Weather (Other) · NTSB CEN21LA030

CESSNA 210 — Lubbock, TX

1 fatal High-time pilotIMCBase-to-final turn
DateOctober 26, 2020
LocationLubbock, TX
AircraftCESSNA 210
Purpose of flightPersonal
ConditionsDay · Instrument Meteorological Cond
Phase / occurrenceApproach-IFR final approach Structural icing
Pilot age69
Pilot total time3,767 hrs · High time
Time in typeUnknown
Fatalities1

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.

NTSB findings

  • Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot
  • Aircraft-Aircraft oper/perf/capability-Aircraft capability-(general)-Capability exceeded
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Freezing rain/sleet-Decision related to condition
  • Aircraft-Aircraft systems-Ice/rain protection system-Airfoil anti-ice, deice-Not installed/available
  • Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Freezing rain/sleet-Effect on equipment
  • Aircraft-Aircraft handling/service-Maintenance/inspections-Scheduled maint checks-Inadequate inspection
  • Aircraft-Aircraft systems-Air conditioning system-Heating system-Damaged/degraded
  • Aircraft-Aircraft systems-Air conditioning system-Heating system-Inadequate inspection
  • Personnel issues-Physical-Impairment/incapacitation-Carbon monoxide-Pilot

What happened

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.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →