CEN09LA233

NTSB accident investigation · Cessna P210N · Georgetown, TX · March 29, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
March 29, 2009, 18:45 local (23:45 UTC)
Place
Georgetown, TX
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N210BFCessna P210N
Defining event
Approach: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report December 29, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
Teledyne Continental Motors, Cessna Aircraft Company, FAA Flight Standards District Office
FAA report
20090329004989A
Case key
73584

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A loss of engine power due to fuel starvation as a result of the pilot's inadequate fuel management. Contributing to the accident was the pilot's improper engine restart procedures.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuel systemAircraft › Aircraft systems · Incorrect use/operationCessna P210N: 1 caseAll aircraft: 181 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna P210N: 5 casesAll aircraft: 1,391 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomeCessna P210N: 2 casesAll aircraft: 267 cases
Use of equip/info: use of policy/procedurePersonnel issues › Task performance · PilotCessna P210N: 1 caseAll aircraft: 191 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was preparing to land when the engine lost power. He attempted to perform a forced landing to a road west of the airport. During the forced landing, the airplane impacted trees and then the road resulting in substantial damage to the airplane. An examination of the airplane revealed that the left main fuel tank was empty; however, the right main fuel tank and tip tank contained fuel. According to a telephone conversation with the pilot, during his pre landing preparation he noted that the left fuel tank was "low" and switched from the left fuel tank to the right fuel tank. Shortly thereafter he noted that the engine had lost power. He attempted to restart the engine by turning the auxiliary fuel pump on and "cranking" the engine. According to the emergency procedures section in the Pilot's Operating Handbook the correct in-flight engine restart procedure requires the pilot to maintain 85 knots indicated airspeed, check fuel quantity, switch the fuel selector to the fullest tank, mixture set to rich, auxiliary pump to the "on" position for three to five seconds with the throttle open, then off, ignition switch to both, and advance the throttle slowly. An examination of the airplane fuel system revealed no contaminants and no anomalies. An examination and test run of the engine revealed no anomalies. The engine data monitoring unit showed a loss of fuel flow prior to the accident.

Factual narrative

On March 29, 2009, at 1845 central daylight time, a Cessna P210N, N210BF, was substantially damaged during a forced landing near Georgetown Municipal Airport (GTU), Georgetown, Texas. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulation Part 91 without a flight plan. The private pilot received minor injuries and the passenger sustained serious injuries. The local flight departed GTU approximately 1750. According to a Federal Aviation Administration (FAA) inspector, the airplane was preparing to land at GTU when the engine lost power. The pilot performed a forced landing to a road west of the airport. During the forced landing, the airplane impacted trees and then the road. The airplane slid for several feet before impacting a mailbox. The nose wheel separated from the airframe, the left main landing gear was bent out laterally, and the right main landing gear was folded under the airplane. The left wing auxiliary fuel tank (tip tank) and the left elevator separated from the airframe. The skin on the fuselage was wrinkled and the horizontal stabilizer was bent. An examination of the airplane revealed that the left main fuel tank was empty and the right tip tank was empty. The right main fuel tank contained a measurable amount of fuel. According to the FAA, the right tip tank was damaged during the landing which allowed fuel to leak from the resulting hole. According to two separate telephone conversations, between the FAA and the pilot and the National Transportation Safety Board (Safety Board) investigator-in-charge (IIC) and the pilot, he was on a base leg for the landing runway and initiated a turn to final approach when he noted that the fuel in the left tank was "low." He had extended his landing gear and his flaps were selected at 10 degrees. The pilot manipulated the fuel selector valve to the right tank. After changing fuel tanks, he noted that he was losing altitude and "noticed the engine power was gone." The pilot stated that he was so low he could "not do anything." He "aimed the airplane for an opening in the trees" and attempted to restart the engine by turning the auxiliary fuel pump on and "cranking" the engine. The pilot stated during this conversation that his headset "drowns out the engine noise." According to a written statement submitted by the pilot, during his pre landing preparation he switched from the left fuel tank to the right fuel tank and the engine lost power. The propeller continued to rotate. He tried to restart the engine "with the auxiliary pump to no avail." According to the report issued by the Georgetown fire department fuel was leaking from the airplane; however, it was not stated where the fuel was leaking from. The airplane was loaded onto a wrecker and transported to the local airport where fuel was drained from the airplane. According to a telephone conversation with an employee with B &G Aviation, LLC who assisted the fire department with draining the fuel, approximately 20 gallons of fuel was drained from the right tank, just to the point to prevent the fuel from leaking from the right tank. Inspectors with the FAA examined the airplane the following morning and observed a measurable quantity of fuel in the right tank. The left main tank was empty and the left tip tank had separated during the impact sequence. According to the emergency procedures section of the pilot's operating handbook for the Cessna 210, the correct in-flight engine restart procedure requires the pilot to maintain 85 knots indicated airspeed, check fuel quantity, switch the fuel selector to the fullest tank, mixture set to rich, auxiliary pump to the "on" position for three to five seconds with the throttle open, then off, ignition switch to both, and advance the throttle slowly. The correct emergency landing without engine power procedure is to maintain 80 knots (with flaps extended), mixture to idle cut-off, fuel selector valve off, ignition off, wing flaps as required (30 degrees recommended), master switch off, touchdown slightly tail low, and apply brakes heavily. According to the pilot, he landed with ten degrees of flaps and turned the master switch, ignition, and avionics off after coming to rest. On September 29 and 30, 2009, the Safety Board IIC and investigators from Cessna Aircraft and Teledyne Continental Motors examined the engine at the Teledyne Continental Motors facility in Mobile, Alabama. The engine was mounted in an engine test cell and equipped with thermocouples, pressure lines, and test pads for monitoring purposes. The engine started without hesitation and ran for no less than 15 minutes through a series of incremental rpm increases. The engine exhibited the ability to run normally without hesitation or stumbling in addition to the ability to produce rated horsepower. On October 1, 2009, an investigator from Cessna Aircraft examined the airplane fuel system under the auspices of an FAA inspector. No contamination was noted in any of the fuel lines and the auxiliary fuel pump functioned as designed. It was also noted that the left main fuel tank was not compromised, aside from the separation of the left tip tank. An examination of the remaining airplane systems revealed no anomalies. The airplane was equipped with a JP Instruments (JPI) Engine Data Monitor (EDM) 700. This unit was removed and sent to the Safety Board Vehicle Recorders Laboratory in Washington, DC, to have the nonvolatile memory downloaded. The unit recorded the following parameters: time, battery voltage, exhaust gas temperature, cylinder head temperature, oil temperature, fuel flow, and outside air temperature. The unit recorded approximately one hour and six minutes, recording a line of data every six seconds, for the accident flight. Fuel flow ranged from 3.7 gallons per hour at the start of the flight to 37.1 gallons per hour. Ten minutes prior to the end of therecording, the fuel flow was 22.1 gallons per hour. At 1842:18 the fuel flow decreased to 14.3 gallons per hour and at 1843:24 the fuel flow had decreased to zero gallons per hour. The exhaust gas temperature and cylinder head temperature experienced a correlating decrease in recorded temperature shortly after the drop in fuel flow. The unit recorded for an additional two and one half minutes following the loss of fuel flow. According to Teledyne Continental Motors, the temperatures recorded were below maximum allowable temperatures for the TSIO-520-P engine.

Aircraft

Registration
N210BF
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000688
Airframe hours
1,780.5
Engine
Cont Motor TSIO-520 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 22, 2008
Departed
GTU · Georgetown, TX
Destination
George Town, TX
Airport
GTU · Georgetown Municipal

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
72
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 1, 2009
Seat
Left
Flight hours
180 total · 25 in this make and model · 180 as pilot in command · 25 in the last 90 days · 4 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 10 knots
Lowest ceiling
None
Temperature
72 °F, dew point 30 °F
Altimeter
30.00 inHg
Observed at
KGTU

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.