# NTSB CEN13LA054: Cessna P210N, N887JA, Conway, AR, November 7, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 7, 2012, 12:04 local (18:04 UTC) - Place: Conway, AR - Coordinates: 35.081111, -92.424446 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0811&lon=-92.4244&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 10, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Vitatoe Aviation, LLC, Continental Motors Inc., Cessna Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 85534 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA054 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85534/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85534 - Page: https://openairdocs.org/ntsb/CEN13LA054 ## Probable cause The pilot's inadequate preflight inspection, which failed to detect the lack of fuel and resulted in fuel exhaustion during climb, and the pilot's subsequent failure to maintain airplane control, which resulted in an aerodynamic stall at low altitude from which he was unable to recover. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P210N, 4 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2073454), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Cessna P210N, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073454), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna P210N, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073454), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna P210N, 6 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2073454), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna P210N, 2 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2073454), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2073454), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not specified (probable cause); cases with it: [Cessna P210N, 8 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2073454), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P210N, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073454), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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 inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=2073454), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Enroute-climb to cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073454), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna P210N, 20 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073454), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-climb to cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna P210N, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2073454), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Enroute-climb to cruise: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2073454), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna P210N, 31 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073454), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airplane experienced a total loss of engine power during climb after takeoff when it was about 300 to 500 feet about ground level. The airplane then impacted trees and terrain about 300 feet north of the departure runway end. A witness stated that the airplane stalled during the climb and banked "hard" right before impacting the ground. There was no fuel smell and no foliage discoloration consistent with a fuel spill at the accident site. Neither of the two header fuel tanks contained fuel. Examination of the engine revealed no evidence of preimpact mechanical malfunction. ## Factual narrative The 1981 Cessna P210N, serial number P2100755, airplane was equipped with a turbo-normalized Continental Motors Inc. IO-550-P, serial number 1005458, which was installed on December 28, 2011, at a total airframe time of 4,605.0 hours, a tachometer time of 3,354.0 hours, and a new tachometer time of 0 hours. The turbo-normalized Continental Motors IO-550-P engine was installed under supplemental type certificate (STC) SA02918CH, in place of the original Continental Motors Inc. TSIO-520-P engine. An entry for the annual inspection of the airplane was included with the engine installation entry. The STC flight manual supplement did not contain flight performance charts. The supplement contained procedures for leaning the engine. According to the STC holder, both the original engine and the STC engine are rated at 310 BHP at 2700 RPM. The original engine was rated plus or minus 2.5 percent. The STC engine is rated plus 5 percent minus 0 percent. The performance is equal to and no less than the original performance. They chose to be conservative and merely state the performance would be as good as or better than the original engine configuration. Major benefits of the STC is the cooler engine operation and much better fuel economy while operating at the same or faster speeds. STC required testing confirmed we could meet those earlier optimistic performance parameters. The original engine allowed manifold pressure up to 36.5 inches of mercury (Hg). By using an engine with a higher compression ratio but limiting manifold pressure to 31 inches Hg, they achieved faster, or at least as fast, speeds with less load on the turbocharger, hence less heat, and using less fuel in cruise. On November 7, 2012, about 1204 central standard time, a Cessna P210N, N887JA, impacted terrain following a loss of engine power after takeoff from runway 26 (4,875 feet by 100 feet, asphalt) at the Dennis F. Cantrell Field Airport (CWS), Conway, Arkansas. The airplane was returning to the airport when it struck trees and the airport property. The airplane sustained substantial damage to the fuselage and wings. The pilot sustained fatal injuries. The airplane was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed but not activated for the flight that was en route to University-Oxford Airport (UOX), Oxford, Mississippi. On November 5, 2012, the airplane was fueled with 37 gallons of fuel for an unknown total amount of fuel for a flight from Topeka, Kansas, to Oxford, Mississippi. The flight duration was approximately 2 hours. The next flight was on the day of the accident from UOX to CWS. There was no record of subsequent fueling or the airplane prior to the accident. On the day of the accident, at 1529, the pilot of N887JA called the Princeton Flight Service Station and filed an IFR flight plan from UOX to CWS, filed a return IFR flight planfrom CWS to UOX, and obtained an abbreviated pilot briefing. The pilot filed the fuel on board for the flights from UOX to CWS and from CWS to UOX as 4 hours and 3 hours, respectively. The proposed filed departure times from UOX and CWS were 0940 and 1130, respectively. The airplane departed UOX on the morning of the accident and flew to CWS, a flight of approximately one hour. The airplane remained at CWS for about an hour before departing on the accident flight. No record of the airplane being refueled at CWS was located. A witness stated that after departure from runway 26, the airplane was about 500 feet above ground level when the rear landing gear wheels began to retract, and there was an "engine surge almost like an RPM drop." About 750 feet above ground level, the airplane pitched up "slightly," banked right, and no engine noise was heard. The airplane continued the right turn and before the right wing impacted a tree, the witness heard the engine RPM. The witness stated that it was "like the throttle was pushed to full power" and "almost like the engine had started again." A second witness stated that when the airplane climbed through about 300 feet above ground level, it stalled, banked "hard right," descended, and impacted on its side. The Federal Aviation Administration Final Forensic Toxicology Fatal Accident Report stated that carbon monoxide and cyanide testing were not performed; specimens were unsuitable for analysis. No ethanol was detected in the vitreous. The following Tested-for-Drugs were detected: Lidocaine detected in blood and in urine. Lidocaine (Local Infection, Lidoderm patch, Intravenous) is a prescription local anesthetic, available in a patch to treat localized pain/neuralgia. It is also used in emergency situations as an anti-arrhythmic agent. The pilot held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He was issued a third class airman medical certificate dated April 24, 2012, with the following limitations: Must wear corrective lenses. Review of the pilot's logbook, which began with a July 13, 2005 flight entry, revealed an entry dated "July 1, 2009 to October 13, 2010" with the following entry: "P210 N887JA." The total duration of flight for the entry was 123.2 hours and actual instrument was 16.0 hours. The next two logbook entries were dated September 18 and September 19, 2012, for a flight review under Part 61.56a in N887JA. The flight durations for September 18 and September 19, 2012 were 1.3 hours and 1.2 hours, respectively. The logbook showed a total flight time of approximately 3,381.1 hours, of which approximately 2,478.3 hours were in the accident airplane make and model. The engine was removed and shipped to Continental Motors Inc. located in Mobile, Alabama, for an engine examination and engine run under the supervision of a National Transportation Safety Board (NTSB) Air Safety Investigator. The examination of the engine revealed no evidence ofpreimpact mechanical malfunction, and the engine ran within test specifications. The airplane was equipped with a J.P. Instruments Engine Data Management system, a Shadin Digital Fuel Management system, and a Garmin 196 GPS. Nonvolatile memory from both systems and the GPS were downloaded by the NTSB Vehicle Recorders Laboratory. Data and a data plot from the EDM download for the accident flight are included in the docket of this report. About 45 seconds prior to the end of recorded data, there were corresponding increases in engine RPM, engine horsepower, fuel flow, and cylinder 1-6 exhaust gas temperatures that were consistent with takeoff/departure. About 15 seconds prior to the end of recorded data, there were corresponding decreases in the above noted parameters, which was preceded by a reduction of fuel flow, and consistent with engine shutdown. About 5 seconds prior to the end of recorded data, the parameters rose. The Shadin Fuel Management system is not connected to the airplane's fuel quantity indicating system and fuel quantities are manually entered by the pilot into the Shadin system. The Shadin download showed 67.4 gallons of fuel remaining and 21.5 gallons of fuel used. All of these readings were from the last reset and not a power cycle. There was no time or date stamp recorded for the last reset. The Garmin 196 GPS was not used during the flight, and the last data recorded on it was June 28, 2012. The airplane was resting on its right side on a tail to nose southwesterly heading and located about 800 feet north of the departure end of runway 26. The outboard section of the right wing was separated from the airplane. The separated section of the right wing was located near a damaged tree located about 155 feet southwest of the airplane. There was no evidence of fire. The main and nose wheel landing gear actuators were retracted. The cockpit landing gear selector was in the retracted position. The cockpit flap indicator indicated a 10 degree flap extension, and the flap actuator was extended about 2.45 inches, which equates to a flap extension of about 10 degrees. There were slash marks consistent with propeller strikes in the pavement between the tree and the airplane. All three of the propeller blades were loose in their hubs and displayed chordwise scratches and S-shaped bending. The fuel selector and fuel selector valve were positioned to the left fuel tank. There was about 2 tablespoons of fuel that was drained from the fuel strainer. The fuel strainer screen did not contain contaminate. Neither of the two header fuel tanks, which had an approximate capacity of a ½ gallon, contained fuel. There was no fuel smell and no foliage discoloration consistent with a fuel spill at the accident site. The hour meter indicated 2,490.7 hours, and the tachometer indicated 155.1 hours. ## Aircraft - Registration: [N887JA](https://openairdocs.org/deregistered/N887JA-2014-05-05), registration cancelled 2014-05-05, S/N P21000755, built 1981 (OpenAirDocs) - Reported make and model: CESSNA P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P21000755 - Year built: 1981 - Engines: Continental Motors IO-550-P 310 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Operator: Pilot - Registered owner: R J Allen & Associates - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 28, 2011 - Departed: CWS, Conway, AR - Destination: UOX, Oxford, MS - Flight plan: IFR - Airport: CWS, Dennis F Cantrell Field Airpor, runway 26, 4,875 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 19, 2012; seat: left; restraint: lap only; toxicology performed; flight hours: 3,381.1 total, 902.7 in this make and model, 2.5 in the last 90 days, 0 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 3,000 ft overcast - Temperature: 55 °F, dew point 43 °F - Altimeter: 30.06 inHg - Observed at: LRF, 17 nm away ## 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 20121107025439A](https://openairdocs.org/incident/20121107025439A), Nov 7, 2012: Cessna P210N, Conway, AR, Substantial damage, 1 fatal. On November 7, 2012, at 1128 CST, Cessna P210N, N887JA, registered to r. j. allen and associates, appeared to experience a lose of power shortly after takeoff… ## Docket (2 files) The files NTSB released with the investigation on March 26, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85534. 47.3 MB in all. - Report of Engine Examination (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410205&FileExtension=.PDF&FileName=Report%20of%20Engine%20Examination-Master.PDF - Pilot Logbook (item 2, .PDF, 45.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410718&FileExtension=.PDF&FileName=Pilot%20Logbook%20-Master.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.