Pilot Debrief

CESSNA 210 near Lubbock, TX — 2020-10-26

Final reportCEN21LA030
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Date
2020-10-26
Location
Lubbock, TX, USA
Airport
LBB
Aircraft
CESSNA 210
Registration
N9622T
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot’s improper decision to fly into icing conditions with an airplane that was not equipped for icing, which led to structural icing and a subsequent loss of airplane control, and the pilot’s impairment from carbon monoxide poisoning due to a cracked heat exchanger. Contributing to the accident was the pilot’s self-induced pressure to complete the flight due to the incoming adverse weather conditions and the inadequate inspection of the cabin air heat exchanger.

Contributing factors

Contributing to the accident was the pilot’s self-induced pressure to complete the flight due to the incoming adverse weather conditions and the inadequate inspection of the cabin air heat exchanger.

NTSB narrative

The instrument-rated pilot had recently purchased the accident airplane, which was not equipped for icing conditions, and was in the process of flying it back to his home base. During the first flight after purchase, he flew at 11,000 ft and was reportedly sick during and after the flight. The pilot was sick and miserable all weekend with symptoms to include queasiness, fatigue, dizziness, and a general malaise. Following a discussion with friends regarding the forecast icing conditions along the route, the pilot departed for his destination airport. While en route, the pilot requested from air traffic control permission to divert to another airport “for fuel considerations” and stated that he had been flying in instrument meteorological conditions (IMC) for a while. The controller directed the pilot to an instrument approach fix but the pilot did not intercept the fix in time, so the controller rerouted him to the east to attempt the approach from the other side. At this time, the pilot would have been in icing conditions, but he did not express concern to the controller. During the approach, the pilot stated that he was experiencing “freezing rain”, but he continued the approach. Based on the airplane’s flightpath it is likely that the autopilot was engaged. The airplane’s flight track revealed that after the airplane passed the final approach fix the airspeed decreased below 50 knots and the airplane made a sharp left descending turn. The airplane impacted the ground behind a residence and a postimpact fire consumed a majority of the fuselage. Available weather data revealed that the airplane was in IMC, icing conditions, and likely encountered supercooled liquid droplets during the flight. These conditions would have created an environment favorable for structural icing. A review of the pilot’s flight planning account revealed that he had requested a weather briefing and would have had access to the most accurate and updated weather information. The pilot reported to his girlfriend that he “wanted to beat the weather” on the day of the accident. This statement is consistent with the pilot’s self-induced pressure to complete the flight due to the incoming adverse weather conditions. A postaccident examination of the airplane revealed thick chunks of ice on and near the leading edges of the airplane that were consistent with structural ice. While the pilot reported an autopilot issue, it is likely that the airplane had accumulated enough structural ice that the autopilot had difficulty functioning properly. Based on the evidence, the accident is consistent with the pilot not able to maintain control of the airplane. The examination revealed that the cabin air heat exchanger had preaccident cracking, which allowed exhausts gases to mix with the cabin air. Based on the condition of the exhaust system and heat exchanger, it is likely that the system was not adequately inspected during the last annual inspection. The pilot’s toxicology revealed an elevated carboxyhemoglobin level. It is likely that the pilot was impaired by the effects of carbon monoxide poisoning and this impairment contributed to the pilot’s overall confusion, willingness to continue flight in icing conditions, and to the circumstances of the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to divert earlier due to worsening weather conditions.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 31 docket documents
View NTSB final reportView NTSB docket

Docket documents31

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