Alva, OK, USA
N310CR
CESSNA 310R
Prior to departing on a night, instrument cross country flight, the pilot contacted Flight Service for a weather briefing. The pilot told the briefer that he was familiar with his destination airfield, and that the automated weather reporting station was out of service due to construction. The closest weather reporting station was approximately 45 miles from his airfield. It was noted that fog was reported in the general area, but due to the out of service weather station it was unknown if the destination airport had fog present. During the flight, the pilot reported to Air Traffic Control that fog was located around his destination airport and he was unsure if he could land or not. On the second approach to the airport, the airplane impacted open terrain just south of the airfield. First responders reported at the time of the crash, visibility was very poor due to fog. A postaccident examination of the airframe and engines revealed no mechanical malfunctions or failures that would have precluded normal operation. Additionally, examination of ground scars and propeller blades indicated the engines were producing power during the collision with the ground. Both global positioning system (GPS) and radar plots depicted the airplane making an approach to the airport, followed by a missed approach. The plots also revealed that during the accident approach, the airplane descended below approach minimums for the airport. Post-mortem toxicology testing indicated positive results for ten different medications, several of them potentially impairing: Gabapentin (also known by the trade name Neurontin), a prescription antiseizure medication that is also used to treat chronic pain from a variety of neurological conditions; Hydrocodone, a prescription narcotic painkiller used for the control of moderate pain; and Dihydrocodeine and hydromorphone, which are metabolites of hydrocodone. Personal medical records obtained on the pilot noted a long history of severe migraine headaches, occurring nearly daily at times, treated with a wide variety of potentially impairing medications with only limited effect. He had been treated for headaches by at least three different physicians, with a medical visit for injected medication less than a week prior to the accident. Additionally, the pilot had denied the use of medication and frequent or severe headaches on application to the FAA for medical certification. Given the pilot’s reported familiarity with the aircraft and the airport, and his extensive reported experience, it seems likely that impairment due to migraine headache, medication use, or both played a role in the accident and the pilot's decision to descend below a safe altitude on the approach to the runway.
HISTORY OF FLIGHT On December 12, 2009, about 2355 central standard time, a twin-engine Cessna 310R airplane, N310CR, was substantially damaged when it collided with terrain while executing an instrument approach to the Alva Regional Airport (AVK), Alva, Oklahoma. The commercial rated pilot, sole occupant, was fatally injured. The airplane was registered to and operated by the pilot. An instrument flight rules (IFR) flight plan was filed for the flight that originated from Sundance Airpark (SHD), Oklahoma City, Oklahoma. Night instrument meteorological conditions prevailed for the personal cross-country flight conducted under 14 Code of Federal Regulations Part 91. There were no reported witnesses to the accident; however, family members were reportedly waiting for his arrival, and heard the airplane as it approached the airport. PERSONNEL INFORMATION The pilot, age 44, held a commercial certificate for airplane single and multi-engine land, and instrument rating-airplane. He also held a flight instructor certificate for airplane single and multi-engine airplane, and instrument-airplane. The pilot's most recent application for 2nd class Airman Medical Certificate, dated May 1, 2009, indicated, "No" in response to "Do You Currently Use Any Medication" and to all items under "Medical History," including specifically; "Frequent or severe headaches," "Neurological disorders; epilepsy, seizures, stroke, paralysis, etc.," "Mental disorders of any sort; depression, anxiety, etc.," and "Other illness, disability, or surgery." The application also indicated "No" in response to "Visits to Health Professional within Last 3 Years." At the time of his medical application, the pilot reported a total flight time of 4,295 hours with 25 hours in the previous 6 months. AIRCRAFT INFORMATION The airplane was a 1976 model Cessna 310R, which was a twin-engine, low-wing, all-metal airplane, with retractable tricycle landing gear. The last annual inspection was performed August 23, 2009, at hour meter reading of 1,317 hours. The time accrued on the airplane since the last annual inspection was approximately 33.1 hours. The airframe had accumulated about 2,518 total flight hours. The airplane was powered by two Continental IO-520-M reciprocating engines, each rated at 285 horsepower. Both engines had accumulated about 603 hours since their last major overhaul. The engines were driving McCauley full-feathering, 3 bladed propellers, each having accrued about 288 hours since overhaul. WEATHER CONDITIONS Prior to departing SHD, the pilot telephoned the Flight Service Station (FSS) to file his IFR flight plan and obtain a weather briefing. During the conversation between the pilot and briefer, it was noted that the briefer did not have a weather report for AVK, the pilot told the briefer that he was based at AVK and familiar with the NOTAMs (notices to airman). Additionally, he told the briefer the reason the weather station was not reporting, was due to runway construction in progress, and that the station was (temporarily) taken down. The automated weather reporting station at Enid, Oklahoma, was used for the weather brief (located approximately 45 nm southeast). The briefer told the pilot that the weather station at Enid was reporting a six hundred foot ceiling, seven miles visibility, with the winds at 170 degrees, at 11knots. The telephone call continued: Briefer: "Temperature and dew point, both seven ..... let's see if they got a forecast there" Pilot: " ....... Temperature and dew point was what ?" Briefer: " one-one, both of them" Pilot: "no, that was the wind ..... what was the temperature and dew point spread ?" Briefer: "... seven, excuse me, seven" Pilot: " okay" Briefer: "seven and seven, yeah" Pilot: "Okay" [later in the briefing] Pilot: " My main concern is fog, but I think we've got enough spread up there at Enid and enough wind that we ought to be good for the next thirty, forty minutes, and that's about all it will take me to get there..." Briefer: " Yeah, .... they're ... currently showing six hundred and seven ......" People near the accident site reported that the weather in the area at the time of the accident was foggy. Additionally, about 30 minutes after the accident notification, the first responders had difficulty in locating the crash site due to poor visibility. COMMUNICATIONS The Federal Aviation Administration (FAA) provided a transcript of air traffic control communications with the accident flight. During the flight the pilot contacted Kansas City Air Route Traffic Control Center (ARTCC). As the pilot approached the airport he contacted ARTCC and said: " I' am established inbound on the approach at AVK" Kansas (ARTCC), acknowledged the pilot and told him to " .... just report canceling IFR - in the air, this frequency, or if unable on the ground through, en route radio" The pilot responded, "okay I will try to cancel on this frequency, or on the ground, got a pretty good layer of ground fog, I don't know if I can slip in there" About 4 minutes later, the pilot radioed the controller and said, "I'm clear on top, I'm gonna circle back around an try to get in one more time", The controller acknowledges the pilot and asks if he's going to try the GPS again. The pilot told the controller, "yeah, I'll try it one more time, but it's pretty heavy ground fog, I don't' know if I can get it or not, I'll try one more shot, if not, I'll turn and go back to [HSD] city" The controller then gave the pilot weather conditions at Gage and Enid (Oklahoma), relaying that the weather report was not saying a lot about any ground fog; with Enid showing winds 170 at 8, visibility 6, mist, 600-overcast, temperature and the dew point both seven, altimeter 29. 87. The pilot acknowledges the information and said, " ...... it's clear until you get within about 10 miles of Alva" Later, the controller gives the pilot his missed approached instructions. About 9 minutes after that, the pilot reported to the controller that he was inbound on the GPS three-five approach. The controller told the pilot to change to advisory frequency, terminate radar services, and to report his down time. The pilot acknowledged the controller; there were no further communications, nor were there any reported emergency or distress calls from the pilot. (transcripts are posted it the docket) RADAR INFORMATION A review of the airplane's radar track showed the airplane approaching the airport's initial approach fix, HINEN, from the southeast. The radar track also reveals that the airplane was at an altitude of 3,300 feet at HINEN. Then, about two minutes later, the track shows the airplane near the final approach fix, CADAP, at the same altitude. About two-and-half minutes after CADAP, radar has the airplane over the airport at 1,700 feet. The radar then tracks the airplane climbing away from the airport in an arc, west of the airport. The aircraft continues the arc and approaches HINEN the second time, from the southwest at about 3,400 feet. The second approach continues in-bound to the airport, passing CADAP at 2,500 feet. About two minutes later with the airplane tracking straight to the airport, the radar reports the airplane at an altitude of 1,600 feet; the last radar hit about 12-seconds later, has the airplane at an altitude of 1,500 feet. AIRPORT INFORMATION Alva Regional Airport (AVK), was a public use airport located about 2 miles south of Alva, Oklahoma. The airport is non-towered and pilots were to use the Common Traffic Advisory Frequency (CTAF). The airport featured a single asphalt runway; runway 17-35 is 4,386-foot long and 75-foot wide. The field elevation is 1,474 feet mean sea level (msl). The instrument approach that the pilot was following was the RNAV (GPS) Runway 35. The published minimums for this instrument approach are; 400-foot ceiling, one-mile visibility and a minimum descent altitude of 1,840 feet. A note on the approach chart states that, "if the local altimeter setting not received, use Enid altimeter setting and increase all MDAs (Minimum Descent Altitude) 140 feet." WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the site on December 13-14, 2009. All major components of the airplane were accounted for at the scene. The airplane came to rest in the up-right position, on a heading of approximately 114 degrees, and about three-quarters of a mile south of runway 35. The pasture that the airplane came to a rest in, was open, relatively flat, with low cut vegetation. The first impact point was a shallow crater which contained several pieces of wreckage, including the left main gear door, the nose gear door, and an antenna. On both sides of the initial impact point several slash marks, consistent with propeller cuts, were found in the ground. From the initial impact point to the aircraft wreckage, a second impact point, similar to the first was found. Additionally, along the wreckage path, an engine cowling, wing tip (main) fuel tank, pitot tube, and various pieces of the airplane were located. The wreckage path was consistent with the airplane impacting the ground at a shallow angle and either "skipping" or sliding along the ground before coming to a stop. The airplane was largely intact, sitting on its belly. The landing gear was in the retracted (up) position; both the gear handle switch and flap switch were found in the up positions. The on-site examination of the airframe failed to identify any pre-impact malfunctions. The aircraft wreckage was retrieved to a salvage yard, where the NTSB along with a technical representative from Teledyne Continental Motors examined the engines. The examination did not reveal any pre-impact mechanical anomalies with either engine or their components. MEDICAL AND PATHOLOGICAL INFORMATION The Board of Medicolegal Investigations, Office of the Chief Medical Examiner, Oklahoma City, Oklahoma, conducted an autopsy on the pilot on December 14, 2009. The cause of death was determined to be "massive head trauma, blunt force." The FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing. The pilot tested positive for Acetaminophen, Bupropion, Cyclobenzaprine, Dihydrocodeine, Duloxetine, Gabapentin, Hydrocodone, Hydromorphone, Naprozen, and Propranolol. Personal medical records obtained on the pilot noted a "life long history of migraine headaches," indicated in 2006 to be present "on average greater than 4 hours per day" and occurring "on average 6 out of 7 days per week ... for 4 months." The records documented treatment of the headaches with propanolol, gabapentin, ibuprofen, naproxen, hydrocodone, injected ketorolac, and injected promethazine; the treatment of muscle spasm with cyclobenzaprine; the treatment of allergy symptoms with injected methylprednisolone; and the use of bupropion for smoking cessation. The records included notes of treatment from a neurologist, and treatment from two different primary care physicians, including the prescription on September 20, 2009, of 60 doses with 2 refills of medication containing 7.5 mg of hydrocodone and the injection of ketorolac on four separate occasions beginning on October 23, 2009 and most recently on December 7, 2009. TEST AND RESEARCH A damaged portable GPS unit (Garmin model 696) was located among the wreckage and sent to the National Transportation Safety Board's Vehicle Recorder Division Laboratory in Washington, D.C. An inspection of the unit revealed that the unit had sustained major damage from impact forces; the main LCD display was severely damaged, numerous surface mounted electronic components were damaged and/or dislodged from the main printed circuit board, and several integrated circuits were damaged due to impact forces. The lab was able to obtain data from the unit, which contained forty-four (42) unique tracklogs dated from September 25, 2009 to December 12, 2010. Downloaded tracklog data included the following parameters for each recorded data point: index, GPS date/time, GPS altitude, distance from previous update [leg length], time since last update [leg time], average groundspeed during the interval [leg speed], average course during the interval [leg course], and latitude/longitude position at the time of the update Tracklog data recovered for December 12, 2010 was stored in the tracklog designated Session 52. Data related to this tracklog began at 1056:22 CST with a latitude/longitude position fix corresponding to Sundance Airpark (KHSD). The final GPS position location fix was recorded at 1158:00 CDT and placed the aircraft at N36° 45.007' and W98° 40.273' with 1,539 ft GPS altitude. The last calculated velocity and direction of travel was 125 mph groundspeed with a course of 355° true. This tracklog ends just south of the Alva Regional airport.
The pilot's impairment due to medication use, a migraine headache, or both, and his decision to continue the approach below minimums without the proper visual references, resulting in the subsequent collision with terrain. Contributing to the accident was the pilot’s falsification of medical information provided to the FAA.
Source: NTSB Aviation Accident Database
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