Aviation Accident Summaries

Aviation Accident Summary NYC96FA101

RIDGEFIELD, CT, USA

Aircraft #1

N450T

Cessna P210N

Analysis

At 0857 edt, the pilot of Cessna P210N, N450T, contacted the FAA Automated Flight Service Station (AFSS) at Millville, NJ. He stated his intention to file an IFR flight plan from Morristown, NJ to Bedford, MA, at 5000 feet and requested a standard weather briefing. The briefer provided info from AIRMET Zule, Update 1, that the freezing level was at 10,000 feet, but said '...the freezing level up around Boston is at 5,000 feet, so anything 5 and above you might pick up icing there.' The pilot filed for 7,000 feet. At 0945 edt, after the pilot had received his weather briefing, AIRMET Zulu, Update 2 was issued, which called for light occasional moderate rime and mixed icing in the clouds and precipitation. Also, it cautioned that the freezing level would be from the surface to 4,000 feet, north of the pilot's destination, sloping to 8,000 feet at his departure point. At 1035, the pilot took off. About 30 minutes later, the airplane's single turbine engine experienced a completed loss of power. The airplane then descended in IMC and collided with trees during a forced landing. Examination of the wreckage revealed no preimpact failure of the engine, airframe, fuel system, or propeller. Investigation revealed N450T was not certifcated for flight in known icing conditions, and that the pilot did not use all anti-ice and deicing equipment as specified by the operator's manual. The pilot of another airplane departed an airport near the accident site. He reported icing at 7,000 feet, but no icing after a descent to 5,000 feet.

Factual Information

HISTORY OF FLIGHT On May 6, 1996, at 1107 eastern daylight time, a Cessna P210N, N450T, was destroyed during a forced landing and collision with terrain near Ridgefield, Connecticut. The commercial pilot and passenger were fatally injured. Instrument meteorological conditions prevailed for the personal flight that originated at Morristown, New Jersey, at 1035. An IFR flight plan had been filed for the flight conducted under 14 CFR Part 91. The pilot contacted the Millville Automated Flight Service Station by telephone, at 0857, and received a preflight pilot briefing for an IFR flight from the Morristown Municipal Airport (MMU), to Bedford, Massachusetts. According to a voice recording of the pilot's briefing, the pilot initially planned to file for 5,000 feet; however, at the conclusion of the briefing the pilot filed an IFR flight plan for an altitude of 7,000 feet. According to air traffic control (ATC) records, the pilot contacted the New York Departure Control after takeoff from MMU, and was issued a final altitude of 7,000 feet. After a frequency change, the pilot reported to the new controller that the airplane was level at 7,000 feet. About 1500, the pilot stated to the controller, "Uh, New York departure, five zero tango having an engine problem." The controller responded that the Danbury Airport was "just off your left there, uh say intentions," and the pilot stated that he wanted a descent into Danbury. During the next 5 minutes, N450T was provided magnetic headings by the controller to the Danbury Airport (DXR). The controller also provided the DXR weather to N450T, which included a ceiling of 800 foot broken, 2,200 overcast, and a visibility of 1 1/2 miles with light rain and fog. When the pilot acknowledged the weather, he also stated, "Uh, we copied that, we've lost our engine." At 1503, the controller asked the pilot if he wanted to "try and get the field visually or try for the approach," which the pilot responded, "I don't know whether we've got enough, uh, glide to get to do the full approach." At 1504:21, the pilot stated, "Is the field just to our right sir," and the controller responded, "Yes sir, ya have it." This was followed by the controller requesting several times if the pilot had Danbury in sight; however, there was no response, and at 1505:22, the controller requested that N450T change frequency and contact the Danbury Tower. The request was not acknowledged. At the time of the frequency change, a New York controller contacted the Danbury Tower controller by telephone and advised him that N450T was, "Fifteen hundred feet, about ah one and a half southwest, it looks like he could make a right base for runway eight right now, but were not talking to him...actually approach just lost radios with him..." At 1505:35, the pilot of N450T contacted the Danbury Tower controller and stated, "That's five zero tango, we've lost our engine, we're trying [to] make the field." The tower controller advised the pilot of the weather and altimeter setting, and the pilot responded, at 1506:07, "Five zero tango, we're going to try it." No other transmissions were received from N450T, and at 1506:47, the Danbury Tower received an emergency locator transmitter signal. The airplane was located on the side of a hill, about 3/4 of a mile south of the Danbury Airport. The accident occurred during the hours of daylight about 41 degrees, 21 minutes north latitude, and 73 degrees, 30 minutes west longitude. PERSONNEL INFORMATION The pilot, Mr. Richard F. Blanchard, held a Commercial Pilot Certificate with ratings for airplane single and multiengine land, multiengine sea, and instrument airplane. His most recent Federal Aviation Administration (FAA) Third Class Medical Certificate was issued on June 8, 1995. Examination of Mr. Blanchard's pilot log book revealed that his total flight time was estimated to 4,000 hours, of which approximately 600 hours were in make and model. He had logged about 561 hours of actual weather experience, of which about 75 hours were in this make and model during the previous 4 years. The flight log book revealed that Mr. Blanchard's first flight in a turbine powered airplane was on October 8, 1992. A 1 hour bi-annual flight review conducted on October 24, 1994, was his only documented flight with a flight instructor in turbine powered airplanes. Four tenths of that 1 hour was under simulated instrument flight. METEOROLOGICAL INFORMATION The pilot of N450T contacted the Millville Automated Flight Service Station (AFSS), at 0857, and received a complete preflight weather briefing for an IFR flight from Morristown to Bedford, Massachusetts. A request for a transcript of the AFSS weather briefing provide to the pilot was requested during the on scene accident investigation. In response to the request, the Millville AFSS provided a statement that, "All services provided by Millville AFSS were normal and there were no pertinent transmissions." A second request was made by the NTSB investigator for a transcript of the briefing, and during October 1996, a certified voice recording of the pilot preflight briefing was provided. A review of the certified copy of the voice recording of the briefing revealed that the pilot stated he would be departing Morristown for Bedford, at 5,000 feet, and requested a standard weather briefing. The AFSS briefer provided the pilot an Airman's Meteorological Information (AIRMET). The AIRMET covered the pilot's area of flight and forcasted IFR conditions throughout the day. The briefer also stated, "They've got another AIRMET for, disregard, the other one's for icing, but the freezing level is up about 8,000 [feet], correction 10,000 [feet], so you'd have to go 10,000 [feet] or above to pick up icing." After the current and forecast weather and winds were provided to the pilot, the briefer stated, "Uh, lets see, the freezing level up around Boston is at 5,000 feet, so anything 5 and above you might pick up icing there." At the conclusion of the weather briefing, the pilot filed an instrument flight plan, and requested an altitude of 7,000 feet. The AIRMET available to the Millville AFSS briefer at the time the pilot received his weather briefing was AIRMET Zulu , Update 1, for Icing and freezing level, valid until May 6, 1000. It provided the following information: AIRMET Icing; For Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York lower, New Jersey, Pennsylvania lower eastern, and coastal waters. From 50 miles south of Bangor, Maine, to 100 miles southeast of Nantucket, Massachusetts, to Atlantic City, New Jersey, to Eire, Pennsylvania, to Toronto, Canada, to 50 miles south of Bangor; Light occasional moderate rime/mixed icing in the clouds and in precipitation, from the freezing level to 20,000 feet. Freezing level; Surface to 4,000 feet, north of Portland to Toronto, Canada, line slipping to 8,000 feet Fort Wayne, Indiana to Newark, New Jersey, and 11,000 to 13,000 feet south of Atlantic City, New Jersey, Pittsburgh, Pennsylvania, and Indianapolis, Indiana. At 0945, May 6, 1996, AIRMET Zulu, Update 2 for Icing and freezing level, valid until May 6, 1600, was issued. It provided the following information: AIRMET Icing; For Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, and coastal waters. From Portland, Maine to 160 miles southeast of Bangor, Maine to 200 miles southeast of Nantucket, Massachusetts, to 160 miles east-southeast of Salisbury, Maryland, to Bridgeport, Connecticut, to Binghamton, New York, to Syracuse, New York, to Portland; Light occasional moderate rime icing in the clouds, below 16,000 feet. Freezing level; Surface to 4,000 feet, north of Portland to Toronto, Canada, line slipping to 8,000 feet near Fort Wayne, Indiana and Newark, New Jersey, and 11,000 to 13,000 feet south of Atlantic City, New Jersey, Pittsburgh, Pennsylvania, and Indianapolis, Indiana. The pilot of a single engine airplane departed the Danbury Airport on May 6, 1996, about 1030, on an instrument flight plan. In a written statement the pilot reported he departed in "rainy conditions. I think the temperature was about 40 [to] 41 degrees [F]." He also stated: "...I reached my 7,000' [foot] clearance somewhere northeast of Danbury...I was concerned about icing since I watched the air temperature decline during my climbout. After reaching 7,000' [feet], the OAT read 1 degree [C]. Only after I reached Hartford did I notice that the rain had turned to ice...Rime ice was forming on my wing struts and windscreen. I notified ATC after a few minutes and they immediately responded to my request for a lower altitude. I was cleared to 5,000' [feet]. There was no icing at that altitude..." WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on May 6 and 7, 1996. The examination revealed that all major components of the airplane were accounted for at the scene. The airplane came to rest at an elevation of about 800 feet above mean sea level (MSL), on the west slope of a 1,000 foot hill. The valley floors on the east and west side of the hill were each about 500 feet MSL. The hill was rock covered, and the slope angle was about 40 degrees. The airplane fuselage was level with the horizon and the engine was pressed against the slope, while the tail and wings were supported by trees. The airplane came to rest on a magnetic bearing of approximately 150 degrees. Initial tree impact scars started approximately 100 feet west of the wreckage at approximately 825 feet MSL. Tree impact scars become progressively lower on the trees in the direction of the wreckage. The tree scars indicate a general magnetic direction of 070 degrees. The ground surrounding the wreckage was fluid soaked, and a strong odor of kerosene was present during both days of examination. The main fuselage was upright and intact. The cabin interior was not compressed or deformed; however, the engine and firewall were shifted aft into the pilot and forward passenger seating area. According to rescue personnel, the pilot and passenger seat belts had been attached and were cut for extraction of the occupants, while the shoulder harnesses had been secured. Examination of the cockpit revealed that the power lever was at idle, the condition lever was at cutoff, the main fuel shutoff switch was in/on, and the fuel boost pump switch was selecting the number two pump. The flap switch was at the first notch, while the screw jack indicated that the flaps were retracted. All pilot circuit breakers were in except for the number one fuel pump, the overspeed warning, and the gyro slave. The left and right wings remained attached to the main fuselage. The outboard 6 feet of the left wing was separated and located on the ground near the left side of the wreckage. Both wings displayed tree impact damage, and both the left and right wing fuel tanks were ruptured and empty of fuel. Control cable continuity was established from the elevator, rudder, and ailerons to the cockpit. The elevator, rudder, and aileron trim indicators were destroyed. Examination of the fuel screens in the left and right wing tanks revealed that they were absent of debris. The fuel selector was removed from the fuselage. An examination revealed that it had been set to the both position and rotated freely. When air was blown into the engine outlet orifice, air flowed unobstructed to the corresponding selected tank position. The air airframe fuel filter was crushed and broken open. The filter was examined and found absent of debris. Several ounces of fuel drained from the fuel lines that were disconnected from the fuel control and engine fuel pump. The fuel was absent of debris, and when tested with water finding paste, it was found to be absent of water. The engine remained attached to the fuselage and was shifted aft against the fire wall. The propeller hub and blades were separated from the fractured nose case, which was partially separated from the gear box. The engine airframe scavenger oil filter by-pass button was extended. When the filter was opened and examined, it was found to contain several small black particles, similar to carbon deposits. The propeller blades remained attached to the propeller hub, and did not display any chord wise twisting or scratches. Two of the blades were at a blade angle greater than 80 degrees, similar to a feathered position, and the third blade was free to rotate in the hub. The landing gear selector switch was destroyed. The left and right main landing gear were partially extended from the fuselage and resting against trees and rocks; however, examination of the landing gear revealed no impact damage to the struts or wheels. The engine, governors, and the propeller hub and blades were removed for further examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on Mr. Richard F. Blanchard, on May 7, 1996, by Dr. Ira J. Kana, of the Chief Medical Examiners Office, Farmington, Connecticut. The toxicological testing report from the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for Mr. Richard F. Blanchard. TESTS AND RESEARCH Engine On May 23, 1996, the engine was examined at the Allison Engine Company, Indianapolis, Indiana, under the supervision of the Safety Board Investigator. Parties to the investigation were also present during the examination. The examination revealed no rotational scoring or damage to the compressor or turbine sections. The engine had received impact damage, and the compressor and turbine wheels would not rotate. Disassembly of the engine revealed no preimpact failure of the internal components. When the turbine section was removed from the engine, it rotated freely. When the compressor section was removed, the accessory gearbox drivetrain rotated freely. Compressor rotation was accomplished; however, it dragged due to impact damage and debris in the first stage blades. Compressor and turbine bearing wear was unremarkable, and the bearings were lubricated. The internal oil filter by-pass button was extended. The filter was removed and found absent of debris. The top and bottom chip detector plugs were removed and also found absent of debris. The engine fuel filter element was removed and found absent of debris. The fuel bowl contained a few ounces of fuel and a small amount of a sandy material. Fuel was also drained from the fuel control, fuel pump, and fuel lines during the disassembly. The engine fuel pump drive shaft was intact and rotated the pump when turned by hand. The pump was bench tested and provided the required pressure. Examination of the fuel control throttle and coordinator assembly indicated that they were in a position related to the ground idle range. Fuel Control On May 24, 1996, the engine main fuel control unit (FCU) was examined at Allied Signal, Inc., South Bend, Indiana, under the supervision of the Safety Board Investigator. Parties to the investigation were also present during the examination. A preliminary examination revealed minor impact damage to the FCU. The Px cover was removed and a coating of oil was observed inside of the unit. The Py fitting for the line to the propeller governor was also removed and revealed a small quantity of oil. The Pc inlet filter was removed and found to be clean and absent of debris. The fuel inlet filter was removed. Fuel was found inside of the FCU, and the filter was absent of debris. The Px cover was replaced and the FCU was installed on a test stand. A complete functional test of the FCU was completed according to the Allied Signal test specifications with no abnormalities noted. A post test disassembly of the FCU was performed with no defects noted, except a small amount of oil throughout the pneumatic section of the unit. The oily substance was analyzed by the Allied Signal Materials Laboratory, and determined to be s

Probable Cause and Findings

improper planning/decision by the pilot, which led to flight into icing conditions; and his failure to use all anti-ice and deicing equipment, as specified by the airplane operator's manual for inadvertent flight into icing conditions. This resulted in loss of engine power due to ice, a forced landing, and subsequent collision with trees during the forced landing. Factors relating to the accident were: the adverse weather (icing) condition, failure of a FAA Flight Service Station briefer to provide adequate icing advisories to the pilot, and low ceiling and trees in the emergency landing area.

 

Source: NTSB Aviation Accident Database

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