# NTSB CEN17LA039: Cessna P210N, N44C, Pleasanton, TX, November 13, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 12, 2016, 18:00 local (Nov 13, 2016, 00:00 UTC) - Place: Pleasanton, TX - Coordinates: 28.954166, -98.519996 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.9542&lon=-98.5200&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report July 20, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 94382 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA039 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94382/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94382 - Page: https://openairdocs.org/ntsb/CEN17LA039 ## Probable cause Maintenance personnel's improper installation of the throttle linkage attachment hardware, which resulted in a partial loss of engine power when the hardware separated in flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine controls: power lever](https://openairdocs.org/ntsb-findings/01057603): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/01057603/cases.md?model=2073454), [All aircraft, 95 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2073454), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna P210N, 8 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2073454), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Cessna P210N, 11 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2073454), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-landing roll: 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 commercial pilot reported that, about 20 minutes into the cross-country flight, the engine suddenly experienced a partial loss of power. The pilot attempted to restore engine power but was not successful. During the subsequent forced landing to a road, the airplane struck a car, resulting in substantial damage to the fuselage and both wings. Examination of the airplane revealed that the hardware that attached the throttle linkage to the engine was not present. Given that the airplane had flown for only a few hours following recent maintenance, it is likely that maintenance personnel did not properly secure the throttle linkage hardware during that maintenance. No other anomalies were noted that would have precluded normal operations. ## Factual narrative On November 12, 2016, about 1800 central standard time, a Cessna P210N airplane, N44C, was substantially damaged during the forced landing to a road, one mile from the Pleasanton Municipal Airport (PEZ), Pleasanton, Texas. The commercial pilot sustained serious injuries and the passenger sustained minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight plan had been filed for the flight. The flight departed South Texas Regional Airport at Hondo (HDO) Hondo, Texas, about 1740, and was en route to Mustang Beach Airport (RAS) Port Aransas, Texas. According to the pilot, he moved the engine throttle control in 1/8 inch and experienced a partial loss of power. The pilot turned the airplane towards PEZ and went through the emergency checklist during which additional power was lost. In a subsequent conversation, the pilot stated that the engine continued to run without hesitation or roughness; as if it was at idle power. When it was apparent that he was not going to make it to the airport he prepared for a forced landing on the airport road. During the forced landing, the airplane struck a car. There were no ground injuries. According to the FAA inspector who responded to the accident, the fuselage and both wings were substantially damaged. A post accident examination of the airplane revealed that the hardware that attached the throttle valve lever to the throttle cable rod-end was not present. The hardware was not found at the accident site. The assembly hardware would include a washer, bolt, castellated nut, and cotter pin. No other anomalies were noted that would have precluded normal operations. According to copies of maintenance records provided by the pilot, an annual inspection was completed on the engine and airframe on June 9, 2016. On September 26, 2016, an overhauled starter adapter was installed. During this maintenance, it would have been necessary for a mechanic to remove the throttle body and linkages to access the starter adapter. Investigators were not able to speak with the maintenance personnel who performed the maintenance. ## Aircraft - Registration: [N44C](https://openairdocs.org/aircraft/N44C), registered now, S/N P21000311, built 1979 (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: P21000311 - Year built: 1979 - Airframe hours: 3135.5 - Engines: CONT MOTOR TSIO-520 P 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 9, 2016, 7 hours before - Departed: HDO, Hondo, TX - Destination: RAS, Port Aransas, TX - Equipment: Handheld GPS, Electronic flight bag or handheld device, Onboard weather, Stall warning system, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: serious; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review August 7, 2016; seat: left; restraint: 3-point; flight hours: 1,519.6 total, 326.7 in this make and model, 1,453.3 as pilot in command, 50 in the last 90 days, 15 in the last 30 days, 0.6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 55 °F - Altimeter: 30.18 inHg - Observed at: KPEZ, 1 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 20161112018469A](https://openairdocs.org/incident/20161112018469A), Nov 12, 2016: Cessna P210N, Pleasanton, TX, Destroyed. While cruising at 3200 ft. MSL, PIC stated he lost manifold boost pressure. The PIC attempted to adjust throttle which did not change the RPM indication due to… ## Other investigations on N44C (1) 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. - [NTSB CHI97LA265](https://openairdocs.org/ntsb/CHI97LA265), Aug 20, 1997: Cessna P210 (N44C), Grayslake, IL, destroyed. Probable cause: excessive airspeed and the pilot's failure to attain the proper touchdown point during landing. Factors associated with the accident were inadequate aircraft preflight and the ditch. ## Docket (4 files) The files NTSB released with the investigation on May 11, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94382. 5.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452113&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Engine Logbook Excerpt (item 2, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452114&FileExtension=.PDF&FileName=Engine%20Logbook%20Excerpt-Master.PDF - Record of Conversation - FAA Inspector (item 3, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452115&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - Record of Conversation - Pilot (item 4, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452116&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-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.