Examining the Aftermath of a Cessna P210 Accident

The NTSB included among factors related to the accident the pilot’s overconfidence in himself—and the airplane.

New Orleans Lakefront Airport. New Orleans Lakefront Airport/Facebook

It wasn’t great flying weather. A sigmet called for numerous embedded thunderstorms with tops to 35,000 feet, possible tornadoes, 2-inch hail and 70-knot gusts. The route of the proposed flight from New Orleans to Sarasota, Florida, ran along the middle of the squall line, which extended from Texas to the Atlantic and was moving eastward at a brisk 30 knots.

The pilot had obtained a briefing the previous evening and had filed an IFR flight plan. He got a second briefing in the morning. When the pilot, his wife and another couple arrived at New Orleans Lakefront Airport, numerous thunderstorms were in the vicinity. Someone asked the pilot why they did not wait until tomorrow, when the weather would be better. “It’s no problem,” the pilot said. “I can handle it.”

Level at FL 210, the pilot reported to ATC that it was “a little rough.” Five minutes later, however, he was back with a more serious problem: He was having trouble with his gyros, and was descending.

The airplane, a Cessna P210R, was equipped with a “known icing” package that included two vacuum pumps, either of which could drive the instruments. Should one of them fail, one of two buttons on the suction gauge would pop out, showing red. It was also equipped, incidentally, with radar and a Stormscope.

Three minutes later, the pilot reported that all of the airplane’s gyros were out and he was descending in an effort to find VFR conditions. But there were no VFR conditions to be found. The pilot then said he would level off at 11,000. Seven minutes had now passed since the first report of gyro trouble. The P210 remained in radar contact for another five minutes but was not heard from again. It finally disintegrated in flight, scattering wreckage over an area 4.5 miles long near Mobile, Alabama.

Investigators concluded from inspecting the vacuum pumps that the left one had failed but the right had not. The attitude gyro appeared to have failed as well—a spinning gyro makes scuff marks on its housing in a crash, and there were none—leaving the pilot with only the electric turn and bank indicator, the directional gyro and the wet compass for guidance. Simultaneous failure of the attitude gyro and a vacuum pump was astronomically improbable, but at least it explained why the pilot believed that both vacuum pumps had failed at once—an equally unlikely event. Although it should, in principle, be possible to fly solely by reference to the turn and bank indicator, pilots who have to do so for a long time often end by losing control.

The National Transportation Safety Board (NTSB) included among factors related to the accident “the pilot’s... overconfidence in himself and the airplane.”

The NTSB report included an account of a recent incident from the pilot’s home base in New York, seemingly intended to suggest that his overconfidence bordered on pigheadedness. The pilot had asked his FBO to have his airplane ready in the morning, but 6 inches of snow fell during the night and the ramp and taxiways were blocked. Freezing rain was falling heavily, and although many jets and turboprops were based at the airport, no aircraft were arriving or departing. Appearing at the FBO, the pilot was incensed to find that his airplane was not ready to go. Various people, including his wife, tried to convince him that the ice-accumulation rate was too high for safety. He insisted, however, that his airplane was certified for flight into known icing conditions, and demanded that the ramp be cleared for him. After this was done, he taxied out, bogged down in snow after 100 yards, and was finally forced to abandon his planned trip.

This story, while an interesting illustration of a certain personality type in action, would have been more germane if the cause of the in-flight breakup had been extreme turbulence, destructive hail or a tornado. Since the cause seemed to be mere equipment failure, it could equally well have happened on any flight in IMC with turbulence, with or without thunderstorms.

The 4,300-hour pilot of a Cessna 310 displayed a different sort of persistence. Returning home near midnight from a business trip, he found ground fog covering his home airport. He flew an approach, missed, and told the controller he would give it one more try.

The field elevation was 1,474 feet, and the minimum descent altitude 1,840. On the first approach, the pilot descended to 1,700 feet before going missed; on the second, radar tracked him down to 1,500 feet. The 310 crashed in a flat, open pasture, about three-quarters of a mile short of the runway. The airplane encountered the ground at a shallow angle and slid or skipped to a stop, remaining largely intact, but the pilot died of massive head injuries. Curiously, the landing gear and flaps were found in the retracted position.

Ground fog can consist of a thin layer on the surface with clear air above it. Thus, descending below minimums is not quite the same as when solid clouds come down to within a couple of hundred feet of the surface.

The pilot’s wife attributed his actions to a strong desire to be back home with his family. The NTSB, however, took a different view. It found that on his application for a second-class medical seven months before the accident, he had given negative answers to all questions regarding use of medications, medical conditions and visits with doctors. But the post-mortem toxicology turned up a whole pharmacopeia in the pilot’s bodily fluids. Investigators subsequently obtained his personal medical records, which revealed that he had a lifelong history of migraine headaches occurring almost daily and lasting more than four hours, for which he had been prescribed, and was still using, a formidable variety of medications, both ingested and injected.

The NTSB attributed the accident to the pilot’s impairment by either medications or a migraine, or both. The evidence for this conclusion was only circumstantial; he had evidently flown for years with the same impairments, and, in the absence of the medical records, the NTSB might instead have blamed fatigue.

What is striking about this story is not the accident itself, which is of a common enough kind, but the pilot’s practice of concealing his medical history from the FAA. Not that it was in any way surprising. He operated a business that required him to travel frequently. He was also a part-time flight instructor. Obviously, someone whose livelihood depends on his flying might not give truthful answers about disqualifying medical conditions.

But what does the pilot tell himself?

I suppose it is what pilots tell themselves about all sorts of other hazardous situations to which they expose themselves (and not just pilots—many people normalize one sort of hazardous activity or another in the same way). We extrapolate from the past. If we have made a habit of scud-running, we note that despite the reputed risks of the activity, we are still alive. If we have descended below minimums before and not crashed, we reason that we can do it again. Experience is a more persuasive teacher than a rule book.

And so the pilot is undaunted by his daily migraines and the salad of polysyllabic painkillers that he uses to control them. He has thousands of hours. He knows what he’s doing; flying isn’t that difficult, when you’re good at it. And then, one day, he descends into ground fog with gear and flaps up, and hits the ground.

How can that be? He would never have believed it.

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, "Technicalities" and "Aftermath," with FLYING readers.

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