Aircraft Accident/Incident Report

South Deerfield, Massachusetts 01373
Friday, September 23, 2011 16:15 EDT

NTSB Narrative Summary Released at Completion of Accident

According to the pilot, during the initial climb, the airplane experienced a loss of electrical power. The pilot said that he unsuccessfully attempted to restart the alternators by cycling the on/off switches. The airplane was in instrument meteorological conditions, and when he saw a clearing in the clouds, the pilot made a “standard rate” spiral down through it. After exiting the clouds, he found a suitable place to land. On the approach, about 300 feet above ground level, the airplane started to porpoise. The pilot attempted to correct the porpoise, but the nose of the airplane struck the top of a tree before impacting the ground. Postaccident examination of the airplane’s flight controls did not reveal any mechanical anomalies. The engine examination revealed that incorrect pistons were installed at the time the engine was overhauled about 350 hours before the accident, but this did not play a role in the accident. The airplane was equipped with a dual alternator system. A postaccident interview with the pilot revealed that he attempted to energize the alternator’s field utilizing the pilot operating handbook procedure for a single alternator system. The dual alternator system emergency procedure was a supplement for the pilot operating handbook, and the checklist that was located in the airplane did not contain the normal or emergency procedures that were required for the dual alternator system. The emergency procedure for the dual system stated to depress the ALT RESTART switch, located next to the circuit breaker panel; the pilot stated that he did not know about the ALT RESTART switch. The No. 1 alternator was tested and examined. The No. 1 alternator functioned for 5 minutes during the test before it stopped producing power. It showed signs of excessive heat consistent with overloading when examined internally. The No. 2 alternator was not tested due to accident damage. The internal examination revealed burnt windings. The onboard engine data monitoring system indicated that the battery voltage decreased rapidly just prior to the loss of electrical power. A postaccident examination of the airplane’s electrical system revealed that the alternator restart battery pack did not contain enough voltage to reenergize the alternator field in the event that an alternator failed. A functional test of the system was required every 25 hours to ensure it worked correctly. The batteries were required as per the Airplane Service Manual to be replaced annually or sooner if the alternators cannot be restarted under a heavy load electrical load. A review of the airplane’s maintenance records revealed that most recent documentation for the alternator restart system batteries change was about 12 years ago. It is likely that the No. 2 alternator failed at an unknown time, which resulted in the entire electrical system on the airplane feeding off of the No. 1 alternator. The No. 1 alternator subsequently overloaded and failed, and the airplane’s battery was unable to sustain the electrical system demand. If the BEFORE TAKEOFF checklist for a dual alternator equipped airplane had been completed, the pilot could have detected that the airplane’s electrical charging system was not working correctly.

NTSB Probable Cause Narrative

The failure of the electrical system due to an alternator failure during flight in instrument meteorological conditions, and the pilot’s inadequate preflight inspection and failure to use the approved checklist for the dual alternator system. Contributing to the accident was the inadequate maintenance because the alternator restart battery pack was not replaced annually, as required by the airplane service manual.

Event Information

Type of Event Accident
Event Date 9/23/2011
Event Day of the Week Friday
Time of Event 1615
Event Time Zone Eastern Daylight Time
Event City South Deerfield
Event State MASSACHUSETTS
Event Country --
Zipcode of the event site 01373
Event Date Year 2011
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 422941N
Event Location Longitude 0723953w
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1610 Eastern Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID ORE
Elevation of weather observation facility 555
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height 2400
Lowest Non-Ceiling Height 2000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 3
Air Temperature at event time (in degrees celsius) 21
Dew Point at event time (in degress fahrenheit) 19
Wind Direction (degrees magnetic) 60
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 5
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.08
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 2
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 30899
NTSB Notification Source FAA New England ROC
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Apr 5 2013 8:03AM
User who most recently changed record johb
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N210LE
NTSB Number ERA11LA502
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model P210N
Aircraft Series Identifier --
Aircraft Serial Number P21000825
Certified Max Gross Weight --
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Aug 11 2011 12:00AM
Airframe hours since last inspection --
Airframe Hours 2985
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name SILENT H LTD
Aircraft Owner Street Address --
Aircraft Owner City WILMINGTON
Aircraft Owner State DE
Aircraft Owner Country USA
Aircraft Owner Zipcode 19810-4902
Operator is an individual? Yes
Operator Name Lawrence E. Hrablook
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Grapevine
Operator State TX
Operator Country USA
Operator Zip code 76051
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code BAF
Departure City West Field
Departure State MA
Departure Country USA
Departure Time 1539
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code BHB
Destination City Bar Habor
Destination State ME
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 4 2013 1:47PM
User who most recently changed record kenj
Since inspection or accident Time of Accident
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --