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NTSB investigation record

DFW08FA153

Completed

Cessna 310Q· N8187Q

NTSB Report
Date
May 25, 2008
Location
Steamboat, CO
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's failure to maintain clearance from mountainous terrain in day visual conditions. Contributing to the accident was the pilot's impairment due to marijuana and inadequate medical oversight of the pilot by the Federal Aviation Administration.

Investigator assessment

Analysis narrative

The commercial pilot departed on a cross-country flight over mountainous terrain in day, visual meteorological conditions. The pilot had filed a flight plan but it was never activated and an Alert Notification (ALNOT) was issued when the airplane did not reach its destination. The airplane struck trees in a shallow descent into slightly rising terrain at an elevation of 9,800 feet mean sea level, approximately 27 miles east of the departure airport. Examination of the airplane and both engines revealed no mechanical discrepancies. Postaccident toxicology testing was consistent with impairment of the pilot due to his use of marijuana within three hours of the accident. The Federal Aviation Administration was aware of multiple convictions of the pilot for alcohol-related offenses, but did not request any documentation of those convictions or additional evaluation prior to issuing the pilot a second-class medical certificate.

Source record

Factual narrative

HISTORY OF FLIGHT On May 25, 2008, approximately 0830 mountain daylight time, a Cessna 310Q, N8187Q, was destroyed when it impacted mountainous terrain in the Routt National Forrest in Steamboat Springs, Colorado. The certificated commercial pilot and the passenger were fatally injured. The airplane was registered to a private individual and operated by the pilot. A visual flight rules (VFR) flight plan was filed for the flight that originated at Yampa Valley Airport (HDN), Hayden, Colorado, about 0800, and destined for Fort Collins/Loveland Municipal Airport (FNL), Fort Collins, Colorado. Visual meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. According to the registered owner of the airplane, the pilot departed from Durango, Colorado, earlier that morning and flew to HDN. The pilot planned to pick up his father in HDN and then fly to FNL, where they would meet up with other family members to participate in the Bolder Boulder 10k race the following day (Memorial Day). The pilot called the owner about 0730 after he landed in HDN. He said that the flight went well and the weather was "beautiful." The owner said the pilot was in good spirits and he did not mention any problems with the airplane. The airplane was topped off with fuel (40 gallons) at Durango for a total of 163 gallons. The owner estimated that the airplane would burn about 30 to 35 gallons for the flight between Durango and Hayden would have had approximately 125 gallons on board when it departed HDN. According to Routt County Search and Rescue personnel, the pilot contacted his sister in Fort Collins at 0758 and stated that they were just about to depart HDN and would be landing in FNL in about 50 minutes. The pilot obtained a weather briefing and filed a VFR flight plan via the Digital Users Access Terminal (DUAT) system. The flight plan indicated a direct route between HDN and FNL using a heading of 083 degrees and an altitude of 13,500 feet mean sea level (msl). Though a flight plan was filed, the pilot never activated the flight plan. He was also not in communication with any air traffic control services prior to the accident and no radar data was available for this flight. A digital camera was found at the accident site and the flash card was removed and downloaded. There was one photograph that was taken during the mishap flight at 0822. The photograph appeared to be taken from the front right seat of the airplane and was of the Mount Werner ski resort in Steamboat Springs. The photo also indicated that the weather was visual meteorological conditions and that the right engine was operating at the time the photo was taken. The airplane was reported missing by the owner when the pilot failed to call and let him know that they had arrived in FNL. The airplane was part of an Alert Notification (ALNOT), and was located by Routt County Search and Rescue personnel on May 27, 2008, on slightly rising terrain at an elevation of 9,800-feet mean sea level between Buffalo Mountain and Mount Werner, approximately 5 miles east of Steamboat Springs. The top elevation of the terrain was approximately 10,000 feet msl. PERSONNEL INFORMATION The pilot held a commercial pilot certificate for airplane single and multi-engine, and instrument airplane. He also held a certified flight instructor rating for airplane single and multi-engine land, and instrument airplane. His last FAA second-class medical was issued on June 29, 2007. At that time, he reported a total of 1,800 hours. According to the pilot's fiancée, she lost the pilot's logbook shortly after the accident. However, she recalled that he had a total of 2,000 to 2,200 hours, of which 25-30 hours were in the accident airplane. She estimated the pilot's total multi-engine time at 1,100 hours. Most of this time was accrued in Cessna 404, 402 and 310 model aircraft. The pilot had been employed as a pilot for approximately two years for a company called AeroSouth, who was a cargo feeder for DHL. He flew a Cessna 404 model airplane once a day, five times per week, from Durango, Colorado, to Albuquerque, New Mexico, then back to Durango. The round trip flight took an average of 2 hours. METEOROLOGICAL INFORMATION Weather reported at HDN, about 27 miles west of the accident site, at 0755, was reported as wind from 070 degrees at 9 knots, visibility 10 miles, ceiling 10,000 foot overcast, temperature 37 degrees Fahrenheit, dewpoint 32 degrees Fahrenheit, and a barometric pressure setting of 30.03 inches of Mercury. Weather reported at the Storm Peak DRI Laboratory, located on Mount Werner, approximately 3 miles south of the accident site, at 0800, reported the wind from 206 degrees at an average speed of 13.4 knots, a maximum wind of 20.4 knots, temperature 31.9 degrees Fahrenheit, and a dewpoint of 25 degrees Fahrenheit. At 0900, the weather was reported as wind from 230 degrees at an average speed of 14.6 knots, a maximum wind of 23.4 knots, temperature 34.3 degrees Fahrenheit, and a dewpoint of 24 degrees Fahrenheit. WRECKAGE AND IMPACT INFORMATION An on-scene examination was conducted on May 29, 2008. The initial impact point was a stand of approximately 60-foot-tall trees. Impact marks on these trees became progressively lower and narrower on a magnetic heading of 085 degrees in the direction of the main wreckage, which consisted of the fuselage, cockpit area, both engines, both wings, right tip tank, and both propeller systems. A section of elevator was imbedded in the top of a tree near the initial impact point. Also found along the wreckage path were several pieces of angular cut wood, the tail cone, a section of the left elevator, left wing tip tank, and the horizontal stabilizer. The right side of the horizontal stabilizer exhibited a crescent shaped impact mark, consistent with the dimension of a tree trunk. Small pieces of bark were imbedded in the impact mark. The distance from the initial impact point to the main wreckage was approximately 900 feet. Impact forces damaged the main wreckage along with the cockpit, fuselage, and inboard fuel tanks, which were consumed by post-impact fire. Both engines came to rest inverted and remained attached to their respective engine nacelles. The left propeller assembly remained attached to the engine; however, the right propeller assembly separated from the engine at the crankshaft flange and was found approximately 30-40 feet forward of the main wreckage. The right wing fuel selector exhibited thermal damage and was found in the main (tip) tank position. The fuel bowl was empty and the fuel screen was partially melted. The left wing fuel selector was found beyond the off position. The fuel bowl had some residual fuel inside, and the fuel screen was absent of debris. The fuel selector handle inside the cockpit was destroyed by post-impact fire. Both of the main fuel tank pumps were intact and their respective fuel screens were absent of debris. The right main fuel tank's fuel screen exhibited a small amount of melted black plastic. Both of the auxiliary fuel tanks fuel finger screens were absent of debris. Examination of the airframe revealed that the all-major flight control surfaces were found at the accident site. Flight control continuity was established for all flight control surfaces to the cockpit area. The landing gear was retracted. The flap actuator was damaged from impact and a flap setting could not be determined; however, a review of the Routt County Search and Rescue on-scene photographs revealed the flaps appeared to be in the retracted position. The elevator trim actuator was not determined. The altimeter sustained impact damage, but the setting in the Kollsman window was 30.03 inches of Mercury. The power quadrant sustained extensive heat damage. The throttle quadrant mounting plate was broken loose, but the p

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