Pilot Debrief

CESSNA 210B near Opal, SD — 2017-03-16

Final reportCEN17FA132
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Date
2017-03-16
Location
Opal, SD, USA
Airport
1SD4
Aircraft
CESSNA 210B
Registration
N9581X
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's loss of airplane control for reasons that could not be determined due to a lack of evidence.

NTSB narrative

The pilot was making a personal cross-country flight to return the airplane to the airport where it was normally stored after the completion of an annual inspection. The route of flight passed near a grass airstrip that was adjacent to the pilot's ranch home, and the wreckage was located about 275 yards from the northwest end of the airstrip. No witnesses to the accident were identified, and it could not be determined whether the pilot was performing a low pass or had attempted a landing at the airstrip. Examination of the accident site indicated that the airplane impacted terrain in a nose-low attitude. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures. Although the reported wind at an airport about 19 miles from the accident site was from 360° at 16 knots, the wind at an airport 53 miles from the accident site was from 320° at 34 knots with gusts to 40 knots. Additionally, weather modeling identified the potential for moderate low-level wind shear (LLWS) and moderate clear air turbulence within about 100 ft of the ground, and the potential for light LLWS from 100 to 500 ft above the ground. Therefore, it is possible that the airplane encountered LLWS and turbulence that contributed to a loss of control. Further, the pilot had severe coronary artery disease, which placed him at increased risk of a cardiovascular event that may have resulted in impairment or incapacitation. The investigation was not able to determine if adverse weather conditions or an acute cardiac event contributed to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted takeoff due to potential low-level wind shear.

NTSB coding

Evidence available

  • Photos
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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