CEN14LA159

NTSB accident investigation · Cessna 310Q · Wapakoneta, OH · March 8, 2014

Accident · No injuriesLimited investigationFinal report
Date
March 8, 2014, 11:20 local (16:20 UTC)
Place
Wapakoneta, OH
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Standing
Aircraft
N69980Cessna 310Q
Defining event
Standing-engine(s) operating: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report March 6, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA, Textron Aviation
FAA report
20140308004349A
Case key
88912

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

On this page

Probable cause

A fire due to a fuel leak of the cabin heater system. Contributing to the accident was the inadequate maintenance of the airplane, which failed to identify leaks in the heater system.

Findings · 2

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.

Air conditioning system: heating systemAircraft › Aircraft systems · FailureCessna 310Q: 1 caseAll aircraft: 5 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 310Q: 2 casesAll aircraft: 320 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

According to the private pilot, the cross-country flight was uneventful. As he parked the airplane on the ramp at the conclusion of the flight, a "puff of smoke" came from below the instrument panel. The pilot immediately shut down the electrical system, but the smoke continued to increase. He completed the airplane shutdown checklist, then he and the passengers exited the airplane. After exiting the airplane, the pilot stated he could hear fire in the nose compartment and saw paint on the nose compartment beginning to discolor. He removed the nose access panel and extinguished the fire with a fire extinguisher. The heater had a history of fuel leaks, as evidenced by cracks found in the heater and fuel evaporation marks in the fuel pump box. Airplane maintenance manuals and manufacturer service bulletins recommended recurring inspections of the heater system and fuel lines, but there was no documentation in the airplane's maintenance records that the inspections had been completed.

Factual narrative

On March 8, 2014, about 1120 eastern standard time (EST), a Cessna 310Q airplane, N69980, experienced fire in the nose compartment while taxiing to the ramp at Auglaize County Neil Armstrong Airport (AXV) in Wapakoneta, Ohio. The airplane was substantially damaged. The pilot and two passengers on-board were not injured. The airplane was registered to and operated by Fluid Process Automation, LLC, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the instrument flight rules (IFR) flight, which originated at Akron-Canton Airport (CAK) in Akron, Ohio. According to the pilot, the flight was uneventful. As he parked the airplane on the ramp at AXV, a "puff of smoke" came from below the instrument panel. Perceiving the electrical system was the sources of the smoke, the pilot immediately shut it down but the smoke continued to increase. The pilot completed the airplane shutdown checklist and exited the airplane with the passengers. After exiting the airplane, the pilot stated he could hear fire in the nose and noticed discolored paint on the nose compartment. He removed the nose access panel and extinguished the fire with a carbon dioxide fire extinguisher. Wreckage The airplane remained intact and the fire damage was limited to the nose compartment and the lower forward portion of the instrument panels and cockpit. Fire damage to the cabin area was limited to some thermal discoloration of the floor on the right side of the cockpit. The exterior damage was located on the upper portion and right side of the nose compartment. The upper section of the nose fuselage skin exhibited large areas of thermal discoloration of the exterior paint as well as bubbling and peeling of the outer layers of the paint. This damage continued down the right side of the nose compartment. The lower right exhaust louvers and the fuselage skin near the heater exhaust exhibited sooting and some thermal discoloration. The interior of the nose compartment was heavily sooted and exhibited thermal damage particularly in the area of the cabin heater, which was located on the rear right side of the nose compartment. The left side of the compartment was heavily sooted with some generalized melting and sagging of wire insulation. On the right side, nonmetallic components (such as wire insulation, tubing and ducts) adjacent to the heater showed melting and thermal discoloration. Several rubber components of the heater assembly were missing and presumed destroyed by the fire. The exterior of the heater and adjacent metallic assembly components were sooted and had evidence of thermal discoloration. During the removal of the heater assembly, the heater assembly drain line was found blocked with a densely packed brownish-grey substance. Heater Examination The heater was a Southwind 8240E. According to maintenance/airplane logbooks and manufacturer information, the heater was installed when the airplane wasmanufactured and overhauled in 1997. A pressure decay test was performed on the combustion chamber in 2003. The current owner and pilot stated he had used the heater several times including the day of the accident. The cabin heater assembly, including the vent and drain lines, the heater fuel pump box, and the light bulb from the heater annunciator light were removed from the airplane and sent to the NTSB Materials Laboratory for further examination. The exterior case of the heater was removed and a pressure test of the combustion chamber and associated heat exchanger muff was performed. Four separate leaks were found. One leak was found in the igniter plug port weld. One leak was found in the heat muff end weld. Two leaks were found in the welds that attach the combustion chamber to the heat exchanger muff, and one of those leaks had a visible crack. The blocked drain line was examined. It was determined that the material in the drain line was densely packed from the open (drain) end to the end. Approximately 0.4 grams of material was removed from the drain line using a thin wooden scraper. The material was brownish gray in color and had a powdery consistency. A sample of the material removed from the drain line was examined using a Fourier Transform Infrared (FTIR) spectrometer. The materials were consistent with lead oxide and aluminum oxides often found in aviation fuel combustion byproduct and other materials found within the aircraft engine compartment and fuel system. There was evidence of fuel leakage in the fuel pump box, with evaporation marks where the fuel accumulated and evaporated off, leaving behind nonvolatile residue. There were several bands of evaporation marks consistent with multiple evaporation cycles. The fuel pump box had visible thermal discoloration, indicating it had been exposed to heat. Pressure testing of the fuel pump was not conducted due to the inability to recreate a pre-accident condition for the fuel pump. Cessna Aircraft Company issued service letter ME73-3 on February 23, 1973, identifying the need for a special one-time inspection of aircraft heaters that have not undergone the first 100-hour inspection. The service letter also states "Service manuals presently recommend a check of the nose compartment with respect to heater fuel system components at each 100 hours." Cessna issued Service Bulletin MEB95-9 on June 16, 1995. MEB95-5 stated "The cabin heater fuel line should be inspected for fuel leaks and corrosion. Leaking fuel lines should be repaired or replaced based on results of the inspection. Minor corrosion pitting can be repaired but line replacement is required if pitting exceeds the limit allowed by this service bulletin. Non-compliance with this service bulletin could result in failure of the cabin heater fuel line; which could subsequently result in a fire." "Compliance – Mandatory, shall be accomplished within the next 100 hours of operation or 12 months, whichever occurs first." A review ofthe airplane's maintenance showed the heater was installed in the airplane at the time of manufacture, and overhauled in 1997. A combustion test was performed on February 3, 2003. No record of any additional inspections of the heater and fuel lines was found.

Aircraft

Registration
N69980
Reported as
Cessna 310Q (Q)
Category
Airplane
Serial number
310Q1053
Built
1974
Engines
Cont Motor I0-520 SERIES, 300 horsepower, reciprocatingCont Motor I0-520 SERIES, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 14, 2013
Departed
KCAK · North Canton, OH
Destination
KAXV · Wapakoneta, OH
Flight plan
IFR
Airport
KAXV · Neil Armstrong, runway 26, 5,500 × 100 ft, asphalt
Equipment
Stall warning system

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
44
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 3, 2013
Seat
Left
Restraint
3-point
Flight hours
1,300 total · 30 in this make and model · 1,200 as pilot in command · 40 in the last 90 days · 25 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 3 knots
Visibility
5 statute miles
Temperature
43 °F, dew point 32 °F
Altimeter
30.04 inHg
Observed at
KAXV

Docket · 8

The files NTSB released with the investigation on January 6, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.2 MB in all.

FAA reports on this event · 1

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