# NTSB CEN17LA148: Cessna T210M, N1215M, Detroit Lakes, MN, April 5, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 5, 2017, 14:10 local (19:10 UTC) - Place: Detroit Lakes, MN - Coordinates: 46.825279, -95.885559 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.8253&lon=-95.8856&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 26, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 94979 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA148 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94979/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94979 - Page: https://openairdocs.org/ntsb/CEN17LA148 ## Probable cause The malfunction of the right main landing gear actuator for reasons that could not be determined because postaccident examination revealed no mechanical anomalies that would have precluded normal operation. Contributing to the accident was the improper decision to disengage the landing gear system circuit breaker before the flight, which was contrary to the manufacturer-recommended procedures. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear actuator](https://openairdocs.org/ntsb-findings/01023233): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna T210M, 4 cases](https://openairdocs.org/ntsb-findings/01023233/cases.md?model=2073451), [All aircraft, 54 cases](https://openairdocs.org/ntsb-findings/01023233/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna T210M, 9 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2073451), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Other (probable cause); cases with it: [Cessna T210M, 2 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2073451), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna T210M, 7 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073451), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=2073451), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Cessna T210M, 7 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=2073451), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The commercial pilot reported that, before the accident flight, the airplane had been experiencing intermittent landing gear problems and that the purpose of the flight was to bring the airplane to a maintenance facility to examine the landing gear system. He added that, before the flight, the landing gear circuit breaker was pulled out "in order to keep the gear in the down position and eliminate the gear warning horn" for the flight. While landing, the pilot noticed that the left wing slightly dropped after touchdown, and the pilot corrected with aileron to maintain the runway centerline. Shortly thereafter, the pilot could feel the right main landing gear (MLG) slowly collapse. The pilot was unable to maintain the airplane on the runway centerline, and the airplane exited the runway surface. The airplane came to rest upright with the right MLG collapsed, and the right horizontal stabilizer was bent. During a postaccident examination, the landing gear were retracted and extended multiple times. Each gear retraction was normal; however, the gear extension cycles resulted in the left MLG and nose landing gear extending and locking, and the right MLG extending with no movement from the downlock actuator. The actuator was removed for further examination, and it was difficult to move. After removal, the actuator released, and the internal spring mechanism freely moved the actuator. The actuator was disassembled with no internal problems noted. According to the Pilot's Operating Handbook, Section 3, "Emergency Procedures, Landing Gear Malfunction Procedures," the landing gear pump circuit breaker was to be positioned to the "in" position for all landing gear malfunction scenarios. ## Factual narrative On April 5, 2017, at 1410 central daylight time, a Cessna 210M single-engine airplane, N1215M, experienced a right main landing gear collapse at the Detroit Lakes Airport (DTL), Detroit Lakes, Minnesota. The commercial pilot, who was the sole occupant, was not injured, and the airplane sustained substantial damage to the right horizontal stabilizer. The airplane was registered to Great Plains Leasing, LLC, Dickinson, North Dakota, and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Visual meteorological conditions prevailed at the time of the accident, and a flight plan was not filed. The flight departed the Moorhead Municipal Airport (JKJ), Moorhead, Minnesota, about 1350. According to the pilot, before the accident flight, the airplane had been experiencing intermittent landing gear problems, and the purpose of the flight was to bring the airplane to a maintenance facility at DTL to examine the landing gear system. Before the flight, the landing gear circuit breaker was pulled out "in order to keep the gear in the down position and eliminate the gear warning horn" for the flight to DTL. While landing at DTL, the pilot noticed the left wing slightly dropped after touchdown, and the pilot corrected with aileron to maintain runway centerline. Shortly thereafter, the pilot could feel the right main landing gear slowly collapse. The pilot was unable to maintain the airplane on runway centerline, and the airplane exited the runway surface. The airplane came to rest upright with the right main landing gear collapsed, and the right horizontal stabilizer was bent. On April 18, 2017, the airplane was examined by a Federal Aviation Administration (FAA) inspector and a mechanic. During the initial examination, the landing gear was retracted and extended multiple times. Each gear retraction was normal, and the gear extension cycle resulted in the left main and nose gear extending and locking, and the right gear extending with no movement from the downlock actuator. After loosening the hydraulic line fittings at the downlock actuator, hydraulic fluid was present at the actuator. The actuator was removed for further examination, and was found difficult to move. According to the inspector, after removal, the actuator released, and the internal spring mechanism freely moved the actuator. The actuator was disassembled with no internal problems noted. On April 24, 2017, a former pilot of the accident airplane stopped into the FAA office in Fargo, North Dakota, to discuss the accident. According to the pilot, he had previously flown the airplane in September 2016 from DTL to JKJ, and experienced an unsafe gear warning horn and advised the airplane owners. During his landing, he landed with the landing gear pump circuit break in and the gear warning horn functioning. He stated that with the landing gear pump operating (circuit breaker in), the pump pressure on the landing gear actuator heldthe gear in the "saddle" until the airplane was on the ground. The weight of the wheels would then keep the gear in the down position. To his knowledge, the airplane had been in storage since his flight. According to the Cessna Pilot's Operating Handbook (POH), Section 3, Emergency Procedures, Landing Gear Malfunction Procedures, all landing gear malfunction scenarios listed in the POH require the landing gear pump circuit breaker to be in the "IN" position. ## Aircraft - Registration: [N1215M](https://openairdocs.org/aircraft/N1215M), registered now, S/N 21061924, built 1977 (OpenAirDocs) - Reported make and model: CESSNA T210M (M) - Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061924 - Year built: 1977 - Airframe hours: 5810 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 29, 2016, 1 hours before - Departed: JKJ, Moorhead, MN - Destination: DTL, Detroit Lakes, MN - Airport: DTL, Detroit Lakes Airport, runway 31, 4,500 × 75 ft, asphalt - Equipment: Stall warning system, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review July 31, 2016; seat: left; restraint: lap only; flight hours: 1,080 total, 1 in this make and model, 300 as pilot in command, 64 in the last 90 days, 9 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 350° at 12 knots, gusting 15 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 46 °F, dew point 28 °F - Altimeter: 30.05 inHg - Observed at: DTL ## 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 20170405003379A](https://openairdocs.org/incident/20170405003379A), Apr 5, 2017: Cessna T210M, Detroit Lakes, MN, Substantial damage. The airplane was being flown to a maintenance facility for repair of an intermittent landing gear alarm. The airplane was flown with landing gear down and the… ## Other investigations on N1215M (2) 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 CEN21FA207](https://openairdocs.org/ntsb/CEN21FA207), May 2, 2021: Cessna T210M (N1215M), Oxford, IA, destroyed, 1 fatal. Probable cause: The pilot’s loss of directional control during landing in gusting crosswind conditions that exceeded the airplane’s capability and his decision to attempt to takeoff from a field, which resulted in… - [NTSB CHI94LA073](https://openairdocs.org/ntsb/CHI94LA073), Jan 27, 1994: Cessna T210M (N1215M), Olathe, KS, substantial damage. Probable cause: the pilot's failure to follow procedures and directives regarding the positioning of the fuel tank selector to the fullest tank for the landing portion of flight. ## Docket (4 files) The files NTSB released with the investigation on June 6, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94979. 2.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 877 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452871&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452872&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - FAA Statement (item 3, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452873&FileExtension=.PDF&FileName=FAA%20Statement-Master.PDF - POH Excerpt (item 4, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452874&FileExtension=.PDF&FileName=POH%20Excerpt-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.