History of Flight
On October 8, 2021, about 1311 eastern daylight time, a Cessna P210N, registration N128EE, was destroyed during an accident near Atlanta, Georgia. The pilot and three passengers sustained fatal injuries. The flight was conducted under Title 14 Code of Federal Regulations Part 91 as a personal flight. Airport security surveillance footage showed the airplane lifting off approximately 1,000 feet down runway 21 in a nose-high attitude. It then rolled left, became inverted, and impacted the ground adjacent to the runway.
Aircraft Information
A review of the airframe logbooks indicated that Airworthiness Directive (AD) 2011-10-09 had been complied with on July 19, 2021. This AD required inspection of seat tracks, including visual inspection for excessive wear, dirt or debris, and locking pin play. The pilot and copilot seats were mounted on seat tracks that allowed fore and aft adjustment. An adjustment bar raised and lowered two locking pins into positions along the tracks to secure the seat. A spring mechanism aided positive locking. Weight and balance calculations, based on recovered documents, occupant actual weights, and baggage, showed the airplane weighed about 4,571 lbs at takeoff with a center of gravity at 51.19 inches aft of datum. The manufacturer's center of gravity range at maximum gross weight was 38.4 to 49 inches aft of datum, and the maximum allowable gross weight was 4,000 lbs.
Wreckage and Impact
The debris area was compact, with ground scars consistent with a nose-first, right-wing-down impact. The fuselage came to rest upright on a heading of 245° magnetic. The engine remained attached and was heavily fire-damaged. The compressor ingested soil, causing leading edge damage to the first stage turbine and bending several blades opposite the rotation direction. The propeller separated; one blade remained attached, four fractured at the hubs. The cabin and instrument panel were consumed by postimpact fire. Both wings separated and sustained fire damage. The tail section was thermally damaged. Flight control cable continuity was partially lost due to overload failures and fire damage. The elevator trim tab actuator was thermally damaged; the inboard rod measured 1.5 inches extended (5° tab down), the outboard rod 1.7 inches (5° tab up). Both rods were free to rotate.
Examination of the front left seat revealed the inboard forward seat attachment foot was 5.25 inches aft of the forward stop. The inboard seat track was fractured at the fifth hole from the front; the seventh hole showed impact deformation. The seat locking pin rested on top of the track with the bottom deformed forward. The outboard seat track was intact, but the locking pin was bent 90° forward and not contacting the track. The ninth hole from the front showed impact deformation. Gouges were present in the seat track.
Additional Information
The pilot operating handbook’s "Before Starting Engine" checklist advised verifying seats, seat belts, and shoulder harnesses were adjusted and locked. The Cessna Pilot Safety and Warnings Supplements warned that a pilot should visually check that the seat was securely on the tracks and locked; failure could allow the seat to slide aft during critical phases. The airframe manufacturer issued Service Bulletin SEB07-R06 Revision 6 (June 11, 2015), requiring installation of a secondary seat stop for the pilot seat and recommending one for the copilot seat. No secondary seat stop was installed on either front seat. The supplement noted prior events involving seat slippage due to discrepancies such as gouged lockpin holes, bent lockpins, excessive clearance, and debris accumulation on tracks.
Medical and Pathological Information
The autopsy report from the Dekalb County Medical Examiner indicated the pilot’s cause of death was inhalation of superheated products of combustion, ruled an accident. Toxicological testing by the FAA Forensic Sciences Laboratory detected ethanol at 0.058 g/dL in cardiac blood, 0.012 g/dL in vitreous, and 0.021 g/dL in urine. N-butanol and n-propanol were also detected. Alprazolam was detected at 5 ng/mL in cardiac blood and in urine. Sertraline and its metabolite desmethylsertraline were present at 1297 ng/mL and 3771 ng/mL, respectively, in cardiac blood, and also in urine. Loratadine, desloratadine, valsartan, atorvastatin, and diclofenac were found in cardiac blood and urine. The pilot’s most recent aviation medical examination was on September 29, 2021, with height recorded as 69 inches.