CESSNA T210K

Full Narrative

HISTORY OF FLIGHTOn January 2, 2017, about 0937 mountain standard time, a Cessna T210K, N272EF, was destroyed when it collided with mountainous terrain near Payson, Arizona. The private pilot and three passengers were fatally injured. The airplane was registered to N9402M Aviation, LLC, of Phoenix, Arizona. The personal flight was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the visual flight rules (VFR) cross-country flight that departed Scottsdale Airport (SDL), Scottsdale, Arizona, at 0912 and was destined for Telluride, Colorado.

According to the co-owner of the airplane, the pilot planned to fly from SDL, where the airplane was based, to Colorado with his family for their annual vacation.

The Federal Aviation Administration (FAA) provided a radar track for an airplane with a 1200 transponder code that corresponded with the airplane's departure time and route. The radar data indicated that the airplane departed SDL at 0912 and proceeded north. The final radar target was at 0937:39, at a Mode C altitude of 6,700 ft mean sea level (msl), and about 0.07 nautical miles (nm) east of the accident site. According to the FAA, the pilot did not receive VFR flight following services or contact any of the low altitude sectors along his route of flight.

An Electronics International MVP-50P electronic display device was recovered from the wreckage and forwarded to the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory for data recovery. The small battery used to power the unit's internal clock had become dislodged, and the unit reverted to an unset time setting. As a result, the flight and engine data time stamps in this report differ by about 20-minutes from the actual time derived from the FAA radar data.

Engine data retrieved from the MVP-50P indicated that the fuel flow, manifold pressure, and rpm increased at 09:33:05, consistent with departure performance. GPS and flight data retrieved from the unit showed the airplane's groundspeed rise from 0 knots and its altitude increase from 1,437 ft, which is about SDL's field elevation, consistent with a departure. The airplane then climbed to the northeast before turning left to a north heading for the remainder of the flight. The engine parameters did not indicate any anomalies during the flight. At 0943:59, the airplane reached a peak altitude of 8,029 ft and subsequently descended to about 7,850 ft. The airplane maintained this altitude within 30 ft for about 2 minutes and then climbed to 7,936 ft briefly before entering a descent and reaching about 6,651 ft at 0947:44. In the next minute, the airplane climbed to about 6,900 ft and then, at 0950:28, descended to and maintained about 6,200 ft, within 100 ft, for about 2 minutes 30 seconds. The last recorded data occurred while the airplane was in a 10-second climb at 0953:06, a GPS altitude of 6,767 ft, and about 0.22 nm from the accident site. In the airplane's final 12 seconds of flight, fuel flow decreased from about 20 to 17.4 gallons per hour, manifold pressure decreased from about 31 to 28 inches of mercury, and rpm remained unchanged.

Track data from the GPS showed that the airplane maintained a straight course after its departure all the way to the accident site located at the mountain rim, which had a published peak elevation that varied between 6,750 feet msl and 8,077 feet msl.

Family members became concerned on the afternoon of January 2 as they had not heard from the flight and were unable to reach the occupants on their cell phones. Around 2100, they notified local law enforcement who traced the flight's location using the pilot's and his wife's cell phones. An alert notice, or ALNOT, was issued at 2252 by Denver Center, and the wreckage was subsequently discovered the following morning at 0427 in a wooded area on the rising face of the Mogollon Rim, a cliff that extends across northern Arizona. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with an airplane single-engine land rating. He did not hold an instrument rating. The pilot's most recent third-class medical certificate was issued on April 10, 2015, with no limitations. At the time of the exam, the pilot reported that he had accumulated 295 total flight hours of which 14 hours were in the previous 6 months.

The last recorded flight in the pilot's logbook was dated August 28 with the remark "Flight Review," but the logbook did not indicate the year the flight took place. An entry in the back of the logbook showed that the pilot's most recent flight review was conducted on May 11, 2016. His previous flight review was dated August 27, 2014.

According to FAA records, the pilot purchased the airplane in 2011. In February 2014, the pilot sold 50% of the ownership to an individual who responded to an advertisement that he posted on an internet website. This individual stated that he developed a friendship with the pilot through their co-ownership of the airplane. He stated that the accident pilot sometimes flew with him as a safety pilot when he practiced instrument approaches, but he did not believe that the accident pilot had aspired to become instrument rated. According to the co-owner, the accident pilot made less than five total cross-country flights each year, and his local flying normally took place ahead of his cross-country flights and was for the purpose of maintaining his currency to carry passengers.

The pilot's business partner flew with the pilot on three occasions and observed him watching a moving map on an iPad during one of the flights. AIRCRAFT INFORMATIONAccording to FAA records, the airplane was manufactured in 1970 and registered to N9402M Aviation, LLC on July 22, 2011. The airplane was powered by a turbocharged, direct-drive, air-cooled, 310-horsepower Continental TSIO-520R engine. A review of the airplane's logbooks revealed that the airplane's most recent annual inspection was completed on October 21, 2016, at a tachometer time and total time of 4,307 hours. The engine logbook indicated that a 100-hour inspection was completed on October 21, 2016, at which time the engine had accrued 311 flight hours since major overhaul. At the time of the accident, the tachometer time was 4,323 hours.

A fuel receipt obtained from Signature Flight Support at SDL showed that the pilot purchased 42 gallons of 100 LL aviation grade gasoline at 0845 on the day of the accident. The co-owner reported that he was the last person to fly the airplane before the accident flight. He returned the airplane with about 44 gallons of fuel onboard about 4 days before the accident.

The owners installed a Garmin 750 GPS that was equipped with a Terrain Awareness Warning System (TAWS) and an engine analyzer in April 2016. The co-owner routinely updated the GPS databases and tested the TAWS system.

An estimate of the airplane's weight and balance was computed using the occupants' weights reported by the medical examiner. The baggage weight was determined by adding the weight of the baggage recovered by the medical examiner to the weight of the baggage that remained with the wreckage. The center row left seat had been removed from the airplane, and two weight and balance scenarios were computed. The first scenario (labeled "Graph no. 1" in the "Weight & Balance Computation" document in the NTSB public docket) assumed that the 218 pounds of baggage was split between the center and aft rows, and the second scenario (labeled "Graph no. 2" in the in the "Weight & Balance Computation" document in the NTSB public docket) split the same baggage weight between the center row and the baggage compartment. Computations showed the airplane's center of gravity within the moment envelope for both scenarios. METEOROLOGICAL INFORMATIONWeather Conditions at Time of Accident

At 0935, the weather conditions recorded at Payson Airport (PAN), Payson, Arizona, elevation 5,157 feet, located about 11 nm south of the accident site, included wind variable at 4 knots with gusts to 10 knots, visibility 10 statute miles, overcast ceiling at 300 ft above ground level (agl), temperature 2°C, dew point 1°C, and an altimeter setting of 30.11 inches of mercury.

Visible satellite imagery showed extensive cloud cover over the accident site with the clouds moving from west to east. Sounding data and infrared satellite imagery were used to determine the likely cloud cover that the airplane encountered along the route of flight. Figure 1, which depicts the cloud cover and the airplane's flight track, shows that the airplane departed in visual meteorological conditions (VMC) and entered a combination of IMC/VMC when it climbed above 7,000 ft. The airplane then entered IMC when it crossed over the Mazatzal Mountains, about 20 nm south of the accident site, and remained in IMC for the rest of the flight.





Figure 1 – Cloud Cover with height (Color Fill) and Accident Flight Track (Line)



A pilot weather report made near the time of the accident reported cloud tops at 11,000 ft about 40 nm west of the accident site. Another report made about 1 hour after the accident reported cloud bases between 5,900 ft and 6,400 ft and cloud tops about 8,000 ft about 50 nm northwest of the accident site. Pilot reports of light rime icing were made about 90 minutes after the accident took place and 45 nm northwest of the accident site.

Weather Forecasts

Airmen's meteorological information (AIRMET) advisories SIERRA and TANGO were issued at 0745 and were valid for the accident site at the time of the accident. AIRMET SIERRA forecasted IMC and mountain obscuration conditions due to clouds, precipitation, and mist, and AIRMET TANGO forecasted moderate turbulence below FL180.

An area forecast issued at 0445 and valid at the time of the accident called for a broken to overcast ceiling at 9,000 ft with cloud tops at 10,000 ft and a south wind gusting to 25 knots.

Sedona Airport, located 35 nm west-northwest of the accident site at an elevation of 4,830 ft, issued a terminal aerodrome forecast (TAF) at 0433 that was valid at the time of the accident. The TAF called for wind from 180° at 11 knots with wind gusts to 20 knots, greater than 6 miles visibility, light rain showers, scattered clouds at 200 ft agl, a broken ceiling at 400 ft agl, and overcast skies at 1,200 ft agl.

The National Weather Service office in Flagstaff, Arizona, issued an area forecast discussion (AFD) at 0343 that discussed the likelihood of IFR conditions along south- and west-facing higher terrain. The AFD specifically mentioned that the Mogollon Rim was likely to have scattered light snow, rain, and rain shower conditions.

Weather Briefing

There was no record of the pilot receiving a weather briefing from Lockheed Martin Flight Service (LMFS), the Direct User Access Terminal Service (DUATS), or ForeFlight Mobile before departure. The pilot did not file a flight plan with ForeFlight Mobile but did enter route information at 0826 for a trip from SDL to Telluride Regional Airport. The pilot did not look at any weather imagery before or during the flight using ForeFlight, LMFS, or DUATS. It is unknown whether the pilot retrieved weather graphics or text weather information from other internet sources.

Two days before the accident, the pilot asked the co-owner to research the weather forecast and cross-check it against the pilot's flight plan to Telluride. After reviewing his flight plan and researching weather, the co-owner informed the pilot that Sunday and Monday, the day before and the day of the accident, were not options and suggested that the pilot drive to Telluride. The co-owner, who was an instrument-rated pilot, stated that he would not have personally flown this route because of the weather forecast.

For further meteorological information, see the weather study in the public docket for this investigation. AIRPORT INFORMATIONAccording to FAA records, the airplane was manufactured in 1970 and registered to N9402M Aviation, LLC on July 22, 2011. The airplane was powered by a turbocharged, direct-drive, air-cooled, 310-horsepower Continental TSIO-520R engine. A review of the airplane's logbooks revealed that the airplane's most recent annual inspection was completed on October 21, 2016, at a tachometer time and total time of 4,307 hours. The engine logbook indicated that a 100-hour inspection was completed on October 21, 2016, at which time the engine had accrued 311 flight hours since major overhaul. At the time of the accident, the tachometer time was 4,323 hours.

A fuel receipt obtained from Signature Flight Support at SDL showed that the pilot purchased 42 gallons of 100 LL aviation grade gasoline at 0845 on the day of the accident. The co-owner reported that he was the last person to fly the airplane before the accident flight. He returned the airplane with about 44 gallons of fuel onboard about 4 days before the accident.

The owners installed a Garmin 750 GPS that was equipped with a Terrain Awareness Warning System (TAWS) and an engine analyzer in April 2016. The co-owner routinely updated the GPS databases and tested the TAWS system.

An estimate of the airplane's weight and balance was computed using the occupants' weights reported by the medical examiner. The baggage weight was determined by adding the weight of the baggage recovered by the medical examiner to the weight of the baggage that remained with the wreckage. The center row left seat had been removed from the airplane, and two weight and balance scenarios were computed. The first scenario (labeled "Graph no. 1" in the "Weight & Balance Computation" document in the NTSB public docket) assumed that the 218 pounds of baggage was split between the center and aft rows, and the second scenario (labeled "Graph no. 2" in the in the "Weight & Balance Computation" document in the NTSB public docket) split the same baggage weight between the center row and the baggage compartment. Computations showed the airplane's center of gravity within the moment envelope for both scenarios. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest on the south face of the Mogollon Rim about 11 nm north of PAN at an elevation of about 6,601 ft. The initial impact point (IIP) was identified by an aluminum fragment embedded about midway in a 50-foot-tall tree and several broken tree branches that came to rest a few feet beyond the IIP. An initial ground scar was marked by airplane fragments and loose dirt about 40 ft forward of the IIP. Portions of the wings and elevators were found along the debris path from the IIP to the main wreckage, about 80 ft from the IIP.

The main wreckage was comprised of the engine, fuselage, and tail section, which was displaced about 30° upward from the ground. The rudder, aileron, and elevator cables were traced from the cockpit to their respective control surfaces. The flap jackscrew measured about 4.4 inches, consistent with a flaps retracted position. The elevator trim actuator screw was separated from the actuator body.

The airplane was equipped with a 2-point restraint system for each occupant and no shoulder harnesses. The passengers' lap belts were each found in the clasped position. Only a portion of the pilot's lap belt was recovered and two of the passengers' belts had separated at their airframe attachment points. The third passengers' lap belt had been cut by recovery personnel.

Both wing fuel tanks were breached and exhibited an odor that resembled 100 low lead aviation grade gasoline. The fuel strainer bowl was removed, and it contained several ounces of uncontaminated liquid of a color and odor that resembled aviation grade gasoline. The fuel selector valve, which was positioned on the left fuel tank detent, was subsequently rotated to each of the three fuel tank ports, and no obstructions were observed.

The vacuum pump functioned normally when manipulated by hand; both vanes and the carbon rotor were intact and unremarkable. The autopilot switch was found in the "ON" position.

The engine displayed a dent and several cracks on the rear left side of the crankcase consistent with impact damage. All six cylinders remained attached to their cylinder bays. The throttle and metering assembly was partially separated from its mount. Multiple ignition leads from the ignition harness were severed from their respective spark plugs. The exhaust system remained attached to the engine and displayed crush damage. The cabin heat exhaust heat exchanger did not display any leaks.

Rotational continuity was established throughout the engine and valve train when the engine crankshaft was manually rotated using a hand tool. Thumb compression and suction were obtained for all six cylinders. The cylinder combustion chambers and barrels were examined with a lighted borescope, and the cylinder bores, valve heads, and piston faces displayed normal operation and combustion signatures. The cylinder overhead components, comprised of the valves, springs, push rods, and rocker arms, exhibited normal operation and lubrication signatures.

An examination of the top and bottom spark plugs revealed varying degrees of impact damage, but signatures consistent with normal wear. The oil filter exhibited impact damage; however, the filter pleats were not contaminated with metallic debris. The oil sump pickup screen did not display any blockage, and the oil pump did not display any anomalies.

Disassembly of the fuel manifold revealed a fluid consistent with aviation grade gasoline inside the valve body. While the fuel screen did not display any obstructions, the unfiltered side of the valve displayed some contaminates. The fuel nozzles were not obstructed except for nozzle Nos. 3 and 5, which were impacted with mud and dirt. Fuel nozzle No. 2 was not recovered.

The throttle body metering unit was removed from its engine accessory housing, and the fuel metering portion of the unit was disassembled. The internal components appeared normal, and the inlet fuel screen was free of debris with the exception of a trace amount of fibrous material.

The left magneto had separated from its mounting flange, and the magneto housing was cracked open exposing its internal components. A small amount of movement was achieved through the magneto drive, and the magneto did not produce a spark. The right magneto remained attached to the accessory case and was capable of normal rotation through the magneto drive. The impulse coupling operated normally and produced spark on all six posts in the correct order.

The three-blade, variable-pitch propeller was attached to the propeller flange. Two propeller blades were attached to the propeller hub, and the third blade was found in the debris path. One blade exhibited "S" bending at the blade tip and aft bending about mid-span. Another propeller blade displayed aft bending deformation, and the remaining propeller blade exhibited forward bending, leading edge polishing, and a gouge towards the blade root. MEDICAL AND PATHOLOGICAL INFORMATIONThe Pima County Office of the Medical Examiner, Tucson, Arizona, performed an autopsy on the pilot. The autopsy report indicated that the pilot's cause of death was "multiple blunt force injuries."

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens recovered from the pilot. A carboxyhemoglobin saturation test revealed no evidence of carbon monoxide in the pilot's cavity blood. The pilot's toxicology results were negative for ethanol and positive for tadalafil in his cavity blood.

Tadalafil, marketed under the trade name Cialis, is used to treat erectile dysfunction and symptoms of benign prostatic hypertrophy. Another brand of Tadalafil, marketed under the brand name Adcirca, is used to treat pulmonary arterial hypertension.

Additional carboxyhemoglobin tests for two of the three passengers did not indicate a presence of carbon monoxide in the heart blood of either occupant. A medical study showed that each of the four occupants suffered severe traumatic injuries. TESTS AND RESEARCHEmergency Locator Transmitter

The airplane was equipped with a Pointer, model 3000, FAA technical standing order type C91 emergency locator transmitter (ELT), which broadcasts radio signals on the emergency radio channel 121.5 MHz. Aircraft receivers monitoring the emergency channel that intercept an ELT signal can announce the signal along with their position to Air Traffic Control. According to a representative of the FAA, the Albuquerque Air Route Traffic Control Center (ARTCC) received four ELT reports from aircraft that intercepted ELT signals near PAN between 0938 and 0942 on the day of the accident. The FAA representative further reported that the four ELT reports were immediately forwarded to the Air Force Rescue Coordination Center (AFRCC). The reporting of ELT signals is governed by FAA Job Order Chapter 5-2-8, which requires ARTCC to send the signal reports directly to AFRCC.

AFRCC receives Cospas-Sarsat distress alerts sent by the United States Mission Control Center and is responsible for coordinating the rescue response to the distress. According to the United States Government Federal Register, the Cospas-Sarsat satellite system only processes signals from 406 MHz ELTs as they ceased processing signals from 121.5 MHz ELTs beginning February 2009. This decision was the result of problems with the frequency band, which inundated search and rescue authorities with inaccurate and false alerts, which impacted the effectiveness of lifesaving services.