# NTSB ANC18LA043: Cessna 210, N9410M, Ramona, CA, June 1, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 1, 2018, 11:18 local (18:18 UTC) - Place: Ramona, CA - Coordinates: 33.038612, -116.910552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.0386&lon=-116.9106&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: FAA FSDO - NTSB case key (mKey): 97405 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC18LA043 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97405/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97405 - Page: https://openairdocs.org/ntsb/ANC18LA043 ## Probable cause The failure of the engine-driven hydraulic pump due to the installation of improper cap screws, which resulted in a gap in the pump housing, a subsequent hydraulic leak, and the landing gear collapsing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: hydraulic fluid](https://openairdocs.org/ntsb-findings/01071015): Aircraft › Fluids/misc hardware · Related operating info (probable cause); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-findings/01071015/cases.md?model=2073446), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01071015/cases.md) - [Landing gear system: main landing gear](https://openairdocs.org/ntsb-findings/01023210): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-findings/01023210/cases.md?model=2073446), [All aircraft, 241 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md) - [Hydraulic power system: pump, main](https://openairdocs.org/ntsb-findings/01022913): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-findings/01022913/cases.md?model=2073446), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/01022913/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073446), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Approach: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330); cases with it: [Cessna 210K, 2 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2073446), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Cessna 210K, 2 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=2073446), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The private pilot was conducting a personal, cross-country flight. He reported that he attempted to lower the retractable landing gear during a visual approach; however, the right main landing gear (MLG) did not fully extend. He attempted to manually pump the landing gear down with the emergency hand pump, but it was very difficult to move, and after several pumps, it would not move at all. Upon landing, the right MLG collapsed and the airplane impacted the ground, which resulted in substantial damage to the right horizontal stabilizer and elevator. Postaccident examination and tests revealed that, when the MLG system was tested using the airplane’s engine-driven hydraulic pump, fluid started leaking from a gap in the pump’s diaphragm seal between the front plate assembly and the rear housing assembly, and the MLG would not extend. Subsequently, the MLG system was tested with an external hydraulic pump, and it functioned properly. The two front plate cap screws on the side of the leaking pump gap were loose, had only three or four threads engaged with the rear assembly, and had insufficient shank length. The corresponding rear housing internal threads were sheared. Due to the installation of cap screws with insufficient shank length, fewer threads were engaged when the screws were tightened. The insufficient length of the shanks likely led to excessive force being applied on the engaged threads when the cap screws were installed, the threads being damaged, and a gap in the pump housing to develop, which allowed fluid to leak from the pump when it was pressurized. The hydraulic leak prevented the right MLG from fully extending and resulted in it collapsing upon landing. ## Factual narrative On June 1, 2018, about 1118 Pacific daylight time, a Cessna 210 airplane, N9410M, sustained substantial damage when it was involved in an accident at Ramona Airport (RNM), Ramona, California. The pilot and the passenger were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, while approaching RNM after a 4-hour flight, he selected the landing gear handle to the “down” position; however, the green gear down light did not illuminate and the main landing gear did not lock in the down position. He then selected the landing gear handle up but the landing gear did not retract. He then attempted to manually pump the landing gear down using the emergency hand pump, but the handle was very difficult to move, and then it would not move. He conducted a visual approach and landing to the runway. During the landing, the right main landing gear (MLG) collapsed, followed by the right wing and horizontal stabilizer impacting the ground. The airplane then veered right, departed the runway, and came to rest on the parallel taxiway. The mechanic who recovered the airplane reported seeing a lot of hydraulic fluid on the airplane’s belly. Examination of the airplane revealed that right horizontal stabilizer and elevator had sustained substantial damage. The landing gear system was operated with an external hydraulic pump, and the landing gear extended and retracted normally; however, during the manual operation of the system, the right MLG down-lock did not engage consistently. The airplane’s engine-driven hydraulic pump was mounted on an external electric-driven system, and when the hydraulic system was pressurized, fluid started leaking from a gap in the diaphragm seal between the rear housing assembly and front plate assembly, and fractured pieces of the diaphragm seal were visible in the gap (see figure 1). The right MLG would not cycle when powered by the leaking pump. When an airworthy pump was used to test the MLG, it functioned properly. Figure 1. A photograph showing the engine-driven hydraulic pump before disassembly. Four cap screws were installed and holding the assembly together; however, the two front plate cap screws on the side with the leaking seal gap were loose and could not be tightened. The screws only had three or four threads engaged with the rear assembly, and the one screw’s shank length was .173 inch shorter than the manufacturer’s specified minimum shank length, and the other was.158 inches shorter than the minimum shank length. The corresponding rear housing internal threads were sheared and displaced. All four of the screws had evidence of locking compound on the threads, which was inconsistent with the aircraft service manual instructions. Only two of the four cap screws had torque markings present. ## Aircraft - Registration: [N9410M](https://openairdocs.org/aircraft/N9410M), registered now, S/N 21059310 (OpenAirDocs) - Reported make and model: CESSNA 210 (K) - Registry model: [Cessna 210K](https://openairdocs.org/model/cessna-210k) (registry code 2073446) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21059310 - Year built: 1970 - Engines: CONT MOTOR IO 520-L53B 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 20, 2017, 221 hours before - Departed: E80, BELEN, NM - Destination: RNM, RAMONA, CA - Airport: RNM, Ramona, runway 27, 5,001 × 150 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review October 28, 2016; seat: left; flight hours: 1,951 total, 1,432 in this make and model, 13 in the last 90 days, 12 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 52 °F - Altimeter: 29.97 inHg - Observed at: KRNM ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20180601016979A](https://openairdocs.org/incident/20180601016979A), Jun 1, 2018: Cessna 210K, Ramona, CA, Substantial damage. On approach to land, the pilot extended the landing gear but did not get a gear down indication. Pilot attempted to retract the gear unsuccessfully. He made a… ## Docket (5 files) The files NTSB released with the investigation on May 6, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97405. 3.9 MB in all. - Materials laboratory factual report 19-042 (item 1, PDF, 6 pages, 7 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8176888&FileExtension=pdf&FileName=19-042-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 2, PDF, 11 pages, 730 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11967924&FileExtension=pdf&FileName=pilot%206120%20master_Redacted-Rel.pdf - Pilot record of conversation (item 3, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11973558&FileExtension=pdf&FileName=ROC%20Pilot%20v2-Rel.pdf - FAA examination summary memorandum (item 4, PDF, 2 pages, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11972408&FileExtension=pdf&FileName=FAA%20Examination%20Summary%20Memo-Rel.pdf - Photographs (item 5, PDF, 4 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11973397&FileExtension=pdf&FileName=Photos%20-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.