At 0933, the airplane was cleared for takeoff from ABQ, and at 0939, radar services were terminated. During the flight, the CBP Air and Marine Operations Center tracked the airplane via satellite tracking. Tracking data showed, at 1004, the airplane approached 0E0 from the north and entered a left downwind for runway 26. The data showed the airplane conducted four landings to runway 26, and at 1024, the satellite signal was lost on the fifth landing.

A pilot-rated witness, who was located in his airplane at 0E0 taxiway/intersection D, observed the airplane performing several touch and go maneuvers on runway 26 (The witness was a tow airplane pilot for glider operations based at 0E0). He stated the accident airplane appeared to be set up for a short field landing based on the final approach descent angle and full flap position. Approximately 10 to 12 feet above ground level (agl), the airplane appeared to flare and then drop onto the runway. The airplane bounced and became airborne with the wings in a straight and level position. The airplane then drifted to the right of runway centerline, and the witness heard the "engine power come up." The airplane's nose suddenly pitched up and approximately 30 to 40 feet agl, the airplane stalled and impacted the terrain in a nose low attitude. The witness and another individual exited their aircraft and ran toward the accident site. They observed the right seat occupant (instructor pilot) exit the right side of the airplane and attempt to assist the left seat occupant (pilot trainee) from the left side of the airplane. The witness stated that after impact, a fire started near the firewall and shortly thereafter, the entire airplane was engulfed in flames. At the time of the accident, the winds were from the southwest approximately 15 knots.

PERSONNEL INFORMATION

Instructor Pilot

The instructor pilot, age 37, held an airline transport pilot certificate, issued October 26, 2001, with an airplane multiengine land rating, and a commercial pilot certificate with an airplane single-engine land and helicopter ratings. The pilot also held a certified flight instructor's certificate, issued October 19, 2006, with an airplane single-engine land rating. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on April 24, 2007, with no limitations or restrictions.

According to the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1), which was completed by CBP, the instructor's total flight time at the time of the accident was 3,687 hours, with 1,047 in single-engine airplanes, and 711 as a flight instructor. He had accumulated 252 hours in the accident airplane make and model, of which 21 were logged as a flight instructor. In the 90 days preceding the accident, the instructor had accumulated 69 total flight hours, of which 25 were in the accident airplane make and model, and 12 total hours in the 30 days preceding the accident.

CBP reported that in 1994, the instructor received his initial flight training at the US Naval Aviation Training Facility, Corpus Christi, Texas. In February 2001, he was assigned as a primary flight instructor in T-34C airplanes. In September 2003, he was hired by the U.S. Immigration and Customs Enforcement service as a pilot. On August 2, 2004, the instructor completed the Cessna 210 initial training per the Aircrew Standardization Manual (ACSM) at the Albuquerque Air Branch. On February 15, 2005, the instructor completed the Cessna 210 initial vendor training with Flight Safety International, Wichita, Kansas.

On February 16, 2007, he completed his CBP instructor pilot initial training per the ACSM at the National Aviation Training Center (NATC) in Oklahoma City, Oklahoma. He was designated as a Cessna C-210 instructor pilot in accordance with the Aviation Operations Handbook and the Crewmember Standardization Manual (CSM) on March 8, 2007. On August 3, 2007, the instructor completed a flight review, instrument proficiency check, and Cessna 210 recurrent training at Flight Safety International. On August 23, 2007, he was designated as an instructor pilot in Cessna 100 and 200 series airplanes.

On July 10 and 11, 2007, the instructor pilot completed vendor supplied stall and unusual attitude flight training in an Extra 300L airplane.

Pilot Trainee

The pilot trainee, age 39, held a commercial pilot certificate, issued on December 10, 2000, with airplane single-engine land and instrument airplane ratings. His most recent FAA first-class medical certificate was issued on October 4, 2006, with no limitations or restrictions.

According to the NTSB Form 6120.1, the trainee's total flight time at the time of the accident was 512 hours, 444 hours as pilot-in-command, and 7 hours in the accident make and model. The pilot's logbook was not located.

CBP reported that in 2004, the trainee received an initial training assessment by the U.S. Border Patrol, El Paso Flight Operations, El Paso, Texas. The assessment was in accordance with Border Patrol procedures at that time, and the pilot indicated he had accumulated 335.7 total flight hours. At an unknown date, the trainee applied for the CBP Pilot Trainee Program. On the application form, the trainee indicated he had accumulated 436 total flight hours.

On February 17, 2007, the pilot trainee entered the CBP Pilot Trainee Program. At that time, the CBP's El Paso Air Branch was establishing the trainee program. While the trainee was stationed in El Paso, he logged approximately 72 hours in helicopters while flying with a CBP pilot who held a flight instructor certificate. CBP reported that the trainee's flight time was accrued while serving as a crewmember on operational missions as time permitted.

On September 18, 2007, the trainee was sent to the CBP Albuquerque Air Unit to begin his fixed wing flight time in Cessna 210 airplanes. Prior to his arrival in Albuquerque, the trainee received ground instruction and computer based training in El Paso, in accordance to the Aircrew Standardization Manual (ASM). During the five days following the trainee's arrival to Albuquerque, the trainee was scheduled with and trained by the instructor pilot on four of those days. During that time, the trainee accumulated 5.9 hours in the Cessna 210. The training was conducted in accordance with the Pilot Trainee Program issued by CBP Air and Marine on March 20, 2007. The training was also conducted in accordance with training procedures developed by the El Paso Air Branch to supplement the Pilot Trainee Program.

During the four days of flight training, the trainee was graded on various components of pre-flight, flight maneuvers, flight techniques, and judgment. A 1, 2, or 3, on a Cessna 100 and 200 series grade sheet, designated the grading format. The grade scores were noted as the following: 1 = Unsafe or well below standards for stage of training and needs additional training, 2 = Below standards and needs additional training, 3 = Within standards.

For the days of September 19, 20, 22, and 23, the trainee received the following scores for these graded components, respectively:

Approach to Landing Stall: 2, 2, 3, 2
Short-Field Landing: 3, 3, 3, 2
Judgment: 3, 2, 3, 3

In addition to the grades, the instructor pilot also provided comments regarding the trainee's flight. The following excerpts were noted in the instructor's comments to the trainee on the September 23rd flight: "Flew a simulated check today, not ready for the real thing...[Trainee] sometimes struggles with aircraft trim, tries to 'muscle' aircraft...Flew a better pattern today, more thorough with pwr settings and BCGUMPS. Sometimes initiates flare too high, but has enough finesse for a safe landing -- except for short field landings, where he doesn't have the airspeed to sacrifice. For short field approaches, needs to work on a stabilized approach and not flaring high."

AIRCRAFT INFORMATION

The 1977-model Cessna T210M, serial number 21061850, was a single-engine, high-wing, retractable tri-cycle landing gear, semi-monocoque design airplane. The airplane was powered by a six-cylinder Teledyne Continental Motors TSIO-520-R9B turbocharged engine, serial number 289602-R, rated at 300 horsepower, and equipped with a three-bladed McCauley constant speed propeller. The airplane was configured to carry a maximum of three occupants; 2 forward seats and a rear observer seat.

The airplane was issued a standard airworthiness certificate on April 4, 1977, and was certificated for normal category operations. The airplane was registered to the owner on September 30, 1986, and was maintained under a continued airworthiness maintenance program. A review of the maintenance logbook revealed the most recent annual inspection was performed on January 5, 2007, at a total airframe time of 4,911.1 hours, and an engine time of 30.1 hours. A 50-hour inspection on the airframe was completed on August 30, 2007, at a total airframe time of 5,103.9 hours, and an engine time of 222.9 hours. Total airframe and engine hours at the time of the accident could not be determined.

The calculated aircraft weight at the time of the accident was 3,636 pounds, and the center of gravity was 43.9 inches aft of datum; both of which were within specified limits.

The airplane was equipped with manual and electric elevator trim. A manual trim control wheel was mounted vertically on the lower front panel between the left and right forward seats. A position indicator was located to the right of the control wheel. Forward rotation of the trim wheel trimmed the nose down; conversely, aft rotation trimmed the nose up. A slide-type trim switch located on the top left control yoke grip controlled the electric trim system. The electric trim system could be overridden at any time by manually rotating the elevator trim control wheel.

A Robertson STOL (short takeoff and landing) kit was installed in accordance with supplemental type certificate (STC) SA1525WE. The kit included wing fences, drooped leading edges, and flap-aileron interconnects. According to the pilot's operating handbook supplement, at 3,800 pounds gross weight, the stall speeds with zero degrees of bank and zero thrust for flap positions up, 20 degrees, and 30 degrees, were 59, 53, and 46 knots indicated airspeed, respectively. The supplement procedure for "Balked Landing" was as follows:

(1) Power - 36.5 INCHES Hg and 2,700 RPM
(2) Wing Flaps - RETRACT IMMEDIATELY to 20 (degrees)
(3) Climb past obstacles at 60 KIAS

- AFTER CLEARING OBSTACLES -

(4) ACCELERATE to 78 KIAS and RETRACT flaps slowly
(5) Cowl Flaps - OPEN.

METEOROLOGICAL INFORMATION

At 1015, the DigiWx weather advisory system, which was maintained and operated by a 0E0 fixed based operator (FBO), reported the wind from 242 degrees at 14 knots, gusting to 18 knots, temperature 17 degrees Celsius, dew point 5 degrees Celsius, an altimeter setting of 30.17 inches of Mercury, and a density altitude of 7,268 feet.

AERODROME INFORMATION

The Moriarty Airport, 0E0, is a public, uncontrolled airport located 2 miles southeast of Moriarty, New Mexico, at 34 degrees, 59.14 minutes north latitude, and 106 degrees, 00.57 minutes west longitude, at a surveyed elevation of 6,199 feet. The airport features one asphalt runway, Runway 8/26, which is 7,700 feet long by 75 feet wide.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in soft, brush-covered terrain, and the airplane came to rest in an upright position on a measured magnetic heading of 027 degrees, approximately 260 feet from the edge of runway 26 and 1,800 feet from the threshold of runway 26. A ground scar, approximately 25 feet in length, was located between the runway edge and the main wreckage. The airplane was destroyed by a post-impact fire.

The left wing remained partially attached to the fuselage, and thermal damage was noted at the wing root. The left wing tip was separated and came to rest adjacent to the 25-foot ground scar. The outboard 2 feet of the wing was crushed upward and aft. The outboard section of the wing leading edge was crushed aft. The aileron and flap remained attached to the wing, and the flap was found extended to the track stop. The flap actuator was measured to .05 inches, which was consistent with the flaps in the 30-degree extended position. Flight control continuity to the aileron was established.

The right wing was destroyed and partially consumed by fire. The outboard 3 feet of the wing was crushed upward and aft. The aileron remained partially attached and displayed thermal damage. The flap was destroyed by fire. Flight control continuity to the aileron was established.

The left horizontal stabilizer was intact and no visible damage was noted. The elevator remained attached to the stabilizer. The right horizontal stabilizer was intact, and the leading edge displayed thermal damage. The elevator remained attached to the stabilizer. Elevator trim was measured to be 1/2 inches tab down, which was consistent with a trim setting of approximately 10 degrees nose up. The vertical stabilizer was intact and thermal damage was noted on the lower forward portion of the surface. The rudder remained attached to the stabilizer. Flight control continuity was established from the cockpit to the elevator and rudder control surfaces.

The cockpit and cabin were destroyed by post-impact fire. Cockpit instruments and controls were destroyed by fire. The propeller and mixture cockpit controls were found in the full forward position, and the throttle was approximately 2 inches aft of full forward. The two forward and rear observer seats were destroyed by fire. The left lap belt was found secured and the right lap belt was unlatched. The airplane was equipped with shoulder harnesses. The left main landing gear was found in the extended position, the right main landing gear was found in the partially retracted position, and the nose gear was separated and found approximately 20 feet west of the main wreckage. Examination of the landing gear position switch indicated the switch was in the down position.

The top engine cowling was destroyed by fire, and the engine was partially separated from the firewall. The oil sump was partially consumed by fire and the oil pickup tube was exposed. The cylinders displayed thermal damage and the number 1 and 3 rocker arm covers were consumed by fire. The upper ignition harness was consumed by fire. The throttle body was destroyed. The 3-blade propeller assembly remained attached to the engine crankshaft. The blades displayed forward twist, leading edge damage, and s-type bends. The engine was retained for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

The instructor pilot was transported from the accident site to the University of New Mexico hospital. During an interview with the pilot, conducted by the NTSB investigator-in-charge (IIC) and a representative of CBP two days after the accident, the pilot stated he sustained injuries to include the following: broken nose, 1st degree burns to the left side of his face, 2nd degree burns to his left wrist and forearm, deep cut to his left leg, burns to his left leg, 2nd degree burns to his right leg, and a minor concussion. The instructor pilot stated he did not sustain any internal injuries.

During the hospital interview and subsequent interviews, the instructor pilot stated he had no recall of the accident flight or the previous several days.

An autopsy was performed on the pilot trainee by the Office of the Medical Investigator, State of New Mexico, on September 25, 2007, and specimens were retained for toxicological analysis by the Federal Aviation Administration's Civil Aeromedical Institute's Forensic and Accident Research Center, Oklahoma City, Oklahoma. According to the autopsy report, "prominent soot" was found within the trachea and mainstem bronchi. The report listed the cause of death for the pilot trainee was "blunt force injuries of head."

Toxicological tests were negative for cyanide and ethanol. A level of 15 percent carbon monoxide was detected in the blood, and an unspecified level of pseudoephedrine was detected in the blood.

TESTS AND RESEARCH

On December 13, 2007, at the facilities of Teledyne Continental Motors, Mobile, Alabama, under the supervision of the NTSB IIC, the engine was examined. According to the engine manufacturer, the engine inspection did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower.

ADDITIONAL INFORMATION

According to the FAA's 2004 Airplane Flying Handbook, Chapter 4, Slow Flight, Stalls, and Spins, section Elevator Trim Stall, "The elevator trim stall maneuver shows what can happen when full power is applied from a go-around and positive control of the airplane is not maintained. Such a situation may occur during a go-around procedure from a normal landing approach...or immediately after a takeoff. The objective of the demonstration is to show the importance of making smooth power applications, overcoming strong trim forces and maintaining positive control of the airplane to hold safe flight attitudes, and using proper and timely trim techniques...During this simulated final approach glide, the throttle is then advanced smoothly to maximum allowable power as would be done in a go-around procedure. The combined forces of thrust, torque, and back-elevator trim will tend to make the nose rise sharply and turn to the left."

FAA Practical Test Standards (PTS) for private and commercial pilots do not require the ability to demonstrate an elevator trim stall. PTS for flight instructors require knowledge and ability to demonstration an elevator trim stall.

CBP Air and Marine Pilot Trainee Program

The purpose of the program is to provide pilot trainees with a structure to advance to an Air Interdiction Agent (AIA). The program is designed to allow current CBP law enforcement officers who do not meet the U.S. Office of Personnel Management (OPM) required 1,500 flight hour requirement for a GS-13 pilot position, to apply for and be selected to transfer from a non-pilot position to a pilot trainee position. Once accepted into the program, the applicant will follow an individual master training program (MTP) in which the trainee will build the required flight hours to meet the 1,500-flight hour requirement as well as hone their skills and knowledge as a pilot.

Shortly after the trainee reports for duty at a CBP Air and Marine office and is accepted into the program, the trainee will go to one of the two NATC for initial assessment. The assessment will be used as a tool to help develop the individual MTP. The assessment is used to establish the "baseline" of the trainee's flight skills and knowledge. The trainee's assigned instructor pilot will develop a MTP tailored to address areas that need improvement as well as items related to CPB Air and Marine aviation with which the trainee has little or no experience. The MTP is then designed to serve as the trainee's "roadmap" to gain experience, skills and knowledge necessary to complete the trainee program. With trainees entering the Pilot Trainee Program with anywhere from 250 to 1,499 flight hours, the MTP is a uniquely individualized training program.



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