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NTSB investigation record

CEN09FA601

Completed

Cessna T210· N9734Y

Date
September 24, 2009
Location
Hilltop Lakes, TX
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The loss of control of the airplane in dark night light conditions due to the pilot’s spatial disorientation.

Investigator assessment

Analysis narrative

The pilot was arriving at a private rural airport in dark night conditions. Witnesses estimated that the visibility was 3 to 5 miles in drizzle or light rain with overcast clouds, with the ceiling as low as 500 to 1,000 feet above ground level. The pilot initially attempted to activate the runway lighting via the pilot-activated system; however, the system was inoperable due to a recent lightning strike. An airport resident contacted the pilot on the Unicom radio and informed him that the lights were inoperable. Another resident attempted to illuminate the runway using headlights from an automobile. The pilot said that he was going to attempt to land on runway 34 using a combination of automobile illumination and the airplane’s landing lights. The pilot was west of the airport when he flew eastbound over the airport and entered a right turn for a landing on runway 34. Several witnesses said that the pilot was not aligned with runway 34 and appeared to be too high to land. The witnesses said the airplane was approximately 50 to 150 feet above ground level when the pilot stated on the radio that he was initiating a go-around. The airplane then almost immediately started a descent, struck trees on the right side of the runway, and impacted an unoccupied home. An examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The dark night conditions that surrounded the airport and the airplane’s acceleration due to a go-around would place the pilot susceptible to spatial disorientation. According to the Federal Aviation Administration’s “Instrument Flying Handbook”, FAA-H-8083-15A, in a Somatogravic illusion “A rapid acceleration...can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low, or dive attitude.”

Source record

Factual narrative

HISTORY OF FLIGHT On September 23, 2009, at 2025 central daylight time (CDT), a Cessna T210N , N9734Y, impacted trees and an unoccupied home while attempting a go-around at Hilltop Lakes Airport (0TE4), Hilltop Lakes, Texas. The airplane was registered to Moe Transportation, Inc. of South Burlington, Vermont, and was operated by a private individual. The personal flight was being conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane was destroyed, and the pilot was fatally injured. No other persons were injured. Dark night visual meteorological conditions prevailed and a VFR flight plan had not been filed. The flight had originated from Shreveport Downtown Airport (DTN), Shreveport, Louisiana, at 1911, en route to 0TE4. The pilot’s first flight of the day departed Burlington International Airport (BTV) Burlington, Vermont, at 0830 eastern daylight time. He refueled the airplane at Flemingsburg-Mason Airport (FGX), Flemingsburg, Kentucky, and departed at 1512 eastern daylight time. The pilot had another refueling stop at DTN before departing for 0TE4. The runway lights at the 0TE4 airport had been inoperative following a recent lightning strike and the pilot was not aware of the inoperative lights. Several witnesses were listening on the 0TE4 Unicom frequency of 122.750 megahertz when they heard someone repeatedly “clicking five clicks” consistent with a pilot trying to activate the pilot control runway lighting. One witness received a static filled in-flight cellular telephone call from the pilot. He told the pilot to attempt contact on the Unicom radio. Several witnesses heard the pilot’s radio call on their radio scanners, but could not reply. A witness who was able to transmit on the Unicom frequency told the pilot that the runway lighting was inoperative. Another witness had positioned his car with the headlamps illuminating the runway and the pilot acknowledged seeing the flashing car lights on the runway. The pilot stated he was going to attempt a landing on runway 34 by using the landing lights on the airplane to illuminate the runway edge reflectors. The pilot was west of the 0TE4 airport when he flew eastbound over the airport and entered a right turn for a landing on runway 34. Several witnesses said the pilot was not aligned with runway 34 and appeared to be too high to land. The witnesses said the airplane was approximately 50 to 150 feet above ground level when the pilot transmitted on the Unicom frequency that he was starting a go-around. The witnesses said the airplane almost immediately started a descent, struck trees on the right side of the runway, and impacted an unoccupied home. There was an immediate post-impact fire. PERSONNEL INFORMATION The pilot, age 57, held a private pilot certificate with an airplane single-engine land rating, and an instrument airplane rating. The pilot was issued a restricted third-class medical certificate on April 16, 2008. The pilot completed a biennial flight review (BFR) on July 28, 2008. One pilot logbook was available during the investigation. The first entry in that logbook was made on July 22, 2008, and the last entry was made on June 4, 2009. The logbook did not list cumulative totals for night experience or instrument experience. At the time of the accident, the pilot had an estimated total of 1,276 hours of pilot experience with an estimated total of 475 hours in the same make and model airplane. The pilot’s logbook, aircraft maintenance logbooks, and other records revealed that the pilot had previously landed at the 0TE4 airport a total of five times. The first three landings were cross country flights from Burlington, Vermont, with en route fuel stops. The pilot’s logbook showed that he made three previous night landings at the 0TE4 airport. The first night landing was on August 1, 2008, and the last was on January 12, 2009. For those previous night landings at the 0TE4 airport, the weather conditions were clear skies and runway lighting was available. For the last two night landings there was visible moonlight. The pilot’s logbook showed that his most recent landing at the 0TE4 airport was a daytime flight on February 3, 2009, when the weather conditions were clear skies. AIRCRAFT INFORMATION N9734Y, serial number (S/N) 210645883, a model T210N, was manufactured by the Cessna Aircraft Company in 1981. It was a high-wing, single engine land airplane. The airplane was originally delivered with a Continental TSIO-520-R6A engine, S/N 522344 rated at 310 horsepower. At the time of the accident, it was powered by a Continental TSIO-520-PcR (6) engine, S/N 278573-R, rated at 310 horsepower, driving a McCauley 3-blade, constant speed, aluminum alloy propeller. It was equipped with retractable landing gear. In addition, the airplane was equipped with a Garmin GNS 430 navigation and communications unit, a JP Instruments EDM-700 engine analyzer, and a Cessna 400B IFCS autopilot. The airplane was issued a standard airworthiness certificate on December 3, 1981, in the normal category. The airplane was registered to the owner on May 26, 2006. The aircraft maintenance records available during the investigation showed that the most recent annual inspection was completed on June 1, 2009, at a tachometer time and aircraft total time of 3,280.4 hours, and an engine total time of 1,193.6 hours. The last maintenance log entry was on August 4, 2009, at a tachometer time of 3,300.3 hours. Examination of data from airplane tracking websites and other records showed that the airplane flew six flights after August 4, 2009, totaling approximately 12 hours. At the time of the accident, the airplane had an estimated total time of 3,312 hours, and an estimated engine total time of 1,225 hours. METEOROLOGICAL INFORMATION Three witnesses at the accident scene were instrument rated professional pilots. One witness estimated the visibility was 3 to 5 miles in drizzle or light rain with overcast clouds. The second witness estimated the visibility was less than 5 miles in light drizzle with a ceiling of 2,000 feet. The third witness estimated the visibility was 5 miles in light rain with a ceiling at 500 to 1,000 feet. At 2053, the automated weather observing system at Easterwood Field Airport (CLL), 30 miles southwest, reported winds from 010 degrees at 10 knots, visibility of 5 miles in rain, overcast clouds at 3,600 feet, temperature 61 degrees Fahrenheit, dew point 54 degrees Fahrenheit, with an altimeter setting of 30.16 inches of Mercury. U. S. Naval Observatory records show that sun set occurred at 1920 and the end of civil twilight occurred at 1944. There was a waxing crescent moon with 27 percent of the moon’s visible disk illuminated. Moon transit occurred at 1725 and moon set occurred at 2228. AIRPORT INFORMATION The Airport/ Facility Directory, Southwest U. S., listed the 0TE4 airport as a private airfield use with prior permission required for landing. Runway 16/34 was listed as 3,000 feet long and 40 feet wide. The runway surface was composed of asphalt. No runway lighting was listed, but there was a note that the runway was outlined with reflectors. The airport operator’s website showed that runway 16/34 had runway lighting, which could be pilot controlled on the Unicom frequency of 122.750 megahertz. The runway lighting system had been inoperative for several weeks due to a lightning strike. A notice to airmen (NOTAM) was not published for the outage of the 0TE4 airport lighting system, nor was one required for the private airport. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board, Cessna Aircraft Company (Cessna), and Teledyne Continental Motors (TCM), examined the wreckage at the accident scene on September 24 and 25, 2009. The accident site was located in a rural residential neighborhood adjacent to 0TE4. The streets surrounding the accident site were

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