GRAND CANYON, AZ, USA
N5138Q
Cessna 210L
There were no witnesses to the nighttime departure accident. In response to an emergency locator transmitter signal, the aircraft was located 3/4 mile off the departure end of the runway. The aircraft had impacted level terrain in a nose-low, left wing-low attitude. Local pilots report that the departure area is devoid of lighting at night and is a black hole requiring flight by reference to instruments after takeoff. The recently licensed private pilot had trained in a Cessna 172 and had 3.2 hours of night flight time and 1 hour of simulated instrument flight time. His 20-flight-hour checkout in the accident aircraft, which was also his high performance aircraft checkout, was completed the day before the accident. The checkout was conducted in daylight, visual flight conditions, and did not include any actual or simulated instrument flight.
HISTORY OF FLIGHT On November 22, 1995, at 2000 hours mountain standard time, a Cessna 210L, N5138Q, impacted the terrain after takeoff approximately 1 mile south of the Grand Canyon Airport, Grand Canyon, Arizona. The aircraft was destroyed and the private pilot and one passenger were fatally injured. The aircraft departed Grand Canyon Airport destined for Flagstaff, Arizona. Visual meteorological conditions prevailed and no flight plan was filed. A friend of the pilot and his passenger dropped them off at the airport terminal about 1930 and left. According to the friend, the pilot's intent was to fly to Flagstaff, drop off his passenger and then continue on to Phoenix, Arizona. The Grand Canyon Air Traffic Control Tower closes at 1900 and there were no witnesses to the departure. The aircraft was not serviced while at Grand Canyon. This same friend told the NTSB investigator that the pilot appeared healthy, rested, and not at all apprehensive about the flight. He was irritated with himself for having skidded one tire on the previous landing earlier in the day and putting a flat (bald) spot on a new tire. In response to a question about the safety of flying at night, the pilot replied that it was no different than flying in the daytime. At 2009, a surveillance satellite operated by the United States Air Force reported receiving an emergency locator transmitter (ELT) signal and initially fixed the position in northern Arizona. Personnel at the USAF Rescue Coordination Center at Langley, Virginia, notified the Los Angeles Air Traffic Control Center and the FAA Flight Service Station at Prescott, Arizona, of the signal at 2015. A second surveillance satellite at 2200 refined the position of the ELT to the area immediately south of Grand Canyon airport. Personnel at the Prescott Flight Service Station then notified the Coconino County Sheriff's Department of the potential of a downed aircraft near Grand Canyon Airport at 2230. Search and rescue personnel located the aircraft and the two fatally injured occupants at 0025 (November 23, 1995). The location of the accident is approximately 3/4 mile off the end of runway 21. The latitude is 35 degrees, 56.2 minutes north and the longitude is 112 degrees, 09.7 minutes west. PERSONNEL INFORMATION The 25-year-old private pilot received his license on October 20, 1995, and had 66 hours total flying time at issuance, all in Cessna 172 aircraft. Included in the 66 hours were 3.2 hours of night time and 1.0 hours of simulated IFR (hood) time. Of the 3.2 hours of night time, 1.2 hours was acquired September 18, 1995, and 2.0 was acquired October 2, 1995. Of the simulated instrument time, 0.5 hours was acquired June 27, 1995, and approximately 0.5 hours was acquired during the private pilot practical test (checkride). The Designated Pilot Examiner who administered the private pilot checkride told the NTSB investigator that his records of the checkride included the comment "good, strong flight." The examiner said that the pilot/applicant flew approximately 0.5 hours of simulated IFR during the checkride which included straight and level flight, turns of 90 degrees in both directions, a climb at best rate of climb speed, a descent, a VOR radial intercept, and recovery from unusual attitudes. The examiners comment in his records regarding the simulated IFR portion of the checkride was "a little rough." On November 13, 1995, the pilot purchased the accident aircraft and had logged no flying time since issuance of his private license on October 20. As a requirement for obtaining insurance on the aircraft, the pilot was required to obtain 20 hours of checkout in the aircraft from a certified flight instructor prior to operating the aircraft as pilot-in-command (PIC). That training was accomplished between November 14 and November 21, 1995, and the pilot was signed off for PIC in high performance aircraft on November 21, 1995. The flight the following day from Flagstaff to Grand Canyon and return, on which the accident occurred, was his first operation of the aircraft as PIC. All of the 20-hour checkout in type was conducted in daylight, VFR conditions. AIRCRAFT INFORMATION At the time of the accident the aircraft had accumulated 2,614 hours total flying time. The aircraft's last maintenance was an annual inspection conducted on January 2, 1995, at 2,439 hours. The flight instructor who flew with the pilot during the 20-hour checkout period stated that the aircraft was well maintained and that all equipment items functioned properly. The only discrepancy he reported noticing during the 20 hours of flying was a occasional brief flicker in the ammeter needle in the direction of discharge, after which the needle returned to center each time. Cessna Aircraft Corporation reported that this flicker is a normal system response to intermittent electrical loads on the system, and indicates that the electrical system was functioning properly. A pre-purchase inspection was performed on the aircraft on November 3, 1995, and the report noted that the instrument panel trim covers, which would have contained the instrument post lights, were not installed. The aircraft was equipped for day, night, VFR, and IFR flight. Although the instrument panel post lights were not installed, there were two overhead instrument panel flood lights and four additional flood lights under the instrument panel glare shield. METEOROLOGICAL INFORMATION The accident occurred during a clear, dark, moonless night. At 2200, a special weather observation taken by control tower personnel reported the weather as: no clouds below 12,000 feet; visibility greater than 10 miles; temperature 29; dew point 19; wind 290 degrees at 3 knots; and altimeter 30.32 inHg. A Safety Board moonlight analysis computer program disclosed that the moon was about 25 degrees below the horizon at the time of the accident. The moon's illumination of the night sky was zero percent. Infrared satellite imagery at the time of the accident was obtained from the National Climatic Center and was interpreted by the National Weather Service (NWS). The NWS forecaster concluded that the skies were clear over northern Arizona at the time of the accident and that stars should have been visible to the pilot. AIRPORT INFORMATION The Grand Canyon Airport is located on a plateau in north central Arizona at an elevation of 6,606 feet. The airport has one runway, 3-21, which is 8,999 feet long and 150 feet wide. The runway slopes downhill to the southwest at an average gradient of 0.008. There are ILS and VOR approaches available to runway 3. The Grand Canyon Air Traffic Control Tower operates between 0700 and 1900 MST daily. At other times, the airport operates as an uncontrolled facility using the tower radio frequency as the common traffic advisory frequency (CTAF). During hours of darkness the runway has medium intensity edge lighting (MIRL). Runway 21 has runway end identifier lights (REIL) and a visual approach slope indicator (VASI). Runway 3 is equipped with a medium intensity approach light system with runway alignment indicator lights (MALSR). The MALSR is focused in a southwesterly direction and is not visible to aircraft departing runway 21. When the air traffic control tower is not operating, runway and approach lighting is activated by pilot controlled lighting (PCL) by keying the radio on CTAF frequency five times in 5 seconds. The lights then remain on for 15 minutes. Ramp and parking facilities are located at the northeast end of the airport opposite the runway 21 threshold. According to interviews of local area pilots, when air traffic and surface winds permit, it is common practice for aircraft to takeoff on runway 21 and land on runway 3 in order to minimize taxi time and distance to the ramp. Several area pilots and airport personnel told the NTSB investigator that the area southwest of the airport is known to be devoid of lighting references at night and is referred to as a "black hole". They stated that nighttime departures into the total darkness require flight by reference to instruments to avoid flying back into the ground. WRECKAGE AND IMPACT INFORMATION The first identified point of impact was in a level area of low scrub brush, 3,800 feet from the end of runway 21 on a magnetic bearing of 197 degrees. The magnetic bearing of runway 21 is 208 degrees. From the point of impact, the wreckage field extended over 300 feet on a magnetic bearing of approximately 180 degrees. At the initial point of impact there was a scrape in the dirt which extended for 28 feet. The left wing tip fairing was located at the end of this scrape. Sagebrush on the right-hand (west) side of the scrape mark was broken on a 30- to 35-degree angle relative to horizontal. The leading edge of the wing tip fairing was abraded at an angle 30 to 35 degrees left wing low laterally and 15 to 20 degrees nose down longitudinally. Seventeen feet further and 11 feet to the right of the wing tip fairing was another impact point, which consisted of a hole 5 feet in diameter and 1-foot deep. Dirt and boulders, some as large as 8 inches in diameter, were expelled from the hole to the south over an additional 8 feet. The majority of the airframe wreckage (wings, forward fuselage, cabin ceiling, aft fuselage and empennage) was located 180 feet beyond the impact hole and in the center of the wreckage field. The right wing was found underneath the left wing which had the cabin ceiling and wing center section attached. Lying adjacent, but separate, was the fuselage aft of the front doorposts. The empennage was attached to the fuselage, but was twisted 180 degrees. The forward cabin consisting of the instrument panel and firewall assembly was also adjacent. According to actuator measurements, the landing gear was retracted, the elevator trim setting was 7.5 degrees tab up, and the wing flaps were extended 4 degrees. The attitude indicator instrument (artificial horizon) was disassembled on-site and showed no evidence of rotational scoring in the gyro cage. The face of the instrument was jammed and displayed a 30-degree left bank and a nose-low attitude. The engine was separated from the fuselage and was 12 feet beyond and 7 feet to the left of the airframe wreckage. The alternator and starter were broken from the accessory case of the engine and were found together about 40 feet beyond the engine. The magnetos were also broken off the engine and had torn loose from the spark plug wires. A muffler, broken from the engine, was found 40 feet in front of the main wreckage and 12 feet left of centerline. Grass under the muffler was scorched. The instrument vacuum pump was attached to the engine but had sustained impact damage. The case was distorted and the carbon rotor was fractured; however, the vanes and the shear coupling were intact. The engine was disassembled and examined by the NTSB at the Teledyne Continental factory. The detailed examination report is appended to this report. The propeller was separated from the engine and was located 35 feet in front of and 15 feet left of the main wreckage. The propeller blades exhibited uniform torsional twisting, chordwise striations, and leading edge damage. The propeller was disassembled and inspected at Southern California Propeller Service by the NTSB investigator and representatives of the McCauley Accessory division of The Cessna Aircraft Company. The McCauley representative opined that substantial power was being delivered to the propeller at impact and that there was no evidence of preimpact failure of the propeller. There was no postcrash fire. Rescue personnel reported a strong smell of fuel present on their arrival at the crash site. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Coconino County (Arizona) Medical Examiner and toxicology tests were performed by the FAA Civil Aero Medical Institute in Oklahoma City, Oklahoma. The toxicology test was negative for carbon monoxide, cyanide, volatiles, and drugs. TESTS AND RESEARCH Five light bulbs from the aircraft were sent to the NTSB Materials Laboratory in Washington, D.C. for evaluation. The metallurgist's factual report is attached. Bulb numbers 1 and 2 are from the underside of the pilot's glareshield and were grossly stretched (the two corresponding bulbs from the passenger side glareshield were destroyed). Bulb numbers 3 and 4 are from the ceiling mounted panel floodlight and "were deformed laterally, but contained minimal amounts of stretching of the individual filament coils." The fifth light bulb was from the tail navigation light. The glass capsule of this bulb was loose in the base at the accident site. The metallurgist reported it was not visibly stretched. The wing tip navigation light bulbs were destroyed. ADDITIONAL INFORMATION The aircraft wreckage was released to the pilot's estate on May 7, 1996.
the pilot's loss of aircraft control as a result of spatial disorientation. Factors were: the pilot's lack of experience in instrument and night flight conditions, inadequate transition/upgrade training, and the dark night light condition.
Source: NTSB Aviation Accident Database
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