The NTSB recently released its report on an accident in which a 20-year veteran of the organization was among the victims. It was the Dec. 16, 2017, nighttime crash of a Cessna T210M near Oldenburg, Indiana, in which all three people and a dog on board the airplane were killed. A second dog survived the crash.
Dr. Paul Schuda, director of the NTSB Training Center in Ashburn, Virginia, was one of the passengers who died in the fated flight. The pilot-in-command was Schuda’s friend Dr. Louis Cantilena Jr., a professor and director of clinical pharmacology and medical technology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Cantilena was a member of CAP’s national Congressional Squadron, and Schuda was an official of the CAP’s National Capital Wing. Also on board was Cantilena’s daughter, Amy, who was a postgraduate student at the University of Kansas Medical Center.
Schuda wasn’t identified by name in the NTSB’s report but was referred to as a pilot-rated passenger. He held a commercial certificate with single-engine land and instrument ratings with more than 2,000 hours of total time, including 265 hours of night experience. He was a flight instructor with single-engine and instrument airplane ratings, and a ground instructor with advanced and instrument ratings. His FAA medical certificate had expired, and he had not applied either for renewal of the certificate or to be qualified for flight using BasicMed. His last flight review had been on April 2, 2016. Presumably because he wasn’t a required crewmember for the flight, the NTSB in its report didn’t raise his lack of a medical certificate as a contributing factor.
Pilot-in-command Cantilena held an ATP certificate with single-engine and multi-engine land ratings. He also was a flight instructor and was rated for single-engine and multi-engine airplanes and instruments. His second-class FAA medical certificate had been issued on Aug. 30, 2016, and required corrective lenses. He had logged 2,986 hours, with 2,902 as pilot-in-command. He had 291 hours at night.
Earlier in the day, Cantilena and Schuda had flown from Frederick Municipal Airport (KFDK) in Frederick, Maryland, to Charles B. Wheeler Downtown Airport (KMKC) in Kansas City, Missouri, to pick up Cantilena’s daughter. They departed KFDK at about 7:23 a.m. Eastern Standard Time (EST) and made a fuel stop at Columbus Municipal Airport (KBAK), Columbus, Indiana, before arriving at Kansas City Downtown.
For the return flight at about 4:32 EST, Cantilena used a subscription service to obtain a preflight weather briefing and to file IFR flight plans. The first leg was from KMKC to KBAK, and the second leg was from KBAK to KFDK. The airplane departed Kansas City Downtown at about 4:57 p.m. and landed in Indiana at about 7:27. Records at the fuel stop indicated that the avgas purchase was completed at about 8:32.
The controller immediately responded, and Cantilena radioed, “Having a partial engine failure. We need to get down right now. I saw KHLB three point six miles. Please confirm, please confirm.”
After the airplane took off from Runway 23 at KBAK, a controller issued instructions to climb to and maintain 11,000 feet MSL. Safety Board investigators used ADS-B information along with communications recordings in reconstructing events and determined that Schuda was handling the radio communications at first.
At 8:45:02, Schuda called Indianapolis Center, “Ah, center, this is Centurion seven six one yankee zulu with you, ah, level, ah, leaving, ah, forty four hundred for eleven thousand.” The controller responded with the current altimeter setting, and Schuda acknowledged. The controller then radioed, “Say altitude leaving and climbing to.” Schuda reported that they were leaving 4,700 and climbing to 11,000.
At about 8:52, the airplane was about 26 miles east of KBAK. It had reached about 7,450 feet MSL and began a gradual descent. At 8:52:06, Schuda made a transmission that wasn’t clear but that investigators interpreted as, “Ah, Indianapolis, Indianapolis, Indianapolis Center, ah…” At 8:52:14, he transmitted, “Indianapolis Center, Centurion seven five one yankee zulu, six one yankee zulu, ah, we are having an emergency, ah.” The controller didn’t respond. The NTSB’s report said it was because he was busy coordinating with another controller at the time.
At 8:52:30, Cantilena transmitted, “Mayday, mayday, mayday, seven six one yankee zulu, over.” The controller immediately responded, and Cantilena radioed, “Having a partial engine failure. We need to get down right now. I saw KHLB three point six miles. Please confirm, please confirm.”
KHLB, Hillenbrand Airport, at Batesville, Indiana, now operating as Batesville Airport, then was a privately owned airport with a 5,953-feet long by 100-feet wide paved runway that had been open to the public. But there was a complication, as the controller explained in the next transmission at 8:52:48. “One yankee zulu, Hillenbrand Airport is off your left and four miles. The airport is listed as closed, but that’s the closest airport to you.”
The airplane began a gradual left turn toward KHLB and, at 8:53:05, the controller radioed, “November one yankee zulu, understand you have an engine failure and you’re gonna go to the Hillenbrand Airport. Is that correct?” Cantilena radioed, “How do we turn the lights on. Do you know anything about this airport?” The controller answered, “Yeah, it is a private airport for Batesville, Indiana, an(d) I can get the, ah, frequency for the lights, but I’m not sure if they are working. The airport is listed as closed.”
In fact, as the airport’s manager later told investigators, the airport had been closed because it was losing money. There had been some discussion about the city of Batesville buying the airport or leasing it from the current owner. That action, it was believed, could make the airport eligible for federal funding. It could not receive federal funding as long as it was privately owned.
The airport was NOTAMed closed on December 6, 2017, just 10 days before Cantilena and Schuda would desperately need it. The manager coordinated the closure with the FAA and Indiana’s Department of Transportation. He filed a NOTAM with the FAA, put “X’s” over the numbers 18 and 36 at the ends, put objects along the runway’s centerline, and turned off all runway lighting.
At 8:53:23, Cantilena radioed, “We’re not gonna make it, we’re not gonna make it, ah, but, two point three miles, that’s all we have, that’s all we have.” The airplane was at about 5,700 feet MSL at that time. The airport’s elevation was 975 feet MSL. The controller responded, “Okay, the airport is ahead and to your left, nine to ten o’clock and three miles. That’s the closest airport, sir.” The controller followed up by telling the pilot, “It’s a one eight six three runway. If you turn due north now, you will be lined up for three six but you’re a little high for three six.” Cantilena responded, “That doesn’t matter. We can circle. Turning to three six zero right now.” The controller said, “Yeah, go north right now. You, you are about a mile south of the Hillenbrand Airport.” Cantilena replied, “Yeah, we gotta get the lights on.”
At 8:54:19, the controller radioed, “I’m looking up for you right now, sir. I’m trying to figure out the frequency to turn the lights on.” Cantilena said, “Sir, we’re not gonna make this. We gotta be able to see, we gotta be able to see.” The airplane was at about 4,000 feet and flying northbound.
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At 8:54:53, Cantilena radioed, “Sir, is there anything else you can do for us. Can you direct me…” The controller responded, “Okay, you’re right over the Hillenbrand Airport, sir, you’re directly over it. The, the CTAF frequency is one two (unintelligible) and you can try that for the lights.” About 25 seconds later, he added, “One two two point seven two is the CTAF. See if that can turn the lights on sir.”
At about 8:56, the controller radioed for the airplane to “turn southbound right now for Hillenbrand Airport. You, you’re now north of the airport about three miles.” The controller said the only frequency he had was 122.72. “It’s a private airport. I don’t know the frequency to turn the lights on. I’m trying to find something for you.” Twenty seconds later, he advised, “All I’m showing is the airport is closed. All I’m showing, sir, that’s the closest airport.” At about 8:56:43, the controller advised that the plane was two miles northeast of the airport. The pilot replied, “I am southwest now, sir. I do not…” That was the last transmission from the airplane. The controller kept radioing the information he had about the airport and the CTAF frequency.
The final ADS-B data point at 8:57:28 showed the airplane about 1½ miles northeast of the threshold for Runway 18 at KHLB at 1,200 feet MSL. That was about ⅔ mile southeast of the accident site. A witness who was located about ⅓ mile southeast of the accident site reported seeing the airplane fly past his house at low level with its lights on and no engine noise.
The airplane went down in a wooded ravine. The first tree strike was about 190 feet from the main wreckage. A fire broke out. After losing contact, the controller asked the pilot of a Cessna 525B Citation business jet to try to spot the Centurion. “I see a ball of fire on the ground,” was the reply. The pilot then canceled IFR and descended VFR to take a closer look. “I see it. It doesn’t look very good. I’d say it’s definitely it,” the Citation pilot radioed.
One thing still operating at KHLB was the airport’s automated weather observation system. At 8:55, the AWOS recorded overcast clouds at 7,500 feet, visibility 10 miles and wind variable at 5 knots. The NTSB’s meteorological study indicated the moon was more than 15 degrees below the horizon, creating dark night conditions.
The Cessna T210M had been manufactured in 1978 and was powered by a Continental TSIO-520 six-cylinder engine putting out 310 horsepower. The engine had been overhauled in June of 2007. At the time of its last annual inspection in June of 2017, the airplane had a total airframe time of 4,655 hours, and the engine had 249 hours since overhaul. New cylinders and pistons had been installed during the overhaul.
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Investigators didn’t find any evidence of preimpact structural failure or a problem with the airplane’s flight control system. When they did an engine teardown, failure of the No. 4 piston was discovered. There was a fracture around the entire perimeter of the piston, with the piston crown separating. The upper piston compression ring and compression ring insert separated. Metal debris was found in other parts of the engine. The investigation could not determine precisely what started the failure or the nature of any manufacturing defect that might have caused it.
The pathological study for Cantilena by the FAA’s Bioaeronautical Sciences Research Laboratory in Oklahoma City found use of the drugs atenolol and fexofenadine. Atenolol is used to treat high blood pressure, and fexofenadine is an antihistamine commonly used to treat symptoms of allergies.
The FAA found that Schuda’s medical history included high cholesterol and cancer. The agency found he had used a cholesterol-lowering satin and other drugs not considered to be impairing for treating the symptoms of cancer and the effects of treatment.
The NTSB did an airplane performance study and determined that the Hillenbrand Airport was the only one within the power-off glide range of the airplane at the time of the engine failure. There was an interstate highway, but the Safety Board noted that attempting to land at night on an unlighted roadway presents significant hazards. It said that the pilot’s decision to go to KHLB was understandable. The Safety Board suggested that the pilot had a long day, had flown a lot and likely was fatigued at the time of the accident. It suggested that the additional stress imposed by the engine failure and the need to execute an emergency landing in dark night conditions may have hampered his ability to maintain situational awareness.
The NTSB commented that Schuda’s medical history “included conditions and medications that, while unlikely to cause any sudden incapacitation, could potentially be impairing. However, the investigation was unable to determine the extent of impairment, if any, that might have been present at the time of the accident.”
The Safety Board determined that the probable cause of this accident was a total loss of engine power due to the failure of the No. 4 piston, which resulted in an attempted forced landing in dark night conditions and a subsequent in-flight collision with trees and terrain. Contributing to the accident were the pilot’s situational stress and fatigue, both of which degraded his performance.
This may have been an especially difficult accident for agency personnel to investigate because of the relationship with Schuda and his service to the cause of safety in aviation and other forms of transportation. The accident becomes especially tragic and somewhat ironic when one considers that the Training Center that he was responsible for running provides training for NTSB investigators and others from the transportation community to improve their practice of accident investigation techniques. As the NTSB explained, “The curriculum promotes independent, objective and technically advanced accident investigations that will enhance the safety of all modes of transportation.”
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.