Pilot Debrief

Cessna P210 near Burlington, WI — 2020-05-15

Final reportCEN20LA179
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Date
2020-05-15
Location
Burlington, WI, USA
Airport
BUU
Aircraft
Cessna P210
Registration
N1JA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot did not maintain a safe altitude during the visual approach, and subsequently lost control which resulted an impact with trees and terrain.

NTSB narrative

After the replacement of an alternator belt that had failed on the previous flight, the pilot departed the airport; however, elected to return. While maneuvering in the traffic pattern about three minutes before the accident, the pilot, via his cellular phone, attempted to call the mechanic who replaced the alternator belt. A review of flight track data and witness information revealed that the airplane remained in the traffic pattern after taking off and that during the final approach, the airplane was at a low altitude and low airspeed. Witnesses observed the airplane stall and impact trees and terrain short of the runway. Witness accounts and impact signatures to the forward fuselage were indicative of a nose-low, low energy impact consistent with an aerodynamic stall. Postaccident examination of the airplane revealed the replaced alternator belt was displaced from the engine driven pulley and the alternator and was found lying near the back and bottom of the engine. Although this condition would affect the airplane’s electrical system, the displaced belt would not affect the engine power performance. No other mechanical malfunctions were noted with the airframe and engine that would have precluded normal operation. Based on the autopsy findings and medical certification files, the pilot had several cardiovascular conditions that could result in sudden incapacitation; however, the operational findings did not suggest any sudden incapacitation or impairment. The pilot appeared to have made some good judgements about returning to the airport when he discovered an issue with his airplane. Thus, the pilot’s medical conditions and use of medications detected on toxicology testing were unlikely to have been factors in this accident. Given the available information, it is likely the pilot was returning to the airport after an alternator malfunction. During the final approach to the runway, the pilot did not maintain control of the airplane, at an already low altitude, and the airplane impacted trees and terrain on short final approach.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the takeoff after failing to retract landing gear.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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