ERA11FA258
ERA11FA258

HISTORY OF FLIGHT

On April 22, 2011, about 2146 eastern daylight time, a Cessna 210D, N3963Y, was substantially damaged following a collision with terrain at Altavista, Virginia. The certificated private pilot was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night, instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from Winchester Regional Airport, Winchester, Virginia, about 1956.

Examination of voice recordings with air traffic control revealed the following. At 1952:12, the pilot informed Potomac Clearance Delivery that he was ready for takeoff. At 1958:22, the pilot checked in with Potomac Terminal Approach Control (TRACON) and was instructed to climb to 8,000 feet. At 2013:30, a controller with Washington Air Route Traffic Control Center (ARTCC) commented to Potomac TRACON, "but he was on like a two seventy heading and I asked him where he was going and he told me direct Lynchburg so I would keep an eye on him." At 2020:59, the pilot stated to Potomac TRACON, "uh Potomac six three yankee just a little disoriented here." The pilot was then offered vectors toward Lynchburg, which he accepted.

For the next 15 minutes, the pilot received vectors from Potomac TRACON. Potomac TRACON also provided vectors around moderate precipitation in the area.

At 2042:41, the pilot checked in with Lynchburg West radar at 8,000 feet and received vectors for the Instrument Landing System (ILS) approach to runway 4 at Lynchburg Regional Airport (LYH). At 2059:33, the Lynchburg West controller stated to LYH tower, "yeah this is a heads up ah six three yankee is ah transitioning through ah your airspace in your departure corridor I gave him like ah one ninety heading I guess that didn't work for him." At 2112:30, the pilot was handed off to LYH tower for the ILS approach to runway 4.

At 2115:51, LYH tower informed Lynchburg West that the pilot of N3963Y was executing a missed approach and that the pilot cited problems with his "engine monitor." At 2116:26, the pilot requested another ILS approach to runway 4. At 2121:30, after the pilot had been instructed to climb and maintain 3,000 feet, Lynchburg West informed him, "…six three yankee low altitude alert ah the mva [minimum vectoring altitude] in your area is two thousand eight hundred I show you at two thousand two hundred sir." The pilot responded, "that's affirmative I'm just trying to get the vors [VHF Omnidirectional Receivers] in here six three yankee."

At 2122:40, Lynchburg West asked the pilot if he would like a Global Positioning System (GPS) approach and the pilot replied that he would prefer another ILS approach. At 2123:24, Lynchburg West called LYH tower and informed the controller that he was keeping the pilot on his frequency and would not be handing him off to tower. LYH issued a landing clearance and responded, "…you can keep him."

At 2123:59, as the pilot attempted the ILS approach for a second time, Lynchburg West queried the pilot, "…are you on the localizer now sir?" The pilot responded that he was, and Lynchburg West stated, at 2124:05, "november six three ah yankee I'm showing you well right of course ah sir advise you climb immediately maintain three thousand." The pilot acknowledged and Lynchburg West stated, at 2124:17, "november six three yankee ah low altitude alert once again climb immediately maintain three thousand." The pilot acknowledged the climb to 3,000 feet.

At 2125, Lynchburg West confirmed that the airplane was equipped with a GPS and offered clearance to KILBE intersection to fly the GPS approach to runway 4. The pilot acknowledged the transmission by stating, "…that'd be okay six three yankee." At 2127:47, Lynchburg West told the pilot, "…I'll let you play with your altitude as much as you need um just try to stay at least above two thousand eight hundred." The pilot acknowledged the transmission.

At 2130:57, Lynchburg West cleared the pilot for the GPS approach to runway 4. The pilot reported, at 2132:49, "…I'm gonna need to make a three sixty right here I'm still having some trouble with my engine monitors."

At 2134:20, the pilot was informed of another low altitude alert and was instructed to climb immediately to 2,800 feet or above and the pilot informed Lynchburg West that he was climbing. At 2136:08, the pilot stated, "ah Roanoke I've got ah complete gyro failure it looks like I need some help with ah both heading and ah altitude monitoring." At 2136:58, Lynchburg West began to provide no-gyro vectors to the pilot. Lynchburg West asked the pilot if he was tracking the LYH VOR, and the pilot responded, "um I'm a little dizzy thanks."

At 2138:38, the pilot stated to Lynchburg West, "I'm currently showing about five thousand two hundred elevation." The controller replied, "that altitude checks."

At 2141:28, Lynchburg West made the following remarks to Washington ARTCC, "um november six three yankee um is the call sign of that aircraft Centurion um the pilot is very disoriented um he reported some equipment problems um he apparently ah he reports he lost he lost his altitude readout and his um gyros um so he's trying to work out um all that but I really do feel like um this pilot is disoriented more than anything else um the last altitude check I had with him was okay um I gave him instructions for no no gyro vectors he was not really picking up on that…"

At 2142:35, the pilot stated, "ah can you give me a course heading six three yankee?" Lynchburg West responded, "…I show you tracking roughly about a one two zero heading."

At 2144:23, Lynchburg West informed the pilot that Washington Center and Greensboro Approach were looking for airports with more favorable weather conditions. The pilot was also informed that any approach into LYH was at the pilot's disposal, including no-gyro vectors. At 2144:58, the pilot responded with his last recorded transmission, "ah roger that I'm gonna turn ah right to ah one eight zero start tracking outbound see if I can't ah get back in line with the ah ah approach and see if you can give me ah a no gyro approach as well."

At 2146:17, Lynchburg West made the following transmission, "november six three ah yankee I show your altitude at one thousand four hundred climb immediately at or above two thousand eight hundred." No response was received from the pilot.

An examination of recorded radar data revealed that the last radar return was at 2146:14, at an altitude of 1,100 feet mean sea level (msl). The recorded radar track was consistent with a right, descending spiral. A review of the last 15 minutes of recorded data revealed that, prior to the last descending spiral, the airplane was continuously turning to the left and right, and varied in altitude between 5,900 feet and 1,600 feet msl.

A witness who lived near the accident site reported that the airplane flew over his house at high speed, in a descending, right hand turn, until it crashed. He estimated the bank angle to be about 80 degrees. He stated that the engine sounded normal when it flew over his house. He reported that the weather conditions at the time were "very dark and foggy."

Three witnesses were interviewed who were located about two nautical miles west of the accident site at the time of the accident. One of these witnesses reported that he was outside and saw an airplane fly over very low. The airplane was so low that the lights on the bottom of the airplane were visible. The airplane "porpoised" up and down about four times. The engine sound increased as the airplane dove, then decreased as it climbed. The airplane went away and returned a few seconds later, not porpoising the second time. The engine noise was then "steady." He reported the weather conditions at the time to be foggy, with rain.

A second witness in the same area observed an airplane making several left race track patterns over his house. He could see the lights of the airplane through the clouds, and it was foggy at the time. He stated that, at first, the engine made a sputtering sound, but later it sounded normal. He heard a whistling sound as the airplane sped up, then it crashed.

A third witness in the same area stated that an airplane came over her house so low that it "kicked her TV off." The airplane initially made two circles over her house, and the engine was popping and sputtering. She then heard the airplane going toward the airport, and she thought it had landed. The airplane then returned at a higher altitude. She heard the engine cut out, and then cut back on. She observed the airplane lights come out of the clouds, heading toward English Field. The airplane made a "weird whining sound" and a few seconds later she heard a "boom" and knew the airplane had crashed.

PERSONNEL INFORMATION

The certificated private pilot held airplane single engine land and instrument airplane ratings. A review of his pilot logbook revealed that, through April 15, 2011, he recorded about 295 hours total flying time. He also recorded 22.9 hours of night time; however, he had recorded zero hours in night, instrument conditions. He recorded 5.4 hours in actual instrument conditions as of April 15, 2011 and 50.6 hours in simulated instrument conditions. The pilot was issued a temporary airman certificate for an instrument airplane rating on March 9, 2011.

AIRCRAFT INFORMATION

The airplane was a single-engine, high-wing, retractable gear airplane, serial number 21058463. It was powered by a Continental IO-520A engine rated at 285 horsepower.

A review of the aircraft maintenance records indicated that an annual inspection of the airframe and engine was performed on September 28, 2010. The aircraft total time at the time of the annual inspection was 6,910.7 hours.

METEOROLOGICAL INFORMATION

The 2154 recorded weather observation at LYH, located approximately 14 nautical miles north-northeast of the accident site, included winds from 030 degrees at 3 knots, an overcast ceiling at 600 feet, 3 miles visibility in mist, temperature 8 degrees C, dew point 8 degrees C, and an altimeter setting of 30.29 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane collided with terrain near the north bank of the Staunton River in the town of Altavista. The fuselage and empennage came to rest against a shear vertical rock face, about 180 feet from the point of initial impact. The wreckage path was oriented on a heading of about 040 degrees. There was no evidence of fire observed.

The first observed point of impact along the wreckage path was a mature hardwood tree. The tree was severed about 50 feet up its trunk. The width of the tree was about 11 inches at the sever point. The tree exhibited a smooth, angular cut and there were black paint transfer marks on the cut surface. Several similar pieces of cut tree limbs of smaller diameter were found near the severed tree.

All of the flight control surfaces were accounted for at the accident site and were in multiple pieces. Flight control continuity could not be determined due to the severe fragmentation of the airplane; however, fragmented sections of flight control cables exhibited stretching and overload breaks consistent with impact forces. The cockpit was found in several sections and installed instrumentation was found severely fragmented. Numerous cockpit gauges and controls were not located or identified.

Both wings were observed separated from the fuselage. The left wing main spar was observed stripped of all structure. The entire left flap was observed attached to the left wing rear spar. The left wing lift strut was observed separated into two pieces. The right wing lift strut remained attached to the wing. The aileron cables were observed separated in a manner consistent with tension overload.

Both horizontal stabilizers were observed separated from the fuselage and both elevators were separated from the horizontal stabilizers. The vertical stabilizer remained attached to the fuselage and the rudder was observed separated from the vertical stabilizer. The fuselage cables for the rudder and elevator were observed throughout the fuselage and were taut. The flap actuator, located in the right wing, was found in the "retracted" position.

The nose landing gear actuator was observed in the actuator extended (gear retracted) position. Both of the main landing gear struts were observed inside the fuselage. The hydraulic power pack was observed loose in the wreckage; however, the landing gear handle position could not be determined.

The fuel selector valve was observed loose in the wreckage debris path and was in the "left tank" position. The fuel selector valve handle and placard were found loose in the wreckage and were in the "left tank" position. The fuel strainer was not found. The aircraft was equipped with bladder fuel tanks and were breached during the mishap sequence.

The engine separated free from the airframe and was located approximately 70 feet east of the main wreckage. The engine cowling fragmented into numerous pieces. All four engine mounts fractured free of the engine and were found in various locations.

The fuel pump, starter adapter, oil pump, vacuum pump, magnetos, the numbers 1, 3, and 5 cylinders, the accessory portion of crankcase, and a majority of the ignition harness separated free of the engine. Approximately 25 percent of the crankcase material separated free due to impact and was not recovered. The throttle body and mixture metering unit exhibited an extensive amount of impact-related damage. Both control arms and shafts for the mixture control unit exhibited impact-related damage. The mixture control screen was safety-wired and the screen was free and clear of debris or contaminates. The fuel manifold was safety-wired and the lead seal was intact and damaged. The fuel manifold was opened and the diaphragm was found intact and the plunger nut was tight. The fuel manifold plunger seal was intact and undamaged. The fuel manifold screen was free and clear of debris or contaminates.

The entire aft portion of the engine exhibited extensive impact-related damage with the crankshaft being visually bent. The aft crankshaft gear and forward and rear camshaft gears were impact-damaged and separated into numerous pieces. Only one of the three separated cylinders remained mostly intact as a unit. Two of the separated cylinders were partially located in numerous pieces. The top and bottom spark plugs in the separated cylinders had electrodes that exhibited normal operation signatures. The engine crankshaft could not be rotated by hand. Cylinder compression could not be evaluated due to the amount of impact-related damage. Valve train continuity and accessory gear continuity could not be confirmed due to the amount of impact-related damage.

Approximately 30 percent of fuel pump assembly was recovered and inspected. The lower fuel pump housing, a portion of the fuel pump drive gear, the fuel pump drive shaft, and the fuel pump drive coupling were recovered. The lower assembly did not rotate by hand. The fuel pump gear was mechanically removed and the fuel pump drive coupling was found intact and undamaged. The fuel pump drive coupling was not removed due to impact damage around it.

The oil pump housing and both gears were found imbedded in the ground at approximately midway along the wreckage path. The oil pump drive gear was visually bent on each end of the gear shaft. Approximately 35 percent of the oil pump housing was not located. The oil filler cap and dipstick were not located at the mishap site. The oil filler neck exhibited mechanical damage to the locking tab and the neck visually appeared to be out of round.

The two-bladed McCauley constant speed propeller separated from the crankshaft flange and exhibited extensive impact-related damage. One of the two propeller blades separated free from its hub socket and was located approximately midway along the wreckage path. The second blade remained in the propeller hub but was loose in its socket. Both blades were bent forward and twisted. Both blades exhibited chord-wise scratches and surface polishing.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed at the Office of the Chief Medical Examiner, Roanoke, Virginia, on April 25, 2011. The autopsy report noted the cause of death as blunt force injuries to the head, torso, and extremities.

Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated negative for cyanide, ethanol, and drugs. Testing for carbon monoxide was not performed because of unsuitable specimens.

The pilot was issued a third class medical certificate, dated June 26, 2009. The following limitations were listed on the certificate, "Must use hearing amplification. Not valid outside the borders of the United States. Not valid for any class after 6/30/2011."

A review of FAA medical records revealed that, on July 28, 2010, the pilot was granted a special issuance third-class medical certificate due to insulin-dependent diabetes. The special issuance required a visit to a treating physician every 3 months, a diabetes evaluation summary from the treating physician, and an annual eye exam.

The pilot was required to carry and use a whole blood glucose measuring device with memory. He was required to measure his blood glucose concentration one-half hour prior to flight, at one-hour intervals during the flight, and within one-half hour prior to landing. The special issuance listed restrictions and requirements based on the observed blood glucose concentration. A copy of the special issuance letter is included in the public docket for this accident investigation.

In correspondence between the pilot and the FAA, it was noted that the pilot was a practicing physician who was also a diabetic specialist.

Investigators located an empty "Clif" energy bar wrapper within the area of the cockpit debris. A blood glucose measuring device was not located or identified during examination of the wreckage. The autopsy report stated that the pilot's stomach contained about 50 milliliters of undigested food (rice pilaf).

TESTS AND RESEARCH

The airplane was equipped with an Electronics International, Inc. MVP-50P engine analyzer and systems monitor. The unit was sent to the NTSB Vehicle Recorder Division, Washington, DC, for general examination and download of data.

The monitor captured most of the accident flight, including GPS data. The last recorded data occurred near the accident site at 2,699 feet GPS altitude (about 2,150 feet above the ground) and at 185 knots GPS speed, following a descent from 6,308 feet GPS altitude. The last recorded engine parameters included the following: engine speed 2,390 rpm, oil pressure 53 psi, cylinder head temperatures between 287 and 343 degrees C, vacuum 4.9 inches of mercury, estimated fuel 13.7 gallons, volt meter 13.7 volts, ammeter 2.7 amps, fuel flow 14.8 gallons per hour, and fuel pressure 9.9 psi. A review of the en route portion of the flight did not indicate any anomalies with the engine, vacuum system, or electrical system.

The rotor and cap from the pneumatically-powered directional gyro, the electric turn and bank indicator, and the engine-driven vacuum pump were forward to the NTSB Materials Laboratory for examination.

Examination of the rotor and cap revealed that the cap was heavily dented inward and distorted on one side. Removal of the cap revealed a mating dent and deformation in the end of the gyro rotor. Close optical examinations did not reveal rotational marks on either the rotor or cap.

The case of the turn and bank indicator was partially crushed and the face was missing. The case was cut open to reveal the interior components. The gimbal structure surrounding the gyro was intact with little or no damage. Disassembly of the gyro revealed light rotational marks on the exterior of the non-rotating stator and on the interior of the rotor consistent with normal operation.

The vacuum pump was severely distorted and damaged. Both end caps of the pump were missing and the housing was crushed onto the rotor. The pump vanes were mostly intact. The input drive shaft and reduced shear section were intact and continuous to the pump rotor. The pump housing was longitudinally cut and the rotor released. Magnified examinations uncovered dents and scuff marks to the end of the rotor consistent with non-rotating impacts.

Additional information and photos of the examined components are included in the NTSB Materials Laboratory Factual Report number 11-090, located in the public docket for this accident investigation.

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