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Accidents · NTSB WPR11FA170 · Final report

Cessna T310R accident near Butte, Montana, March 19, 2011

On March 19, 2011 at about 10:05 pm local time, a Cessna T310R, registered N4914A, was substantially damaged in an accident during approach (IFR missed approach) near Butte, Montana (Bert Mooney International airport). It was a personal flight under general aviation rules (Part 91). 1 person was killed. The weather was instrument conditions (cloud, fog or low visibility).

The NTSB's probable cause their words, unchanged

The pilot's loss of airplane control during the missed approach for undetermined reasons. Contributing to the accident was the rapid and unforecast deterioration of the weather conditions to below the landing minimum and the pilot's decision to attempt the approach despite his knowledge of those conditions.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
March 19, 2011 · about 10:05 pm local time
Place
Butte, Montana · Bert Mooney International · map
Type
Accident
Injuries
1 person was killed.
Weather
instrument conditions (cloud, fog or low visibility)
Aircraft
Cessna T310R · all T310Rs on the register
Registration
N4914A · no longer on the register · serial 310R1400
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

Shortly before embarking on the flight, the instrument-rated pilot filed an instrument flight plan and checked the weather using a computer-based filing system. At that time, the destination airport was reporting visual meteorological conditions, with similar conditions forecast for the planned arrival time. The pilot did not list an alternate airport in the flight plan. About halfway through the flight, the pilot contacted the air traffic controller responsible for the destination airport’s airspace. By that time, the weather conditions at the destination had deteriorated, with reports of snow and fog and visibility below the instrument approach minimums. The controller provided updated weather information and asked the pilot if he wanted to continue with the initial approach. He responded that he did and that he would divert to an alternate airport if necessary. The pilot was then cleared for the approach, and the airplane began to descend toward the initial approach fix (IAF). Shortly thereafter, a scheduled air carrier airplane destined for the same airport contacted the same controller. The controller relayed the weather information, and the crew of that airplane responded that they would delay the approach to see if the weather conditions improved. About that time, the accident airplane reached the IAF and began the approach. The air carrier pilot then requested and received approval to divert to an alternate airport due to the weather conditions. The accident pilot most likely did not hear this exchange because he had switched to the airport frequency. Due to limitations in radar coverage, the air traffic controller was not able to see the airplane once it had descended to the approach altitude. About 4 minutes after the air carrier airplane began to divert, the accident pilot reported that he was performing a missed approach. The controller provided missed approach instructions and asked for the pilot's intentions. The pilot read back the instructions but did not state his intentions. The controller asked if he would like to divert to the alternate airport, and, after a series of delayed and partial responses from the pilot, a call of "Mayday Mayday" was heard on the controller's frequency. For the next 35 minutes, the controller unsuccessfully attempted to contact the pilot. During that period, an air medical flight also canceled a landing approach into the airport due to deteriorating weather conditions. Multiple witnesses reported the sounds of a loud, low-flying airplane northwest of the airport about the time of the landing attempt. The witnesses reported the sudden onset of a gusting wind, heavy snow, low visibility, and ice accumulations during that period. The airplane wreckage was located a few miles from the witnesses, about midway between the airport and the missed approach hold location. The wreckage distribution and flight instrument readings were indicative of a high-speed, steep nose-down, left-turning descent into the ground, with a heading almost opposite the direction of the missed approach route. Engine instrument indications, and both the engine and propeller damage signatures, were consistent with the engines producing similar amounts of power at the time of impact. The airplane was equipped with instruments and systems required for flight in instrument meteorological conditions (IMC) and flight into known icing. Additional equipment included an autopilot and a global positioning system (GPS) navigation and communication transceiver capable of receiving and displaying current weather information via satellite. Impact damage prevented a determination of the operational status of those systems. Available ground-based radar tracking data indicated smooth heading and altitude changes and minimal altitude deviations prior to the pilot being cleared for the approach, consistent with autopilot use. According to the prior owner of the airplane, the autopilot was susceptible to becoming disengaged during turbulent conditions, and, as such, it is possible that at some point during the approach the pilot was forced to revert to flying the airplane manually. Under such circumstances, the pilot's workload would have rapidly increased. Additionally, the likely accumulation of ice on the airplane's airframe would have reduced flight performance and added to his workload as he attempted to monitor the ice accumulation and operate the deice system. The pilot had recently purchased the airplane and likely had minimal solo experience flying it in IMC. The airplane was about 2 months overdue for its annual inspection, and 12 months overdue for its transponder, static, and altitude reporting systems check. However, postaccident examination of the airframe remnants did not reveal any failures or malfunctions which would have precluded normal operation. The engines exhibited indications of wear that would have resulted in a gradual reduction in engine power over its life, rather than a sudden loss of power. Although the severe weather conditions were not forecast, the pilot was accurately advised of the deteriorating conditions by the controller prior to the approach, and he would have had access to airport terminal reports via the airplane's radio and his GPS navigation system. The lack of a filed alternate airport indicates that the pilot was not prepared for the severity of the weather conditions. The airplane was carrying ample reserves of fuel, with enough to return to the departure airport if necessary.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Other weather encounter during approach (IFR initial approach)
  2. Loss of control in flight during approach (IFR missed approach) defining event
  3. Collision with terrain or object (not controlled flight into terrain) during approach (IFR missed approach)

The NTSB's findings

  • cause Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • factor Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below approach minima › Decision related to condition
  • factor Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below approach minima › Accuracy of related info
  • Aircraft › Aircraft handling/service › Maintenance/inspections › Scheduled maint checks › Not inspected
  • cause Aircraft › Aircraft oper/perf/capability › Performance/control parameters › (general) › Not attained/maintained

Pilot

  • Certificate: commercial pilot
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 1,745 hours in all; 52 in this make and model; 1,687 as pilot in command
  • Last flight review: August 8, 2009
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: unk
  • Injury: fatal

The aircraft

  • Airframe total time: 4,259 hours
  • Last inspection: annual inspection, December 11, 2009; 150 hours since
  • Maximum gross weight: 5,680 lb
  • Seats: 6
  • Landing gear: retractable
  • Engine 1: Cont Motor TSIO-520 (piston); 0 hours total
  • Engine 2: Cont Motor TSIO-520 (piston); 0 hours total
  • Fire on the ground

The flight

  • Departed from: GTF Great Falls MT at 9:20 pm
  • Destination: BTM Butte MT
  • Flight plan: IFR
  • Runway 15, 9,001 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 300° at 8 knots
  • Visibility: 0 statute miles
  • Sky: broken clouds at 400 ft
  • Temperature: 30°F (-1°C), dew point 28°F (-2°C)
  • Altimeter: 29.62 inHg
  • Observation at 9:53 pm from BTM, 6 miles away

Injuries

FatalSeriousMinorNone
Flight crew1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.