# NTSB CEN14LA194: Cessna T210M, N761BT, Lee's Summit, MO, April 6, 2014

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: April 6, 2014, 17:45 local (22:45 UTC)
- Place: Lee's Summit, MO
- Coordinates: 38.924999, -94.328613 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.9250&lon=-94.3286&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report October 27, 2014
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Federal Aviation Administration
- NTSB case key (mKey): 89044
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA194
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89044/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89044
- Page: https://openairdocs.org/ntsb/CEN14LA194

## Probable cause

The pilots’ inadequate preflight planning and fuel management, which resulted in fuel exhaustion, a loss of engine power, and a forced landing on a soft field. Contributing to the accident was the flying pilot’s improper use of flaps during the forced landing.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Cessna T210M, 5 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073451), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md)
- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna T210M, 7 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073451), [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 T210M, 7 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073451), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Equipment/furnishings: emergency equipment](https://openairdocs.org/ntsb-findings/01022560): Aircraft › Aircraft systems · Not used/operated; cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/01022560/cases.md?model=2073451), [All aircraft, 10 cases](https://openairdocs.org/ntsb-findings/01022560/cases.md)
- [Personnel issues](https://openairdocs.org/ntsb-findings/02040000): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/02040000/cases.md?model=2073451), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02040000/cases.md)
- [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cessna T210M, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2073451), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/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 T210M, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=2073451), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md)
- [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna T210M, 3 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073451), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md)
- [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna T210M, 17 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073451), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna T210M, 17 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073451), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna T210M, 11 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073451), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T210M, 18 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073451), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

Two company pilots were repositioning the airplane when it experienced a total loss of engine power. The left-seat pilot had to maneuver around obstructions to perform a forced landing to a field. The airplane landed with partial flaps on a soft field. A landing using full flaps would have reduced excess impact energy and mitigated airplane damage and injury. The left-seat pilot reported that he did not use his available seat belt. Examination of the airplane revealed no usable fuel onboard. No mechanical anomalies were noted that would have precluded normal airplane operation.

## Factual narrative

On April 6, 2014, at 1745 central daylight time, a Cessna T210M, N761BT, experienced a total loss of engine power during cruise flight. The pilot performed a forced landing to a field near Lee's Summit, Missouri. The airplane sustained substantial damage. Both company commercial-rated pilots sustained serious injuries. The airplane was registered to and operated by Mar-Tech Engineering LLC and was operating under 14 CFR Part 91 as an aerial survey positioning flight. The flight originated from Jacksonville Executive Airport at Craig, Jacksonville, Florida, at 1303 eastern daylight time and was destined for Lee's Summit Municipal Airport, Lee's Summit, Missouri. The company chief pilot stated that the flight was being positioned to meet a cable company employee on the following day at 0900 to perform aerial survey work. He said that the next stop after Lee's Summit, Missouri, or Kansas City, Missouri, may have been Denver, Colorado. Two pilots would be used during the survey with the left seat pilot as the pilot-in-command and the right seat pilot as a survey equipment operator which would make use of a laptop. Pilots would alternate flying the airplane on flights. He stated that the company prefers to employ pilots with flight instructor certificates. National Transportation Safety Board (NTSB) Pilot/Operator Aircraft Accident/Incident Report (Form 6120.1) forms were emailed to both pilots to complete and return to the Investigator-In-Charge. A form was received from the left seat pilot and not from the right seat pilot. The left seat pilot stated: "After loading the plane, filing a flight plan, having the plane fully topped off on all four tanks by the FBO truck, and performing our normal preflight procedure, we took off at a little after 1:00 pm from KCRG in Jacksonville, FL. I filed an IFR flight plan through Duals and we flew as directed towards our destination, filed as KLXT. The flight went according to plan. The only thing both my passenger and myself noted and discussed was that the manifold pressure was fluctuating between 23 and 30 inches without me changing the setting manually for about a period of approximately ten minutes. My passenger (who is also a pilot) and I discussed and decided to keep flying as it was not enough of a problem to deviate from our planned flight and the engine ran smoothly. After ten minutes the manifold pressure leveled out at the desired setting of 26.5 inches. We continued on with the flight as normal at 12,000 feet with the engine leaned in accordance with the POH and the placard above the engine instruments. About 12 miles from airport my passenger and I double checked flight time as the fuel gauges were reading a little lower than expected. We had been flying for 5.1 hrs. These planes have a 7 hour+ range, and we regularly and routinely fly them over 6 hours at a time. We were less than 5 miles from airport and had visual confirmation of the runway. Suddenly we lost power and immediately looked for aplace to land. At the time the field on the south side of highway looked best. The gear was put down and we ran through the checklist and were able to get the motor started, we climbed to gain as much altitude as possible and headed directly for the airport. About 2, 3 miles from the airport we lost power again, at this time our options were limited and I had to decide between a lake and woods on the east side of airport, or a small field next to a baseball complex. My passenger (who is also a pilot for my company) and I agreed it was our best option. We aimed for the field and had to bank hard right at the last minute because of a tree line and power line and houses on the other side of the field. We hit firmly and were both wearing our seat belts. I was able to push my door open and climb out and the passenger did the same. Basically as soon as we got out of the plane there were some first responders there to help." FlightAware showed that the airplane climbed to and remained at cruise altitude of about 12,000 feet for about 1:30 hours and descended to and remained at cruise altitude of about 8,000 feet for about three hours. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the left tip tank contained about 1 gallon of fuel, the right tip tank contained about 1 gallon of fuel, the left main tank contained less than 2 ounces of fuel, the right main tank contained less than 2 ounces of fuel, and the fuel strainer bowl contained about 1 ounce of fuel. The FAA inspector stated that the airplane landed uphill on a soft field. Both wings were collapsed, and the wing flaps were extended to the 10-degree position. The cockpit propeller and mixture controls were at the forward stops. The cockpit throttle control was at the aft stop and bent in the lateral direction. The fuel selector was in the off position, which was placed into that position by an unknown first responder. The left seat pilot reported in his Form 6120.1 that he did not use his shoulder harness and that a shoulder harness was not available. The chief pilot stated that the airplane was equipped with shoulder harnesses. The FAA inspector confirmed that shoulder harnesses were installed on the airplane. Advisory Circular 91-65, Use of Shoulder Harness in Passenger Seats, stated in part: "On December 17, 1985, the National Transportation Safety Board (NTSB) issued safety recommendation A-85-124, recommending issuance of an advisory circular to provide information on crash survivability aspects of small aircraft. The recommendation was the result of an NTSB general aviation airplane crashworthiness project. In the project, the Safety Board examined 500 relatively severe general aviation airplane accident, to determine what proportion of the occupants would have benefited from the use of shoulder harnesses and energy-absorbing seats. The Safety Board found that 20 percent of the fatally-injured occupants in these accidents could have survivedwith shoulder harnesses (assuming the seat belt was fastened) and 88 percent of the seriously injured could have had significantly less severe injuries with the use of shoulder harnesses." The left seat pilot fractured two vertebrae in his lower back, and the right seat pilot fractured his jaw and right foot/ankle. The left seat pilot reported on Form 6120.1 that he held a flight instructor certificate with airplane single-engine, airplane multiengine, and instrument airplane ratings. The FAA had no record that either pilot held a flight instructor certificate. The chief pilot said that the company operated 9 airplanes and employed 13 pilots, all of whom were employed on a full-time basis. The company has conducted over 20,000 hours of flying over the past 20 years and this accident was the second in the company's history. All flight operations were conducted under Part 91. The chief pilot stated there was a pilot safety meeting in December 2013, which was attended by the left and right seat pilots in addition to all of the other company pilots. Pilots were told not the fly the accident airplane on flight legs that were in excess of three hours without stops for fuel to determine the fuel burn of the airplane.

## Aircraft

- Registration: [N761BT](https://openairdocs.org/deregistered/N761BT-2018-05-31), registration cancelled 2018-05-31, S/N 21062132, built 1977 (OpenAirDocs)
- Reported make and model: CESSNA T210M
- Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs)
- Registry engine: [Continental TSIO-520-R](https://openairdocs.org/engine/continental-tsio-520-r) (registry code 17267, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 21062132
- Year built: 1977
- Airframe hours: 6543
- Engines: Continental Motors TSIO-520- R 310 horsepower reciprocating
- Damage: Substantial damage
- Flight: Other work use, Part 91
- Operator: Mar-Tech Engineering, LLC
- Registered owner: Mar-Tech Engineering, LLC
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, June 25, 2013
- Departed: CRG, Jacksonville, FL
- Destination: LXT, Lee's Summit, MO
- Flight plan: IFR
- Equipment: Handheld GPS, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 31; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review March 24, 2013; seat: left; restraint: lap only; flight hours: 1,500 total, 1,100 in this make and model, 1,200 as pilot in command, 150 in the last 90 days, 50 in the last 30 days, 5 in the last 24 hours
- Pilot-rated passenger; age 27; injuries: serious; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: unknown; seat: right; flight hours: 514 total, 214 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 170° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: 9,500 ft broken
- Temperature: 59 °F, dew point 36 °F
- Altimeter: 29.86 inHg
- Observed at: LXT, 4 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 20140406005159A](https://openairdocs.org/incident/20140406005159A), Apr 6, 2014: Cessna T210M, Lee'S Summit, MO, Substantial damage. This aircraft was enroute from jacksonville executive airport (kcrg) to Lee'S Summit Municipal Airport (klxt). During the descent into klxt, the engine lost…

## Docket (10 files)

The files NTSB released with the investigation on August 20, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89044. 8.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Left Seat Pilot (item 1, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415325&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20%0D%0ALeft%20Seat%20Pilot-Redacted.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Operator (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415326&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Operator-Master.PDF
- Record of Conversation - FAA Inspector (item 3, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415327&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF
- Record of Correspondence - FAA Inspector (item 4, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415328&FileExtension=.PDF&FileName=Record%20of%20Correspondence%20-%20FAA%20Inspector-Master.PDF
- Record of Conversation - Chief Pilot (item 5, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415329&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Chief%20Pilot-Master.PDF
- Flight Plan (item 6, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415330&FileExtension=.PDF&FileName=Flight%20Plan-Redacted.PDF
- FlightAware Plot (item 7, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415331&FileExtension=.PDF&FileName=FlightAware%20Plot-Master.PDF
- FAA Advisory Circular 91-65 (item 8, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415332&FileExtension=.PDF&FileName=FAA%20Advisory%20Circular%2091-65-Master.PDF
- Left Seat Pilot Information (item 9, .PDF, 497 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415333&FileExtension=.PDF&FileName=Left%20Seat%20Pilot%20Information-Redacted.PDF
- Right Seat Pilot Information (item 10, .PDF, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415334&FileExtension=.PDF&FileName=Right%20Seat%20Pilot%20Information-Redacted.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.

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