Pilot Debrief

CESSNA T210 near Cedaredge, CO — 2013-11-20

Final reportCEN14FA064
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Date
2013-11-20
Location
Cedaredge, CO, USA
Aircraft
CESSNA T210
Registration
N6832B
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's spatial disorientation while operating in dark night conditions in snow showers and his subsequent failure to maintain airplane control, which resulted in overstress of the airplane and an in-flight breakup. Contributing to the loss of control was the pilot's diverted attention while coordinating for an instrument flight rules clearance.

Contributing factors

Contributing to the loss of control was the pilot's diverted attention while coordinating for an instrument flight rules clearance.

NTSB narrative

The instrument-rated pilot was flying the airplane inbound to Aspen-Pitkin County Airport (ASE) on a night visual flight rules flight. While level at 13,500 feet msl, the pilot requested an instrument flight rules (IFR) clearance, most likely due to worsening weather conditions associated with snow showers. The controller issued an IFR clearance and requested that the pilot transmit the necessary flight plan information. While the pilot transmitted this information, the airplane began a climbing left turn. After noticing the airplane turn about 180 degrees, the controller queried the pilot, who had not recognized the turn and stated that his autopilot had disconnected. The controller subsequently issued the pilot a heading back toward ASE, which the pilot accepted. However, the airplane continued to turn left and then began a rapid descent to impact. Portions of the left wing, left flap and aileron, and left horizontal stabilizer and elevator were found separated from the main wreckage area. It is likely that the airplane entered instrument conditions, and the pilot became spatially disoriented as he was coordinating the instrument clearance and was unaware of the airplane's left turn and climb after the autopilot disconnected. Further, during the final rapid descent, the design stress limits of the airplane were exceeded and an in-flight breakup occurred.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have maintained heading and altitude after autopilot disconnected.

NTSB coding

Evidence available

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

Docket documents18

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