An ill-fated flight
Flying into icing conditions
Three days earlier
The pilot had recently purchased N9622T—a Cessna 210—and flown the airplane from Nebraska to Belen Regional Airport in Belen, New Mexico, to visit his girlfriend for the weekend before heading home to Corsicana, Texas. He had felt sick during the flight, and he continued feeling queasy, fatigued, dizzy, and generally ill during the weekend. On the morning of October 26, the pilot planned the flight to Corsicana, using ForeFlight to review convective weather charts at 6:28 and 6:58 a.m. At 11:46 a.m., he used ForeFlight again to obtain a weather briefing for the IFR flight from Belen Regional Airport (BRG) to C. David Campbell Field–Corsicana Municipal Airport (CRS).
The pilot planned a cruising altitude of 11,000 feet msl and to depart at 11:55 a.m. The 661-mile flight to the east would cross from Mountain Daylight Time into Central Daylight Time—one hour ahead.
Cloudy and bitter cold weather enveloped Belen’s nontowered airport as the pilot approached the fuel pump to top off the Cessna’s tanks. The cold conditions made it unpleasant if not difficult to operate the equipment, and when an airport employee helped him fuel the aircraft he thanked him, saying he appreciated it. Light snow began to fall as the airport employee watched the Cessna depart.
The flight
At 12:06 p.m., the pilot contacted Albuquerque Tracon. Shortly thereafter, ATC radar identified the Cessna 3 miles southeast of Belen Regional Airport at 6,800 feet msl. As it reached 7,200 feet msl, the controller cleared the Cessna to Corsicana via radar vectors with instructions to climb and maintain 9,000 feet msl. The controller warned that along the route, the flight would need to be at 12,000 feet for about 20 miles. Moments later ATC instructed the pilot to turn north and climb to 12,000 feet msl.
N9622T was now 15 miles south of Albuquerque, heading north and staying to the west of the Manzano Mountain Wilderness area. ATC planned to turn the Cessna east and back toward Corsicana once the airplane was above the high terrain. At 12:17 p.m., the controller instructed N9622T to turn right to a heading of 040 degrees. The pilot complied, freezing rain looming in his flight path.
At 12:22 p.m., the controller warned N9622T of possible light, mixed icing 8 miles ahead, reported by an aircraft descending out of Flight Level 180. The pilot of N9622T reported to ATC that he had already picked up icing from light freezing rain, yet he didn’t express concern. He never mentioned that the Cessna wasn’t equipped for flight into known icing (FIKI) or that he’d welcome assistance when the controller offered.
About five minutes later, ATC cleared the flight direct Corsicana. Since the pilot requested a lower altitude and Albuquerque Center had lower minimum vectoring and IFR altitudes, the tracon controller handed N9622T off to Albuquerque Center, which at 12:33 p.m. approved a descent to 11,000 feet and 17 minutes later to 9,000 feet msl.
After about two hours en route, N9622T crossed into Texas and the pilot checked in with Fort Worth ATC requesting to divert to Lubbock Preston Smith International Airport for fuel considerations. The controller cleared N9622T direct to the airport.
It was now 2:58 p.m. Central time. N9622T contacted Lubbock Approach and the controller asked if the pilot wished to fly direct to an initial approach fix or receive vectors to final. The pilot opted for the latter. Lubbock Approach descended the flight to 5,200 feet msl at 3:22 p.m.
After six minutes, the controller cleared N9622T for the Lubbock RNAV (GPS) Y approach to Runway 35 Left with instructions to fly a heading of 020 and maintain 5,200 feet until established. The pilot asked, “That was the One Seven Right approach, correct?” The controller reiterated, “Three Five Left approach, the RNAV Yankee Three Five Left.”
Two minutes later, responding to the Cessna pilot’s question about the next intersection, ATC advised, “Centurion Two Two Tango, you’re coming up at UFACI, that’s the final approach fix and you are cleared for the RNAV Y Three Five Left approach once established.” The pilot of N9622T responded, “Roger, I’m getting…can you just give me vectors please?” to which the controller replied, “Centurion Two Two Tango, you want me to break you off and bring you back around for it again?” The pilot confirmed, and ATC cancelled the clearance and issued a vector for another approach.
At 3:31 p.m., the pilot requested the EMUMY intersection and received instructions to continue his heading, then expect to pass the intersection and make a right turn back to it. The controller cleared N9622T again for the RNAV (GPS) Y Runway 35 Left approach.
About 15 minutes into the approach, ATC queried the pilot about icing and he confirmed experiencing icing and freezing rain. Again, he did not express concern or declare an emergency. Three minutes later, N9622T checked in with Lubbock Tower and was cleared to land.
At 3:57, the tower controller issued a low altitude alert: “Centurion Two Tango check your altitude immediately, the minimum vectoring altitude in your area is 5,200 feet.”
The pilot mentioned autopilot problems but the controller again instructed the Cessna to climb to 5,200 feet and advised, “There is an antenna at 12 o’clock a mile and a half.” The pilot of N9622T read back the climb to 5,200 feet, and the tower reissued the climb and altitude instructions. A minute later, the tower advised, “Low altitude alert, Centurion Two Tango check your altitude immediately, the MVA is 5,200 feet…Centurion Two Tango, radar contact lost.” There was no further communication.
Analysis
Self-induced pressure, faulty maintenance, weather, and aircraft limitations played a key role in this accident. That morning, several friends—including the pilot’s girlfriend—expressed concern about icing conditions forecast along the route and they attempted to persuade the pilot to postpone the flight. But the pilot insisted that he wanted to beat the weather and would stay farther south to avoid the conditions.
While fueling the Cessna 210, the Belen airport employee questioned the pilot about departing in worsening weather. He told investigators something seemed off with the pilot that morning, that he seemed fatigued. That and worsening weather conditions had prompted him to ask the pilot if he was sure he should be flying, but he had responded that he was OK, he was heading down home to Texas.
The Cessna’s maintenance logbook showed the exhaust system had been inspected during the last annual inspection—about seven flight hours before the accident flight—and the airplane was determined to be in an airworthy condition. However, an examination of the airplane revealed that the cabin air heat exchanger contained cracks in the metal barrier that separates the engine exhaust gas and the cabin air. These cracks exhibited corrosion and deposits on the surface consistent with having been there before the accident, allowing exhaust fumes to enter the cabin and expose the pilot to carbon monoxide (CO) poisoning.
Odorless, tasteless, and colorless, CO is hard to detect and extremely dangerous as it impairs judgment and decreases a pilot’s ability to control the airplane. Unfortunately, N9622T did not have CO detectors installed.
During the earlier flight from Nebraska to Belen, the pilot had climbed the Cessna to 11,000 feet msl to avoid a smoke layer en route. The symptoms he described after the flight and throughout the weekend were similar to CO poisoning. With cold outside temperatures during the accident flight, the pilot would have certainly used cabin heat. The insidious nature of CO poisoning again likely led to impaired decision making before and during that flight—especially noticeable in his response to experiencing freezing rain.
Precipitation in the accident region was very light, and light accumulating freezing drizzle was reported at the surface. The area was covered by a center weather advisory and airmets that warned of freezing rain, freezing drizzle, light snow, and moderate or greater icing conditions. At 3:53 p.m., Lubbock Airport’s METAR showed the wind from 020 degrees at 15 knots with gusts to 21 knots. The visibility was 4 miles in light freezing drizzle and mist. The ceiling was overcast at 700 feet agl. The temperature was minus 4 degrees Celsius with a dewpoint of minus 5 degrees Celsius. When the pilot reported an autopilot issue during the approach, it was likely that the airplane had accumulated enough structural ice from the freezing rain that the autopilot couldn’t function properly.
After N9622T crossed the intermediate fix and turned inbound, its groundspeed decreased gradually from about 80 to 50 knots. Then after crossing the final approach fix at about 4,700 feet msl with a 48-knot groundspeed, the Cessna made a sharp left descending turn before impacting the ground.
Freezing rain’s effect on airframes is severe. When warm air exists between two subfreezing layers (as in a temperature inversion), snow melts as it falls through the warmer air. As the melted droplets then fall into the subfreezing air below, they become supercooled and freeze on impact with an aircraft’s surface.
Investigators found numerous chunks of ice in the wreckage near the wings and still attached to some of the airplane’s leading-edge surfaces. The ice chunks—ranging in size from one to two inches thick and two to five inches long—were concave shaped and featured a smooth surface on the inside of the curve.
The NTSB’s probable cause cited the pilot’s improper decision to fly into icing conditions with a non-FIKI approved airplane and subsequent structural icing and loss of control, the pilot’s impairment from CO poisoning, his self-induced pressure to complete the flight, and faulty maintenance. And, yes, all those factors played a prominent role in this accident. Sadly, as this accident shows, several elements can combine to forge an accident chain that if left intact leads to unsafe decisions and a dire outcome. 
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