In‐flight Fire, Emergency Descent

and Crash in a Residential Area

Cessna 310R, N501N

Sanford, Florida

July 10, 2007

Aircraft Accident Summary Report 

NTSB/AAR-09/01/SUM 

PB2009-910401 National

Transportation 

Safety Board 
NTSB/AAR-09/01/SUM 

PB2009-910401 

Notation 7943B 

Adopted January 28, 2009 

Aircraft Accident Summary Report 

In-flight Fire, Emergency Descent 

and Crash in a Residential Area 

Cessna 310R, N501N 

Sanford, Florida 

July 10, 2007 

National 

Transportation 

Safety Board 

490 L’Enfant Plaza, S.W. 

Washington, D.C. 20594
National Transportation Safety Board. 2009. In-flight Fire, Emergency Descent, and Crash in a Residential Area, 

Cessna 310R, N501N, Sanford, Florida, July 10, 2007. Aircraft Accident Summary Report NTSB/AAR-09/01/SUM. 

Washington, DC. 

Abstract: This report explains the July 10, 2007, accident involving a Cessna 310R, N501N, operated by the National 

Association for Stock Car Auto Racing corporate aviation division as a personal flight. The airplane crashed while 

performing an emergency diversion to Orlando Sanford International Airport, Orlando, Florida, after an in-flight fire. The 

flight had been released despite a known unresolved maintenance discrepancy. Safety issues discussed in this report relate 

to the resetting of circuit breakers, the inspection and maintenance of electrical systems in general aviation aircraft, and 

the establishment of safety management systems in general aviation corporate operations. Safety recommendations 

regarding these issues are addressed to the Federal Aviation Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, 

marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent 

Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety 

recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in 

transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation 

reports, safety recommendations, and statistical reviews. 

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publications also may be obtained from the website or by contacting: 

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To purchase this publication, order report number PB2009-910401 from: 

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The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board 

reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
Aircraft Accident 

Summary Report 

Contents 

Contents .......................................................................................................................................... i

Figures............................................................................................................................................ ii

Abbreviations ............................................................................................................................... iii

Executive Summary..................................................................................................................... iv

1. The Accident.............................................................................................................................1

1.1 History of Flight .......................................................................................................................1

1.2 Wreckage and Impact Information...........................................................................................2

1.3 Operator and Personnel Information ........................................................................................7

1.3.1 General Information.......................................................................................................7

1.3.2 The Accident Pilots........................................................................................................7

1.3.3 Other NASCAR Aviation Division Personnel...............................................................8

1.3.4 Preaccident Maintenance and Airworthiness Responsibilities and Procedures ............9

1.3.5 Postaccident Changes ..................................................................................................10

2. Investigation and Analysis ....................................................................................................11

3. Safety Issues............................................................................................................................15

3.1 Circuit Breaker Reset Hazards ...............................................................................................15

3.2 Critical Circuit Breaker Identification....................................................................................17

3.3 Electrical Systems ..................................................................................................................18

3.4 Safety Management Systems..................................................................................................19

4. Conclusions.............................................................................................................................23

4.1 Findings..................................................................................................................................23

4.2 Probable Cause.......................................................................................................................24

5. Recommendations..................................................................................................................25

Board Member Statement...........................................................................................................27

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Figures 

Figure 1. Aerial photograph of main wreckage and impacted homes. The blue arrows 

show the general westerly direction of the airplane’s travel at impact........................................... 3

Figure 2. Diagram showing the location of impacted homes and trees and pertinent 

wreckage. The blue arrows show the general westerly direction of the airplane’s travel at impact. 

(Diagram not to scale.).................................................................................................................... 4 

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Abbreviations 

A&P airframe and powerplant 

AC advisory circular 

agl above ground level 

AOPA Airplane Owners and Pilots Association 

ATP airline transport pilot 

CFR Code of Federal Regulations 

DAB Daytona Beach International Airport 

DOM director of maintenance 

FAA Federal Aviation Administration 

ICAO International Civil Aviation Organization 

IS-BAO International Standard for Business Aircraft Operations 

NASCAR National Association for Stock Car Auto Racing 

NBAA National Business Aviation Association 

PIC pilot-in-command 

PVC polyvinyl chloride 

SAFO safety alert for operators 

SFB Orlando Sanford International Airport 

SMS Safety Management System 

SOP standard operating procedures 

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Aircraft Accident 

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Executive Summary 

On July 10, 2007, about 0835 eastern daylight time, a Cessna Aircraft Company 310R, 

N501N, part of the fleet operated by the National Association for Stock Car Auto Racing 

(NASCAR) corporate aviation division, crashed while performing an emergency diversion to 

Orlando Sanford International Airport, Orlando, Florida. The two pilots on board the airplane (a 

commercial pilot and an airline transport pilot) and three people on the ground were killed. Four 

people on the ground received serious injuries. The airplane and two homes were destroyed by 

impact forces and a postcrash fire. The personal flight was operating under the provisions of 

14 Code of Federal Regulations Part 91 on an instrument flight rules flight plan. Visual 

meteorological conditions prevailed at the time of the accident. 

The National Transportation Safety Board determines that the probable causes of this 

accident were the actions and decisions by NASCAR’s corporate aviation division’s 

management and maintenance personnel to allow the accident airplane to be released for flight 

with a known and unresolved discrepancy, and the accident pilots’ decision to operate the 

airplane with that known discrepancy, a discrepancy that likely resulted in an in-flight fire. 

This report discusses safety issues related to the resetting of circuit breakers, the 

inspection and maintenance of electrical systems in general aviation aircraft, and the 

establishment of Safety Management Systems in general aviation corporate operations. 

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Aircraft Accident 

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1. The Accident 

1.1 History of Flight 

On July 10, 2007, about 0835 eastern daylight time, a Cessna Aircraft Company 310R, 

N501N, part of the fleet operated by the National Association for Stock Car Auto Racing 

(NASCAR) corporate aviation division, crashed while performing an emergency diversion to 

Orlando Sanford International Airport (SFB), Orlando, Florida. The two pilots on board the 

airplane (a commercial pilot and an airline transport pilot [ATP]) and three people on the ground 

were killed. Four people on the ground received serious injuries. The airplane and two homes 

were destroyed by impact forces and a postcrash fire. The personal flight was operating under 

the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules 

flight plan. Visual meteorological conditions prevailed at the time of the accident. 

According to NASCAR corporate aviation division personnel, the commercial pilot was 

acting as pilot-in-command (PIC) for the personal flight, with the ATP acting as a “safety 

pilot.”1 The airplane departed Daytona Beach International Airport (DAB), Daytona Beach, 

Florida, about 0822, destined for Lakeland Linder Regional Airport, Lakeland, Florida. 

According to Federal Aviation Administration (FAA) air traffic control records, about 

0832:49, shortly after reaching a cruise altitude of 6,000 feet mean sea level, the ATP contacted 

air traffic control to declare an emergency, stating, “smoke in the cockpit we need...to land at 

Sanford.”2 The air traffic controller cleared the flight to proceed directly to SFB and descend to 

2,000 feet. DAB airport surveillance radar data indicated that the airplane subsequently turned 

toward SFB and began to descend. The last radio transmission from the airplane was received 

about 0833:15. This transmission terminated midsentence and seemed to include the phrase, 

“shutoff all radios, elec[trical].”3

 

The Safety Board’s aircraft performance radar study indicated that the last transponder 

signal4 from the accident airplane was received about the time of the last radio transmission. At 

 

1

 According to NASCAR policies, a pilot acting as PIC on a NASCAR airplane must hold an ATP certificate. 

However, NASCAR personnel stated that the commercial pilot was allowed to fly the Cessna 310 as long as the 

ATP was on board, acting as a “safety pilot.” 

2

 The airplane was not equipped with a built-in fire extinguishing system, nor was it required to be so equipped. 

NASCAR personnel stated that a handheld fire extinguisher was installed in the airplane, as required by regulations, 

and was mounted on the cockpit floor just forward of the right side pilot’s seat. Investigators were unable to locate 

the airplane’s handheld fire extinguisher in the wreckage and, therefore, could not determine if the pilots engaged in 

any smoke- or fire-fighting efforts. 

3

 This phrase was consistent with the checklist guidance for an in-flight fire or smoke emergency in the 

Cessna 310R Pilot Operating Handbook, which stated – “Electrical load – REDUCE to minimum required.” 

4

 Transponders are electronic devices, installed on aircraft, which transmit unique aircraft-identifying codes 

and, often, other information, such as aircraft altitude, in response to radio-frequency interrogations from 

ground-based equipment. Transponders operate using airplane-provided electrical power. 
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that time, the airplane was about 8 nautical miles northwest of SFB and was turning toward the 

airport while rapidly descending. Primary radar returns5

 that were recorded for about another 

1 minute 30 seconds showed the airplane maintaining a heading of about 150° towards SFB. The 

last of these primary radar returns was recorded about 0834:45; the Board’s study estimated that, 

at that time, the accident airplane was about 3 miles northwest of SFB and descending through 

about 1,200 feet above ground level (agl). The airplane subsequently crashed in a residential area 

about 0.7 nautical miles west of the last primary radar return. 

According to several witnesses near the accident site, the airplane was traveling 

“extremely fast,” was “very low,” and its wings were “rocking” as it descended. Just before 

impact, the airplane entered a “steep bank” and made a sharp turn to the west. Several witnesses 

reported seeing smoke trailing from the airplane, and one witness stated, “Smoke was trailing 

from the port side.” 

1.2 Wreckage and Impact Information 

The primary debris path was about 300 feet long and oriented on a westerly (about 255°) 

heading. The airplane first struck a north-south line of trees in a right-wing-low attitude at a 

height of about 65 feet agl. About 270 feet beyond the first tree strikes, the airplane struck a 

palm tree at a height of about 20 feet agl. The airplane then grazed the northeast corner of a 

house and subsequently impacted the next two houses along the street. A postcrash fire ensued, 

destroying the airplane and the second- and third-impacted homes. 

Airplane debris was found along the wreckage path, beginning near the impacted 

north-south line of trees and continuing to the impacted houses. (See figures 1 and 2.) The 

instrument panel glare shield6 was located on the roof of the first house. Most of the fuselage, 

the wings, the instrument panel, some avionics, seats, and the right engine were found in and 

around the second- and third-impacted homes. 

 

5

 Primary radar signals occur when a radio signal reaches and returns from the skin of an aircraft or other 

target. There are no unique identifiers for airplanes, and, typically, no altitude information is associated with 

primary radar returns. 

6

 The glare shield is a molded foam component that protrudes slightly aft of the instrument panel to reduce 

glare for pilots viewing the flight instruments. 
Aircraft Accident 

Summary Report 

Figure 1. Aerial photograph of main wreckage and impacted homes. The blue arrows show the 

general westerly direction of the airplane’s travel at impact. 

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Aircraft Accident 

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Figure 2. Diagram showing the location of impacted homes and trees and pertinent wreckage. 

The blue arrows show the general westerly direction of the airplane’s travel at impact. (Diagram 

not to scale.) 

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Aircraft Accident 

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The airplane was fragmented and severely burned; however, there was no indication of 

preimpact structural failure. Flight control cable continuity for the rudder and elevators was 

verified from the cable separation points (about the mid-cabin area) to the control surfaces in the 

empennage. Aileron control cable continuity was verified from the left wing root outboard to the 

left aileron bellcrank. Numerous separations in the control cables in the right wing and forward 

fuselage exhibited signatures consistent with tensile overload. 

Although much of the airplane was destroyed during the postimpact fire, investigators 

observed some discolorations and/or soot deposits on airplane parts that were not directly 

exposed to the postcrash fire. For example, the instrument panel deck skin7 that was located 

outside the area where the postcrash fire occurred showed signs of thermal damage. Localized 

areas of the underside of this component exhibited discolored primer paint, patches of 

charred/bubbling paint, and soot deposits, all of which were consistent with an in-flight fire. 

Additionally, the instrument panel glare shield, which is normally attached to the upper surface 

of the instrument panel deck skin, was found with thermal damage at the attachment point. (The 

glare shield was found on the roof of the first house, which was unburned.) 

Further, the cabin door was found about 60 feet away from the main wreckage, as 

illustrated in figure 1, unburned and with latching pins undamaged. However, numerous soot 

deposits were noted on the interior side of this door, again consistent with an in-flight fire. These 

soot deposits trailed across the lower portion of the door from an area that would have been near 

the lower edge of the instrument panel on the intact airplane to the aft edge of the door. The 

undamaged latching pins and the location and existence of the observed trailing soot deposit are 

consistent with the pilots having opened the cabin door to vent smoke during an in-flight fire. 

Most of the airplane’s electrical system components and associated wiring that were 

recovered were severely damaged or destroyed, and most of the electrical insulation had been 

burned off those wires. Examination of some small sections of recovered wiring and one partial 

wire bundle found among the fuselage wreckage showed characteristics, such as strand fusing 

and globules of resolidified copper, that may be consistent with electrical arcing and/or exposure 

to heat from the postimpact fire. Too little remained to positively identify which system or 

systems those wires were associated with or to determine when the observed characteristics were 

created. Recovered flight instruments, cockpit avionics, controls, switches, and circuit breakers 

exhibited severe postimpact fire damage and yielded no usable information regarding their 

preaccident configuration or condition. A component of the weather radar antenna assembly and 

some attached electronic circuit boards exhibited severe impact and thermal damage; however, 

no evidence of arcing or other electrical faults was observed. 

The insulation on most of the airplane’s wiring was burned off. However, some wiring 

with unburned insulation had markings that identified that wiring as having polyvinyl chloride 

(PVC) insulation. PVC wire insulation can produce incapacitating fumes when burned,8

 and 

PVC-insulated wiring has not been used as a general-purpose wire in new airplane designs by 

 

7

 The instrument panel deck skin is a sheet metal component that is fastened horizontally above the instrument 

panel, acting as a ceiling to the instrument panel compartment. 

8

 Studies indicate that PVC releases toxic hydrogen chloride gas (hydrochloric acid) when it is heated. 
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Cessna and other manufacturers since the early 1970s. However, the FAA permitted the 

continued use of PVC-insulated wiring in airplanes in which it was already being installed,

including Cessna 310s, which Cessna has been manufacturing since 1953. Because 

PVC-insulated wiring discovered in the wreckage had identifying numbers consistent with 

wiring commonly used by Cessna, it is likely that the PVC wiring in the accident airplane was 

installed by Cessna when the accident airplane was manufactured in 1977. 

Six original (white) pages with pilot-recorded maintenance discrepancies9

 were 

recovered loose near the wreckage. These entries were dated from March 14, 2007 to July 9, 

2007, and addressed the following topics, in chronological order: 1) right engine idle; 2) 

transponder mode C; 3) propeller deice amperage draw; 4) horizontal situation indicator 

sensitivity; 5) right engine revolutions per minute; and 6) weather radar system. 

The discrepancy pages recovered from the wreckage indicated that the first three 

discrepancies had been addressed by maintenance personnel, but the last three (dated June 28, 

July 6, and July 9, respectively) had not.10 The weather radar discrepancy page, which was dated 

July 9, 2007 (the day before the accident), stated: 

Radar went blank during cruise flight. Recycled – no response...smell of 

electrical components burning turned off unit – pulled radar [circuit breaker] – 

smell went away. Radar inop[erative]. [Underlining in original.] 

The company pilot who experienced the weather radar system anomaly told investigators 

that he documented and reported the weather radar discrepancy to NASCAR personnel, leaving 

the white original page in the discrepancy binder in the airplane and providing the yellow copy 

to the director of maintenance (DOM), in accordance with the company’s standard operating 

procedures (SOP). (For additional details, see the Accident Analysis section of this report.) 

However, no corrective action was recorded on the original white page of this discrepancy form. 

Additionally, NASCAR Aviation Division personnel could not produce the yellow copy of this 

form or any other written documentation indicating that any troubleshooting or corrective 

maintenance actions had been taken to resolve the discrepancy before the accident flight. 

 

9

 NASCAR pilots documented airplane maintenance discrepancies on nonserialized, duplicate reporting forms 

in binders on each airplane. The maintenance discrepancy report form consisted of two pages—a white original and 

a yellow carbon copy—in an airplane maintenance discrepancy binder. The white original page was to remain in the 

airplane’s maintenance discrepancy binder until corrective maintenance action was taken, and the director of 

maintenance was to receive the yellow copy. 

10 According to the director of maintenance, after satisfactorily addressing a maintenance discrepancy, the 

responsible maintenance technician was to record the corrective action on the white sheet and then initial and date 

the sheet. 
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Aircraft Accident 

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1.3 Operator and Personnel Information 

1.3.1 General Information 

At the time of the accident, NASCAR’s corporate aviation division11 operated a fleet of 

nine airplanes, including seven corporate jets, one turbopropeller-driven airplane, and the 

accident airplane. NASCAR employed 10 maintenance technicians and about 25 pilots in 

support of its airplane fleet. According to NASCAR records, the airplanes were flown about 

1,950 flights per year for a total fleet use of about 2,500 to 3,000 flight hours, primarily 

transporting NASCAR’s corporate personnel. The accident airplane, a light twin piston-engine 

airplane, manufactured in 1977 and purchased by NASCAR in March 1995, was based and 

maintained at DAB. The accident airplane was the only piston-engine powered airplane operated 

by NASCAR’s corporate aviation division, and, unlike the rest of the NASCAR fleet, was used 

primarily to transport parts, goods, and documents for NASCAR, rather than personnel. In 

addition to these business flights, the accident airplane was occasionally used by the commercial 

pilot for personal flights. As previously noted, NASCAR’s policies did not permit any pilot who 

was not an ATP to act as PIC in a company airplane; therefore, the commercial pilot had to be 

accompanied by the ATP on all such flights. 

1.3.2 The Accident Pilots 

The commercial pilot, age 53, was a medical doctor and was hired by NASCAR as a 

medical officer; he was not on NASCAR’s payroll as a pilot. As PIC, he occupied the left seat 

during the accident flight. The commercial pilot held a commercial pilot certificate with 

single-engine, multiengine, and instrument ratings. The commercial pilot also held an FAA 

third-class medical certificate, dated December 2005, with no limitations. 

A review of company and FAA records indicated that the commercial pilot had 

accumulated about 276 total flight hours, 106 hours of which were in multiengine airplanes, and 

26 hours of which were in Cessna 310 airplanes. He had flown about 11 and 6 hours, 

respectively, in the 90 and 30 days before the accident flight. The commercial pilot last flew the 

accident airplane 4 days before the accident. The day before the accident, the commercial pilot 

saw patients in his office from 0800 to 1300 and then returned home. He did not perform any 

scheduled or emergency surgeries, nor was he on call after he left the office. 

The ATP, age 56, was hired by NASCAR as a pilot on October 1, 1985. He occupied the 

right seat during the accident flight. He held a multiengine ATP certificate and type ratings in 

several business jet airplane makes and models, including the Cessna Citation (-500, -550, 

and -600), Dassault Falcon (-50 and -2000), British Aerospace HS-125, Beechcraft Premier IA 

 

11 NASCAR’s corporate aviation division is a separate entity not related to the aviation departments operated 

by NASCAR member race teams. 
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jet, and Learjet (-60 and -JET). The ATP also held a first-class FAA airman medical certificate, 

dated June 2007, with the limitation that he “must wear corrective lenses.” 

Company records indicated that the ATP had accumulated 10,580 total flight hours, 

67 hours of which were in Cessna 310 airplanes. He had flown about 50 and 17 hours, 

respectively, in the 90 and 30 days before the accident flight. According to NASCAR, the day of 

the accident was the ATP’s third duty day in the last 9 days. He last flew the accident airplane 

with the commercial pilot 4 days before the accident. The ATP was not on duty the day before 

the accident, and, on the day of the accident, his duty day began about 0700 (about 1.5 hours 

before the accident flight’s departure). The accident flight was his first flight of the day. 

The commercial pilot and the ATP both completed Cessna 310 proficiency training at a 

professional flight training facility on January 25, 2007.12 During postaccident interviews, the 

commercial pilot’s instructor stated that the commercial pilot needed extra classroom instruction, 

and an additional 2 hours of simulator instruction to pass the course. The instructor stated that 

the chief pilot told him that the commercial pilot would never fly the Cessna 310 without another 

pilot on board. The instructor stated that although he was aware of this stipulation, the 

commercial pilot successfully completed the training by his own merits. 

During postaccident interviews, the ATP’s instructor stated that the ATP was “highly 

qualified,” required little or no academic instruction, and showed “exceptional” proficiency 

during his two simulator sessions. The ATP completed the training in less than the programmed 

syllabus time. According to NASCAR aviation division personnel, the ATP’s Cessna 310 

training was conducted to enable him to serve as the safety pilot for the commercial pilot. 

1.3.3 Other NASCAR Aviation Division Personnel 

NASCAR’s aviation director, who was the head of NASCAR’s aviation division at the 

time of the accident, held an ATP certificate and type ratings in 10 airplane models. He had been 

employed by the company since 1987 and had been the company’s aviation director, reporting 

directly to the president of NASCAR, since 1994. 

The chief pilot had been employed in that position by NASCAR since August 2004. He 

held an ATP certificate and type ratings in three airplanes and reported to the aviation director. 

The DOM held an FAA airframe and powerplant (A&P) mechanic certificate with inspection 

authorization. He had been employed by NASCAR since October 1996 and had been DOM since 

1998. The DOM reported to the aviation director. The maintenance technician who was 

responsible for the accident airplane was also an FAA-certificated A&P mechanic with 

inspection authorization. He was hired by NASCAR in October 1995. 

 

12 According to the training syllabus, the 3-day course typically included 9 hours of classroom training, 

1.5 hours of briefing, 6 hours of simulator training, and 1.5 hours of debriefing. 
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1.3.4 Preaccident Maintenance and Airworthiness Responsibilities 

and Procedures 

NASCAR’s aviation department was operated under 14 CFR Part 91 and thus, was not 

required by the FAA to establish official standard operating procedures. Nonetheless, 

NASCAR’s corporate aviation division did develop an SOP manual containing the company’s 

policies and procedural guidance. However, investigators found evidence that the SOP guidance 

was not consistently updated13 or adhered to by company personnel. For example, the SOP 

indicated that company airplanes were for corporate use and that a pilot acting as PIC on a 

NASCAR airplane must hold an ATP certificate. Yet, the commercial pilot, who was not ATP 

rated, was permitted to fly the accident airplane for personal use. 

The guidance contained in the SOP manual was also not readily accessible to company 

personnel and, therefore, was not often referenced. When investigators asked NASCAR’s 

aviation director for a copy of the SOP manual, he could not immediately locate a copy. The 

aviation director told investigators that company personnel did not always follow NASCAR’s 

SOPs and that the SOPs were mostly “used as a training tool.” 

Moreover, the SOP lacked crucial specifics. The SOP stated, for example, that NASCAR 

personnel were to make and maintain records of all scheduling and maintenance issues related to 

its airplanes and that those records should be easily retrievable. However, the SOP did not 

contain any specific information about the methods, procedures, or tools to be used for 

scheduling or tracking airplane maintenance, and evidence indicates that maintenance 

information was not accessible to all NASCAR aviation division personnel. For example, 

although the DOM used maintenance tracking computer programs to track scheduled 

maintenance requirements on all the NASCAR airplanes, other NASCAR personnel did not have 

access to these programs. Maintenance technicians had to contact the DOM to get maintenance 

information for the airplanes on which they worked. NASCAR did not have a communication 

procedure for providing flight operations personnel (pilots and schedulers) with airplane 

airworthiness information. 

The SOP indicated that the DOM was ultimately responsible for ensuring that all 

NASCAR airplanes were maintained in an airworthy condition at all times and for releasing 

airplanes for flight after maintenance; however, the SOP did not specify a means for the DOM to 

communicate the maintenance status of an airplane to anyone else within NASCAR. Further, 

NASCAR had no system through which any individual, including the DOM, could remove an 

airplane from the flight schedule because of airworthiness concerns. In practice, such a decision 

was made collaboratively by the aviation director, chief pilot, and DOM. Planned and unplanned 

maintenance activities were finalized through a combination of verbal and e-mail coordination 

between those individuals. 

Although the DOM, chief pilot, and aviation director did discuss the weather radar 

discrepancy writeup, none of these individuals took any actions to ensure that the discrepancy 

 

13 At the time of the accident, the most recent SOP revision page was dated September 30, 2004. 
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was addressed before agreeing that the airplane could be flown. According to the chief pilot, the 

DOM told him: “It will be okay. Just tell [the ATP] not to turn it on.” 

1.3.5 Postaccident Changes 

NASCAR’s corporate aviation division began to address many of these procedural 

concerns almost immediately after the accident. The division made several changes to improve 

communication about, and awareness of, airplane airworthiness status. These changes included 

the following: 

• Using aircraft status boards14 that detail the planned maintenance activity and general 

status for each airplane in the maintenance department and the schedule and 

availability of the maintenance technicians; 

• Placing an aircraft status log in each airplane’s maintenance discrepancy logbook for 

pilots to review before flight; 

• Implementing an improved maintenance-tracking tool that provides a report of 

upcoming scheduled maintenance for each airplane in NASCAR’s fleet and is 

available on-demand to pilots and maintenance and other NASCAR personnel; and 

• Developing new, serialized maintenance discrepancy forms that include a number of 

additional entry categories and enable better tracking of maintenance issues. 

NASCAR corporate aviation division also made several revisions to its SOPs,15 such as 

requiring a placard that states “IN MAINTENANCE” to be placed near the airplane’s entrance 

during maintenance and to be removed by the maintenance technician only when the airplane is 

returned to service. The revised procedures also require maintenance and flight crew personnel 

to meet face-to-face before each flight to discuss the airworthiness of the airplane. 

 

14 The status boards listed the planned maintenance activity for and general status of each airplane. The 

availability and schedules of the maintenance technicians were also indicated on these boards. 

15 According to the NASCAR corporate personnel department, every pilot and maintenance technician received 

the updated procedures and was individually briefed on the new procedures and responsibilities. In addition, these 

changes were communicated in memos and at a flight crewmember group meeting. 
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Aircraft Accident 

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2. Investigation and Analysis 

On a flight in the accident airplane the day before the accident, another company pilot 

had turned off the weather radar and manually pulled the related circuit breaker, cutting 

electrical power to the system, in response to a weather radar system malfunction and a “burning 

smell.” The burning smell subsequently “went away,” according to the pilot’s entry in the 

airplane’s maintenance discrepancy binder, and the pilot flew the airplane for more than an hour 

without further incident before landing. 

Company records indicate that the weather radar system was installed in the airplane in 

May 1988. Its display was mounted in the instrument panel, and the associated 5-ampere circuit 

breaker was located on the bottom row of the main circuit breaker panel, with associated wiring 

located along the left cockpit sidewall, to the left of the commercial pilot’s left leg. Examination 

of similar airplanes revealed that the densest concentration of wiring in Cessna 310R airplanes is 

in this area. In addition, fuel lines to instrument panel gauges are routed through this area. 

The events on the day before the accident indicate that an electrical problem existed in 

the weather radar components or related wiring. Pulling the circuit breaker for the weather radar 

stopped a symptom (the burning smell) of the problem by removing electrical power from the 

circuit; however, it did not correct the underlying problem. Airplane electrical system anomalies 

that result in smoke and/or burning odors are indications of possible fire hazards. Moreover, the 

heat, smoke, fumes, and restrictions to visibility associated with an in-flight fire can represent a 

significant hazard to airplane occupants and adversely affect an airplane’s airworthiness. 

Therefore, the Safety Board concludes that the weather radar system anomaly that was 

experienced and formally documented by the NASCAR company pilot the day before the 

accident could have developed at that time into a significant in-flight smoke and fire event; 

however, the anomaly was temporarily alleviated when the company pilot pulled the related 

circuit breaker. 

Upon landing, the company pilot left the weather radar circuit breaker pulled, placed the 

maintenance binder with the white copy of the discrepancy report on the throttle quadrant, and 

provided the yellow copy and a verbal briefing of the incident to the DOM. He also reported the 

maintenance discrepancy to the maintenance technician who had primary responsibility for the 

accident airplane. According to 14 CFR 91.213, general aviation operations like NASCAR’s 

aviation division may operate nonturbine-powered airplanes (such as the Cessna 310), with 

noncritical inoperative equipment if the inoperative item is not required for flight and is either 

1) removed from the airplane, the cockpit control placarded, and the maintenance recorded, or 

2) deactivated and placarded as inoperative.16 Further, Federal regulations state that an 

appropriately rated pilot or mechanic must determine that the inoperative equipment does not 

constitute a hazard to flight. 

 

16 The FAA explains that equipment may be deactivated in some cases, by pulling the circuit breaker, while 

other cases might require that equipment be deactivated by a certificated and appropriately rated maintenance 

person. 
National Transportation Safety Board 12

Aircraft Accident 

Summary Report 

Postaccident interviews indicate that NASCAR’s aviation director, DOM, and chief pilot 

discussed the weather radar discrepancy on July 9—the day before the accident, after the 

company pilot reported it. However, no one examined the airplane to investigate the 

discrepancy; no maintenance personnel stated that they had been in the airplane since the 

discrepancy was reported; and no company personnel 1) removed the airplane from service; 2) 

reset the circuit breaker; 3) placed a placard in the cockpit regarding the discrepancy; or 4) 

deactivated the weather radar system, collaring the associated circuit breaker and placing a 

placard in the cockpit indicating the system’s inoperative status. The Safety Board concludes that 

without examining the weather radar system, and then either removing the airplane from service 

or placarding the airplane and collaring the circuit breaker, as well as making a maintenance 

records entry, it was not permissible to fly the airplane under Federal regulations. 

The final safeguard against the operation of an airplane with an unresolved maintenance 

discrepancy is a thorough pilot preflight inspection. In this case, the Safety Board’s investigation 

showed that both pilots had access to information that could have alerted them that the accident 

airplane had an unresolved maintenance discrepancy on the morning of the accident and could 

have led them to take appropriate actions to ensure that the discrepancy was addressed before 

flight. Postaccident interviews indicated that the ATP was specifically advised of the weather 

radar discrepancy by a telephone call from NASCAR’s chief pilot the night before and in person 

by the maintenance technician who was responsible for the accident airplane the morning of the 

accident flight. On both occasions, the ATP dismissed the issue as unimportant.17 

There is no indication that anyone specifically advised the commercial pilot of the 

weather radar discrepancy, but he was the designated PIC for the accident flight and, as such, 

had primary responsibility for determining the airplane’s airworthiness. He was responsible for 

reviewing all maintenance discrepancy reports in the airplane’s binder. The maintenance 

discrepancy binder was prominently placed on the throttle quadrant and would have been easy to 

review during the preflight inspection or before the airplane departed. The Safety Board 

concludes that the ATP and the commercial pilot had sufficient information about the weather 

radar discrepancy and the burning smell to determine that the condition constituted a hazard to 

flight and to refuse the airplane unless and until additional actions were performed by 

maintenance personnel. The Safety Board further concludes that the pilots accepted the airplane 

as made available by NASCAR management and maintenance personnel, despite the fact that no 

diagnostic, corrective, or interim maintenance action had been taken to address the discrepancy. 

On the day before the accident, the airplane was flown uneventfully for at least 1 hour 

after the pilot pulled the weather radar circuit breaker. In contrast, on the accident flight, the 

airplane was only airborne for about 10 minutes before the pilots reported a problem. The 

airplane crashed about 2 minutes later. The most likely reason for the rapid onset of the problem 

is that one of the pilots reset the radar circuit breaker, thus reinitiating the development of the 

problem encountered on the previous flight. The circuit breakers would have been difficult for 

the ATP to reach and were next to the left leg of the commercial pilot, but nothing was found to 

indicate which pilot reset the circuit breaker or when. Examination of the wreckage also 

 

17 It is unlikely that the accident pilots believed they would need to activate the weather radar system during the 

relatively short accident flight conducted in visual conditions. 
National Transportation Safety Board 13

Aircraft Accident 

Summary Report 

indicated that the heat of the in-flight fire was most intense in the area above the left-side 

instruments, where wiring (including weather radar wiring) and other combustible materials 

were located. However, impact and fire damage to the airplane prevented physical confirmation 

that the circuit breaker was reset. 

Examination of heat and soot evidence on the instrument panel deck skin, which was not 

exposed to the intense postimpact fire, indicated that there had been a fire in the area forward of 

the left-side instrument panel. The location of the cabin door (about 60 feet from the main 

wreckage) and the undamaged door latching pins, indicated that the door was likely unlatched 

during flight to alleviate conditions of heat and smoke and was subsequently thrown clear during 

the impact sequence. Also, the soot trail on the cabin door was consistent with the flow of smoke 

being drawn from below the instrument panel and out the door by the slipstream. 

Given the previous day's events, the weather radar system and/or its associated wiring 

was most likely the source of the fire. The flammable fluid lines located near that system’s 

wiring may have provided additional fuel for the fire; the Safety Board could identify no other 

likely sources of smoke or fire.18 Although the weather radar system and/or its wiring is the most 

likely source of the fire, the Safety Board concludes that there was insufficient evidence to 

conclusively determine the origin of the in-flight fire. 

General aviation pilots often reset circuit breakers during preflight preparations unless 

the circuit breakers are placarded or collared to show that the associated system is to remain 

unpowered. Further, the accident airplane’s “Before Starting Engines” checklist included an item 

stating “Circuit Breakers—IN.” Therefore, the Safety Board concludes that it is likely that one of 

the pilots, consistent with routine and/or the “Before Starting Engines” checklist for the accident 

airplane, reset the weather radar circuit breaker, which restored electrical power to the weather 

radar system’s wiring and resulted in the in-flight fire. 

The Safety Board considered several explanations for the airplane’s rapid right turn 

before it crashed in the residential area. Following is a list of possible scenarios and the Board’s 

analysis of each: 

1) Did the pilots lose control of the airplane because of exposure to smoke and 

fumes? Although the pilots reported smoke in the cockpit when they diverted to SFB, 

autopsies revealed no evidence of smoke or soot inhalation in the pilots’ tracheas and 

did not show definitive evidence of hydrochloric acid (a byproduct of burning PVC) 

exposure.19 Further, toxicological tests did not detect evidence of carbon monoxide or 

cyanide in the commercial pilot’s blood.20 This suggests that the pilots did not suffer 

 

18 As previously mentioned, some individual wire strands and one wire bundle found among the wreckage 

showed characteristics that could be consistent with either electrical arcing or exposure to heat from an intense fire. 

It was not possible to identify which system those short wire fragments were associated with or what caused the 

observed characteristics. 

19 The Office of the Medical Examiner for Volusia and Seminole Counties, Florida, performed autopsies on the 

pilots. The autopsy reports indicated that both pilots died as a result of “multiple blunt force trauma.” 

20 Toxicological tests to detect the presence of carbon monoxide and/or cyanide were not performed for the 

ATP. 
National Transportation Safety Board 14

Aircraft Accident 

Summary Report 

a prolonged exposure to a significant amount of smoke, which would be consistent 

with the short time between the takeoff, declaration of an emergency, and impact. 

Further, the airplane’s bank shallowed as it reached a westerly heading, indicating 

that the pilots may have had some control of the airplane as it impacted the trees. 

 

2) Did in-flight fire and/or heat compromise the flight controls and make the 

airplane uncontrollable? As mentioned above, the airplane’s relatively shallow bank 

at the time of impact suggests that the pilots were able to manipulate the flight 

controls. Also, an evaluation of the duration, intensity, and location of the fire 

indicates that it is unlikely that fire or heat behind the instrument panel could have 

been severe enough to render the flight control systems partially or fully 

inoperative.21 

3) Did the pilots intentionally attempt to divert to an alternate landing site when 

they recognized that they would not reach SFB? Aerial photographs of the area 

surrounding the accident site show some fields and marshy areas to the west of the 

site. The airplane’s sudden, rapid right turn, followed by its shallower bank as it 

neared a westerly heading, would be consistent with an intentional diversion. It seems 

likely that the pilots would choose to try to reach an alternate landing site if they 

believed that they would not be able to reach SFB. However, at the time of impact, 

the airplane’s flaps and landing gear were not extended and the airplane was traveling 

at a high speed, which would indicate that the pilots had not configured the airplane 

for an immediate emergency landing. 

4) Did the pilots lose situational awareness because of a preoccupation with the 

in-flight fire? An in-flight fire, especially one located in front of the pilots and 

directly over their legs, would be very distracting, and it is likely that the pilots would 

want to get the airplane on the ground as soon as possible. Therefore, it is possible 

that the pilots were distracted by or coping with the in-flight fire. 

The Safety Board concludes that, after analyzing the available evidence, it was not 

possible to definitively determine the events that led to the accident airplane’s maneuvers away 

from SFB. 

21 The only portion of the flight control system that would have had lengthy exposure to the in-flight fire was 

the steel control shaft that extended through the instrument panel. 
National Transportation Safety Board 15

Aircraft Accident 

Summary Report 

3. Safety Issues 

3.1 Circuit Breaker Reset Hazards 

Circuit breakers are installed on aircraft to protect wiring. When current flow in a system 

exceeds a predetermined value for a period of time, the circuit breaker activates, or “trips,” to 

stop current flow through that system by breaking the electrical circuit. To use the system after a 

circuit breaker trips, a pilot must reset that circuit breaker manually. Historically, it has been 

common practice to reset a circuit breaker on an airplane one time after the breaker trips. The 

rationale behind this one-time reset practice is that if the circuit breaker tripped because of 

anything other than a transient or nuisance event and if the triggering condition was still present, 

the circuit breaker would trip again shortly after being reset. Consistent with historical guidance 

related to circuit breakers, page 7-24 of the accident airplane’s pilot operating handbook states, 

in part: 

All electrical systems in the airplane are protected by push-to-reset type circuit 

breakers.... Should an overload occur in any circuit, the resulting heat rise will 

cause the controlling circuit breaker to “pop” out, opening the circuit....After 

allowing to cool for approximately three minutes, the circuit breaker may be 

pushed in...to reenergize the circuit. However, the circuit breaker should not be 

held in...if it opens the circuit a second time as this indicates a short circuit. 

However, this practice does not consider the cumulative nature of wiring damage and that 

the removal of power only temporarily stops the progression of the damage. The aviation 

industry has begun to recognize the potential hazards of resetting noncritical circuit breakers 

even once. For example, the Transportation Safety Board of Canada report on the September 2, 

1998, accident involving an in-flight fire on a SwissAir MD-1122 documented the importance of 

not resetting noncritical circuit breakers and recommended that “[r]egulatory authorities 

establish the requirements and industry standard for circuit breaker resetting.” In addition, the 

Safety Board conducted a review of commercial aviation accidents involving in-flight fires and, 

based on its findings, issued several similar safety recommendations. In Safety Recommendation 

A-01-83, the Board recommended that the FAA develop and issue an advisory circular (AC) to 

address in-flight fire issues.23 On January 8, 2004, the FAA issued AC 120-80,24 “In-Flight 

Fires,” which stated, in part: 

 

22 -For additional information, see Transportation Safety Board of Canada, In-flight Fire Leading to Collision 

with Water, SwissAir Transport Limited Flight 111, McDonnell Douglas MD-11, HB-1WF, Peggy’s Cove, Nova 

Scotia, 2 September, 1998, Aviation Investigation Report A98H0003. 

23 The Safety Board issued Safety Recommendations A-01-83 through -87 on January 4, 2002. The full text of 

the recommendation letter is available online at <http://www.ntsb.gov/recs/letters/2001/A01_83_87.pdf>. Based on 

the FAA’s issuance of AC 120-80, the Board classified Safety Recommendation A-01-83 as “Closed—Acceptable 

Action” on April 15, 2004. 
National Transportation Safety Board 16

Aircraft Accident 

Summary Report 

Crewmembers may create a potentially hazardous situation if they reset a CB 

[circuit breaker] without knowing what caused it to trip. A tripped CB should not 

be reset in flight unless doing so is consistent with explicit procedures specified in 

the approved operating manual used by the flight crew or unless, in the judgment 

of the captain, resetting the CB is necessary for the safe completion of the flight. 

Air carrier manuals and training programs should contain company policies and 

explicit procedures regarding resetting tripped CBs, both during flight and on the 

ground. The procedures shown in the manuals used by the air carrier’s 

crewmembers, maintenance personnel, and airplane ground servicing personnel 

should be consistent with the airplane manufacturer’s guidance.25

Many 14 CFR Part 121 (transport category) operators provide their pilots with and follow 

procedures based on the AC guidance and have revised their operating handbooks and checklists 

to contain written instructions regarding which circuit breakers are considered essential and may 

be reset. Moreover, aircraft operated under Part 121 commonly have indicators, such as circuit 

breaker markings or coloring, or segregated placement of specific circuit breakers in the cockpit, 

showing which circuit breakers are critical. 

Although most 14 CFR Part 121 operators have made changes that reflect current 

guidance regarding the resetting of tripped circuit breakers, evidence from this investigation 

indicates that many Part 91 pilots and operators have not yet made changes to address current 

guidance about circuit-breaker resets. One reason might be that individuals operating airplanes 

under Part 91 are less likely to have a formal system for addressing AC guidance. As a result, 

many general aviation pilots, mechanics, and operators may not have reviewed AC 120-80. Even 

if general aviation personnel have reviewed the AC, the guidance contained in manuals provided 

by general aviation airplane manufacturers often directly conflicts with the guidance contained in 

AC 120-80. Additionally, because the guidance in that AC focused more on transport category 

operations, airplanes, and systems, general aviation pilots, mechanics, or operators who did 

review the AC might not have perceived its relevance to their operations. 

In fact, general aviation pilots still receive information contrary to the guidance in the 

AC, indicating that it is acceptable to reset circuit breakers one time, even for nonessential 

systems. For example, a May 2007 article in Flight Training, a periodical published by the 

Aircraft Owners and Pilots Association (AOPA)26 provided pilots the following advice: 

Circuit breakers can be reset simply by pushing in the black button. Wait a few 

moments to allow the breaker to cool before resetting. Also, don't try to reset a 

 

24 The full text of AC 120--80 is available online at <http://rgl.faa.gov/Regulatory_and_Guidance_Library/ 

rgAdvisoryCircular.nsf/0/ed51f1681e9d8c5e86256e4a00744607/$FILE/AC120-80.pdf>. 

25 According to the AC, this guidance was directed to crewmembers operating transport category airplanes 

under 14 CFR Part 121 and also to crewmembers of passenger-carrying airplanes operating under other parts, 

including Part 135 and Part 91. 

26 AOPA is a general aviation organization with about 400,000 members. The organization publishes several 

magazines and e-mailed newsletters, written primarily for general aviation pilots. 
National Transportation Safety Board 17

Aircraft Accident 

Summary Report 

breaker more than once. If it pops again after the first reset, it's a good indication 

that a serious problem exists somewhere in the circuit that demands professional 

attention.27

As discussed previously, it is likely that one of the pilots reset the circuit breaker 

associated with the weather radar system out of habit or based on the “Before Starting Engines” 

checklist associated with the accident airplane. Given the conditions at the time of the flight, it is 

unlikely that the pilots believed that they needed the weather radar system. However, the 

operating handbook aboard the accident airplane gave no indication that resetting a circuit 

breaker once might be dangerous, even though in this case that action likely led to a recurrence 

of an earlier problem and, ultimately, to an in-flight fire. 

The Safety Board concludes that existing guidance in manuals provided by general 

aviation airplane manufacturers regarding the resetting of circuit breakers often does not 

consider the cumulative nature of wiring damage and that the removal of power only temporarily 

stops the progression of such damage. The Safety Board further concludes that if general 

aviation pilots, maintenance personnel, and operators had a more thorough understanding of the 

potential hazards of a reset circuit breaker (as outlined in AC 120-80), they would be less likely 

to reset a tripped circuit breaker without knowing what caused that circuit breaker to trip. 

Therefore, the Safety Board believes that the FAA should develop a safety alert for operators 

(SAFO) informing general aviation pilots and maintenance personnel of the circuit breaker 

policy contained in AC 120-80. The Safety Board further believes that the FAA should require 

that the contents of the SAFO requested in the previous safety recommendation be included in 

initial and required biennial training for general aviation pilots and maintenance personnel. 

Although 14 CFR Part 91 operators do not operate under FAA-approved operations 

specifications and are subject to less FAA scrutiny than Part 135 and 121 operators, information 

describing the hazards associated with resetting nonessential circuit breakers could easily be 

made available to general aviation operators, pilots, and mechanics. Some of the options 

available to the FAA for dissemination of this information, other than the previously 

recommended training, include publishing the information on the FAA’s safety-related websites 

and providing the information to pilots directly via e-mail or regular mail. 

3.2 Critical Circuit Breaker Identification 

Although resetting a circuit breaker can pose a hazard, some systems must remain 

powered to ensure safe flight. FAA AC 23-17 and its subsequent revisions provide guidance for 

aircraft manufacturers related to limiting unnecessary circuit breaker resets by identifying circuit 

breakers associated with critical systems. In part, the AC states: 

The FAA recognizes that some required circuit protection devices are associated 

with circuits that can have no significant impact on safety in flight. Therefore, the 

 

27 This quote is from “Training Notes and News: Popped circuit breaker” in the May 2007 issue of Flight 

Training, published by AOPA. 
National Transportation Safety Board 18

Aircraft Accident 

Summary Report 

responsible Aircraft Certification Office...and [the manufacturer] should identify 

which circuits and circuit protection devices are essential to safety in flight. 

On February 23, 2004, the FAA issued Policy Statement ACE100-2002-005 to clarify 

guidance issued in AC 23-17 regarding the identification of critical and noncritical systems and 

their circuit breakers in general aviation aircraft.28 This policy statement acknowledged that the 

criticality of an electrical system depends on certain variables, such as the equipment on board 

the airplane and the flight conditions for any given flight. As a result, the need to reset circuit 

breakers associated with these systems varies with operational circumstances. Applying this 

analysis to the accident flight, which was a relatively short flight conducted in visual 

meteorological conditions, the weather radar would not be considered a critical system; the 

weather radar system was not needed for safe flight. 

The FAA’s guidance indicated that the airplane manufacturers were to work with the 

FAA to identify an airplane’s critical systems during the certification process and develop 

related procedures to keep those critical systems powered. However, although this FAA 

guidance might have successfully addressed issues related to critical systems and resetting of 

critical circuit breakers in newly certificated airplanes, it did not address those issues for older 

airplanes that are currently being manufactured under existing certifications. Pilots who are 

unaware that circuit breakers should be reset only if the associated system is critical may 

unwittingly reset a noncritical circuit breaker and, in doing so, unnecessarily introduce a hazard. 

The Safety Board concludes that identification, by an aircraft’s manufacturer or those 

responsible for postmanufacture modifications, of which of an aircraft’s systems are critical to a 

flight (or to a realm of flight) would enable pilots to make better-informed decisions regarding 

which circuit breakers they should or should not attempt to reset before or during flight. 

Therefore, the Safety Board believes that the FAA should require aircraft manufacturers and 

those responsible for postmanufacture modifications to improve existing guidance, or create new 

guidance, regarding which circuit breakers pilots should and should not attempt to reset before or 

during flight and to disseminate the resultant guidance to airplane mechanics, pilots, and owners. 

3.3 Electrical Systems 

The accident airplane had been flown by various operators since it was manufactured in 

1977 and was equipped with circuit breakers and wiring associated with both original equipment 

and modifications made during the 30 intervening years. The weather radar system, which was 

significant to this accident, was a postmanufacture equipment modification. Postaccident 

examination of Cessna 310R airplanes similar to the accident airplane revealed that the densest 

concentration of wiring in those airplanes is in the area where maintenance personnel would 

have been working during the weather radar system modification. Although postimpact damage 

precluded a definitive determination of the ignition source, this accident highlights an ongoing 

 

28 The full text of FAA Policy Statement ACE100-2002-005 is available online at 

<http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgPolicy.nsf/0/23080994EFAD2D0A86256E44004BE9B3?

OpenDocument>. 
Aircraft Accident 

Summary Report 

and as-yet unaddressed issue regarding wiring and circuit breakers in general aviation. 

Postmanufacture electrical system modifications and installations often result in general aviation 

maintenance personnel performing critical work among densely packed layers of wiring of 

different ages and materials; this work would be more safely performed if general aviation 

maintenance personnel were kept abreast of current industry concerns related to wiring. 

The FAA regulations for maintenance of transport-category airplanes have been revised 

to address wiring-related concerns, such as 1) deteriorated (aging) wiring; 2) corrosion; 

3) improper wire installation and repairs; and 4) contamination of wire bundles with metal 

shavings, dust, and fluids. The FAA also requires operators of transport category airplanes to 

keep their maintenance personnel updated regarding current wiring-related concerns and best 

practices. Although electrical/wiring systems in general aviation airplanes are subject to hazards 

and concerns similar to those in transport-category airplanes, the FAA has not addressed similar 

issues with regard to maintenance personnel working on general aviation airplanes. 

The Safety Board concludes that more thorough and continually updated guidance and 

information regarding maintenance and inspection of airplane electrical systems and wiring for 

general aviation maintenance personnel would increase the likelihood that they will be aware of 

current industry wiring-related concerns such as deteriorated (aging) wiring, corrosion, improper 

wire installation and repairs, and contamination of wire bundles with metal shavings, dust, and 

fluids and would greatly increase the likelihood that their work will comply with current best 

practices. Therefore, the Safety Board believes that the FAA should require that initial and 

recurrent training for maintenance personnel working on general aviation aircraft include the 

most current “best practices” regarding inspection and maintenance of electrical systems, circuit 

breakers, and aging wiring. 

3.4 Safety Management Systems 

An operator’s SOPs can provide useful procedural guidance if those SOPs are clear, 

detailed, readily available, and adhered to by company personnel. Although NASCAR’s 

corporate aviation division had developed an SOP manual that established guidelines and 

procedures for its operations, those SOPs were not an integral part of the normal operating 

regimen and, in fact, were commonly disregarded by NASCAR personnel. Moreover, the SOPs 

were incomplete. For example, NASCAR’s corporate aviation division’s SOPs did not define a 

procedure for preventing the flight of an airplane with an unaddressed maintenance discrepancy 

and, thus, they did not prevent the release and acceptance of the accident airplane on the day of 

the accident, although pertinent NASCAR aviation flight, maintenance, and management 

personnel were aware of the discrepancy before the accident flight departed. The airplane should 

not have been allowed to fly until the discrepancy was addressed. 

Contrary to Federal regulations, company policy, and basic good operating practice, 

NASCAR maintenance and management personnel permitted the accident airplane to be released 

for flight with a significant maintenance discrepancy unaddressed. Therefore, the Safety Board 

concludes that, although NASCAR’s corporate aviation division’s SOPs included procedures 

designed to ensure that airplane maintenance discrepancies would be properly addressed and 

National Transportation Safety Board 19
National Transportation Safety Board 20

Aircraft Accident 

Summary Report 

airplane airworthiness maintained, there was no formal method for determining and ensuring that 

an airplane was safe for flight; thus management, maintenance, and flight operations personnel 

allowed the operation of an airplane with a known and unaddressed discrepancy. 

The Safety Board notes that increasing numbers of operators in the aviation industry have 

been incorporating a Safety Management System (SMS) into their operations. An effective SMS 

program formalizes a company’s SOPs and establishes methods for ensuring that those SOPs are 

followed. Guidance issued in November 2006, by the International Civil Aviation Organization 

(ICAO) in Annex 6, “Operation of Aircraft,” states that after January 1, 2009, “[Member] States 

shall require, as part of their safety program, that an operator implements a [SMS] acceptable to 

the State of the Operator....” It is generally agreed that a successful SMS program is one that 

incorporates proactive safety methods to evaluate a company’s flight and maintenance 

operations to, at a minimum: 

• Identify safety hazards; 

• Ensure that remedial action necessary to maintain an acceptable level of safety is 

implemented; 

• Provide for continuous monitoring and regular assessment of the safety level 

achieved; and 

• Continuously improve the company’s overall level of safety. 

The continuous monitoring and regular assessments involved in a formal SMS program 

would have helped to ensure that NASCAR aviation division personnel adhered in practice to 

their established processes and procedures and likely would have prevented the accident 

airplane’s release for flight without corrective maintenance or ensured the placarding and 

deactivation of the circuit breaker. After this accident, NASCAR’s corporate aviation division 

established an SMS program in compliance with the International Standard for Business Aircraft 

Operations [IS-BAO].29 NASCAR’s SMS implementation involved extensive review of and 

changes to their procedures, manuals, safety systems, and culture. After implementation, the 

NASCAR aviation department successfully completed an extensive registration audit by IS-BAO 

SMS auditors. 

The National Business Aviation Association (NBAA)30 actively encourages its business 

aviation members to incorporate SMS programs into their operations and endorses the IS-BAO 

program. At the time of this writing, the more than 120 IS-BAO-registered corporate aviation 

 

29 The International Business Aviation Council, comprised of business aviation associations from around the 

world, developed IS-BAO as a code of best practices designed to help business flight departments worldwide 

achieve high levels of safety and professionalism. 

30 The NBAA was founded in 1947 to support business aviation in the United States and around the world, in 

part by encouraging aviation safety. 
National Transportation Safety Board 21

Aircraft Accident 

Summary Report 

operators include NASCAR Aviation, Hendrick Motorsports, Incorporated, and many NASCAR 

corporate sponsors.31 

The Safety Board recognizes the benefits of SMS programs and issued a related safety 

recommendation in its report on the October 14, 2004, accident involving Pinnacle Airlines 

flight 3701 near Jefferson City, Missouri.32 Safety Recommendation A-07-10 asked the FAA to 

require that all 14 CFR Part 121 operators establish SMS programs.33 

The FAA responded that it had been actively engaged in SMS-related rulemaking 

activities and plans to comply with the ICAO guidance by requiring air carrier implementation of 

SMS programs. 

Based on the FAA’s actions and stated rulemaking intentions related to 14 CFR Part 121 

operators, the Safety Board classified Safety Recommendation A-07-10 as “Open—Acceptable 

Response,” on January 22, 2008. In a November 26, 2008, Information for Operators, the FAA 

stated that they would be filing a difference with ICAO with regard to the January 2009 deadline 

for SMS programs because the FAA has not yet developed regulations or policy for 

implementation of SMS by U.S. operators. These regulations and policies are currently under 

development. 

Although the FAA is addressing the issue of SMS programs with 14 CFR Part 121 

operators, it has not explicitly addressed the issue of SMS for Part 91 operators. In June 2006, 

the FAA published AC 120-92, “Introduction to Safety Management Systems for Air 

Operators,” which states, in part, the following: 

An SMS is essentially a quality management approach to controlling risk. It also 

provides the organizational framework to support a sound safety culture. For 

general aviation operators, an SMS can form the core of the company’s safety 

efforts.34 

Although the FAA recognizes that general aviation operators, such as NASCAR’s 

corporate aviation division, which operate under Part 91, would benefit from an SMS, the FAA 

has done nothing to ensure that corporate operators adopt SMS programs. The Safety Board 

concludes that SMS programs would provide corporate flight departments a formal system of 

risk management, safety methods, and internal oversight programs that could improve safety. 

 

31 Hendrick incorporated an SMS program into its operations after a King Air 200 aircraft carrying two pilots 

and eight passengers, Hendrick racing team personnel, crashed near Martinsville (Stewart), Virginia, on October 24, 

2004. For additional information, see the Safety Board’s website at <http://www.ntsb.gov/publictn/ 

2006/AAB0601.pdf>. 

32 For additional information, see National Transportation Safety Board, Crash of Pinnacle Airlines 

Flight 3701, Bombardier CL-600--2B19, N8396A, Jefferson City, Missouri, October 14, 2004, Aircraft Accident 

Report NTSB/AAR-07/01 (Washington, DC: NTSB 2007) 

33 The full text of this recommendation is available online at <http://www.ntsb.gov/recs/letters/ 

2007/A07_1_11.pdf>. 

34 The full text of AC 120-92 is available online at <http://rgl.faa.gov/Regulatory_and_Guidance_Library/ 

rgAdvisoryCircular.nsf/0/6485143d5ec81aae8625719b0055c9e5/$FILE/AC%20120-92.pdf>. 
Aircraft Accident 

Summary Report 

Therefore, the Safety Board believes that the FAA should develop a safety alert for operators 

encouraging all 14 CFR Part 91 business operators to adopt SMS programs that include sound 

risk management practices. 

National Transportation Safety Board 22
Aircraft Accident 

Summary Report 

4. Conclusions 

4.1 Findings 

1. The weather radar system anomaly that was experienced and formally documented by the 

National Association for Stock Car Auto Racing company pilot the day before the accident 

could have developed at that time into a significant in-flight smoke and fire event; however, 

the anomaly was temporarily alleviated when the company pilot pulled the related circuit 

breaker. 

2. Without examining the weather radar system, and then either removing the airplane from 

service or placarding the airplane and collaring the circuit breaker, as well as making a 

maintenance records entry, it was not permissible to fly the airplane under Federal 

regulations. 

3. The airline transport pilot and the commercial pilot had sufficient information about the 

weather radar discrepancy and the burning smell to determine that the condition constituted a 

hazard to flight and to refuse the airplane unless and until additional actions were performed 

by maintenance personnel . 

4. The pilots accepted the airplane as made available by National Association for Stock Car 

Auto Racing management and maintenance personnel, despite the fact that no diagnostic, 

corrective, or interim maintenance action had been taken to address the discrepancy. 

5. There was insufficient evidence to conclusively determine the origin of the in-flight fire. 

6. It is likely that one of the pilots, consistent with routine and/or the “Before Starting Engines” 

checklist for the accident airplane, reset the weather radar circuit breaker, which restored 

electrical power to the weather radar system’s wiring and resulted in the in-flight fire. 

7. After analyzing the available evidence, it was not possible to definitively determine the 

events that led to the accident airplane’s maneuvers away from Orlando Sanford 

International Airport. 

8. Existing guidance in manuals provided by general aviation airplane manufacturers regarding 

the resetting of circuit breakers often does not consider the cumulative nature of wiring 

damage and that the removal of power only temporarily stops the progression of such 

damage. 

9. If general aviation pilots, maintenance personnel, and operators had a more thorough 

understanding of the potential hazards of a reset circuit breaker (as outlined in Advisory 

Circular 120-80), they would be less likely to reset a tripped circuit breaker without knowing 

what caused that circuit breaker to trip. 

National Transportation Safety Board 23
Aircraft Accident 

Summary Report 

10. Identification, by an aircraft’s manufacturer or those responsible for postmanufacture 

modifications, of which of an aircraft’s systems are critical to a flight (or to a realm of flight) 

would enable pilots to make better-informed decisions regarding which circuit breakers they 

should or should not attempt to reset before or during flight. 

11. More thorough and continually updated guidance and information regarding maintenance 

and inspection of airplane electrical systems and wiring for general aviation maintenance 

personnel would increase the likelihood that they will be aware of current industry 

wiring-related concerns, such as deteriorated (aging) wiring; corrosion; improper wire 

installation and repairs; and contamination of wire bundles with metal shavings, dust, and 

fluids and would greatly increase the likelihood that their work will comply with current best 

practices. 

12. Although National Association for Stock Car Auto Racing’s corporate aviation division’s 

standard operating procedures included procedures designed to ensure that airplane 

maintenance discrepancies would be properly addressed and airplane airworthiness 

maintained, there was no formal method for determining and ensuring that an airplane was 

safe for flight; thus management, maintenance, and flight operations personnel allowed the 

operation of an airplane with a known and unaddressed discrepancy. 

13. Safety Management System programs would provide corporate flight departments a formal 

system of risk management, safety methods, and internal oversight programs that could 

improve safety. 

4.2 Probable Cause 

The National Transportation Safety Board determines that the probable causes of this 

accident were the actions and decisions by National Association for Stock Car Auto Racing’s 

corporate aviation division’s management and maintenance personnel to allow the accident 

airplane to be released for flight with a known and unresolved discrepancy, and the accident 

pilots’ decision to operate the airplane with that known discrepancy, a discrepancy that likely 

resulted in an in-flight fire. 

National Transportation Safety Board 24
Aircraft Accident 

Summary Report 

5. Recommendations 

The National Transportation Safety Board recommends that the Federal Aviation 

Administration: 

Develop a safety alert for operators informing general aviation pilots and 

maintenance personnel of the circuit breaker policy contained in Advisory 

Circular 120-80. (A-09-12) 

Require that the contents of the safety alert for operators requested in Safety 

Recommendation A-09-12 be included in initial and required biennial training for 

general aviation pilots and maintenance personnel. (A-09-13) 

Require aircraft manufacturers and those responsible for postmanufacture 

modifications to improve existing guidance, or create new guidance, regarding 

which circuit breakers pilots should and should not attempt to reset before or 

during flight and to disseminate the resultant guidance to airplane mechanics, 

pilots, and owners. (A-09-14) 

Require that initial and recurrent training for maintenance personnel working on 

general aviation aircraft include the most current “best practices” regarding 

inspection and maintenance of electrical systems, circuit breakers, and aging 

wiring. (A-09-15) 

Develop a safety alert for operators encouraging all 14 Code of Federal 

Regulations Part 91 business operators to adopt Safety Management System 

programs that include sound risk management practices. (A-09-16) 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

MARK V. ROSENKER ROBERT L. SUMWALT 

Acting Chairman Member 

DEBORAH A. P. HERSMAN STEVEN R. CHEALANDER 

Member Member 

KATHRYN O’LEARY HIGGINS 

Member 

Adopted: January 28, 2009 

 

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Aircraft Accident 

Summary Report 

Member Robert L. Sumwalt filed the following concurring statement on 

January 29, 2009. 

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Aircraft Accident 

Summary Report 

Board Member Statement 

Member Robert L. Sumwalt, concurring: 

I applaud staff for their diligent efforts in investigating this accident and proposing 

recommendations to prevent future accidents. And, I commend my colleagues on the Board for 

having the foresight to unanimously adopt a probable cause that, I believe, truly gets to the 

underlying reasons this crash occurred. 

A less-than-thorough investigation might simply have stated that there was an in-flight 

fire that somehow led to the pilots crashing the aircraft into houses. However, in this case, 

investigators went beyond the obvious factors which, I believe, helps the Safety Board achieve 

its ultimate mission of accident prevention. 

When the layers of the investigation were peeled back, a picture emerged that revealed 

that the organization—NASCAR corporate aviation division—enabled this tragic and 

unnecessary crash. NASCAR enabled the accident by failing to have adequate procedures in 

force to prevent such an event and/or by failing to ensure compliance with the procedures they 

did have in place. As the facts of the accident surfaced, it became apparent that this accident 

started before the aircraft even left the ground. 

Failures on NASCAR's part allowed an un-airworthy aircraft to be dispatched and flown 

with a known maintenance discrepancy that directly led to the crash. 

Examples of NASCAR not having adequate procedures include: 

• No communication procedures for providing flight operations personnel (pilots and 

schedulers) with airplane airworthiness information. 

• No specific procedure for the director of maintenance to communicate maintenance 

status of an aircraft to anyone else within NASCAR. 

• No system through which any individual, including the director of maintenance, 

could remove an aircraft from flight status because of an airworthiness concern. 

• No procedure spelled out for a pilot to determine airworthiness before flight. Instead, 

the organization relied on an informal procedure where in most cases (not all), a pilot 

would attempt to determine airworthiness by a preflight fact sheet taped to the 

airplane with highlighted items signed off by a mechanic. 

And for procedures that were in a manual, there was widespread evidence that many of 

those procedures were not followed. Of important note—when NTSB investigators interviewed 

the director of aviation after the accident, he could not readily locate the Standard Operating 

Procedures (SOP) manual. Examples of not following NASCAR's existing procedures include: 

National Transportation Safety Board 27
Aircraft Accident 

Summary Report 

• NASCAR's director of aviation told investigators that company personnel did not 

always follow NASCAR's SOPs, and SOPs were mostly "used as a training tool." 

This is contrary to industry guidance for SOPs indicating that procedures should be 

written the way the organization intends to operate, and once the procedures are in 

place, the organization makes every effort to operate that way. 

• Investigators uncovered gross deviations from SOP. For example, the SOP manual 

stated that aircraft would not be operated for personal business and that the pilot-incommand (PIC) must possess an Airline Transport Pilot certificate. Conversely, this 

flight was personal in nature and the PIC did not meet those qualification 

requirements. 

• The last three maintenance discrepancies had not been addressed by maintenance, 

contrary to federal requirements. 

NASCAR is an organization with an impressive reputation and a sizeable net worth. 

They had hundreds of millions of dollars invested in their aviation department. Yet, at the time 

of the accident, they did not have the essential underpinnings of a professionally run aviation 

department-standard operating procedures that are rigorously followed and adhered to. 

According to FAA Advisory Circular AC 120-71A, "Standard operating procedures are 

universally recognized as basics to safe aviation operations." 

A primary function of aviation department leadership is to ensure their aviation 

department operates to the highest standards. In this accident case, it appears that the NASCAR 

flight department management failed to provide leadership that could have safeguarded against 

such a tragic event. 

The message to top leaders of organizations that operate aircraft is clear: You should take 

steps to ensure that your organization is receiving the professional aviation leadership and 

management that you expect. One way of ensuring a high standard is to conduct internal and 

external audits of your aviation department. A well-run aviation department should have 

meticulous written policies, procedures and guidelines that are rigorously followed. One 

standard discussed in this report is the International Standard for Business Aircraft Operations 

(IS-BAO). This takes a quality management approach to managing a business aviation 

department. Sadly, less than 130 organizations throughout the world have demonstrated and 

achieved this standard. 

Do you want a professionally run aviation department, or do you want an expensive 

flying club? This accident tragically illustrates the potential consequences of a less than 

professionally managed flight department. 

National Transportation Safety Board 28