Pilot Debrief

CESSNA 210H near Melbourne, AR — 2021-08-09

Final reportCEN21FA364
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Date
2021-08-09
Location
Melbourne, AR, USA
Airport
42A
Aircraft
CESSNA 210H
Registration
N5940F
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to maintain control of the airplane with full flaps during the takeoff.

NTSB narrative

The pilot was conducting a personal flight to his home airport. A witness at the departure airport reported observing the pilot conduct a preflight examination of the airplane and then taxi the airplane to the runway for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll and that the airplane lifted off near the departure end of the runway. Witnesses who were located beyond the departure end of the runway reported that the airplane was flying low and seemed to be turning just before it crashed. The airplane impacted trees and terrain. A postcrash fire ensued and destroyed the airplane. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operations. The flap actuator was found in the fully extended position (30°). The elevator trim actuator was measured at a 2-inch extension, which was consistent with a 20° nose-down position. With the flaps fully extended, the airplane’s ability to climb and maneuver was significantly degraded. As a result, the pilot was unable to maintain airplane control while making a turn at a low altitude after liftoff. Postmortem toxicology testing showed that the pilot’s hemoglobin A1C level was 7.2%, which indicated the pilot’s diabetes was uncontrolled (but not severely) during the months before the accident. His elevated glucose (sugar) level placed him at risk for fatigue, dehydration, and blurred vision. The investigation could not determine whether the pilot’s uncontrolled diabetes impaired his ability to properly monitor the airplane’s configuration and safely perform the takeoff and climb.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have set flaps to 20° instead of 30° for takeoff.

NTSB coding

Evidence available

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

Docket documents11

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