CEN17LA162

NTSB accident investigation · Cessna 210 · Salida, CO · April 20, 2017

Accident · No injuriesLimited investigationFinal report
Date
April 19, 2017, 19:10 local (Apr 20, 2017, 01:10 UTC)
Place
Salida, CO
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9589TCessna 210
Defining event
Approach-VFR pattern base: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA, Continental Motors
FAA report
20170419002509A
Case key
95033

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

The pilot’s inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation.

Findings · 3

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 210: 2 casesAll aircraft: 1,391 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna 210: 6 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 210: 4 casesAll aircraft: 719 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

The private pilot was landing the airplane at the conclusion of a cross-country flight when the engine experienced a total loss of power in the airport traffic pattern. The pilot attempted to restart the engine without success and subsequently landed the airplane in a field, where it impacted a fence and irrigation equipment. The pilot stated the right fuel tank was selected at the time of the accident. Postaccident examination revealed that the right tank contained 14 to 15 gallons of fuel, and that the left fuel tank contained about 1 gallon of fuel. The fuel selector was in the right tank position. The engine functioned normally during a postaccident test run. Given the lack of engine anomalies, it is likely that the airplane was operating on the left tank at the time of the accident, and the loss of engine power was the result of fuel starvation; it is likely that the pilot moved the fuel selector to the right tank position during his attempt to restart the engine.

Factual narrative

On April 19, 2017, about 1910 mountain daylight time, an Cessna 210 airplane, N9589T, impacted a fence and irrigation equipment during an off airport forced landing while on a visual approach to the Harriet Alexander Field Airport (ANK), Salida, Colorado. The private pilot was not injured, and the airplane was substantially damaged. The airplane was being operated by the pilot as a 14 Code of Federal Regulations Part 91 business flight. Visual meteorological conditions existed at the airport at the time of the accident, and no flight plan was filed. The flight originated from Page Municipal Airport (PGA), Page, Arizona, about 1700.The pilot was delivering the airplane to a new owner in Denver and was landing at ANK for fuel. She stated she flew the first hour and thirty minutes with the left fuel tank selected then she switched to the right fuel tank for the remainder of the flight. The en route portion of the flight was uneventful. She stated the fuel mixture was leaned during the flight and increased to full rich as she descended. She stated that she entered the ANK traffic pattern, turned onto base leg, and after leveling the wings, noticed "everything went quiet." She attempted to restart the engine with no success. Unable to make it to the runway, she chose a field in which to land. The airplane landed hard and contacted a fence and irrigation equipment during the landing roll resulting in substantial damage to the right wing. The ANK airport manager who assisted in removing the airplane from the field reported they drained 14 to 15 gallons of fuel from the right wing and about 1 gallon of fuel from the left wing prior to moving the airplane. An examination of the airframe and engine were conducted on May 5, 2017 at ANK. The upper engine cowling had been removed from the airplane. A visual inspection of the engine was conducted, and no impact damage was noted. The wings had been removed from the airplane during the wreckage retrieval. The airplane was moved from a hangar to an open ramp and secured. An examination of the engine was conducted during which the top spark plugs were removed and appeared to have normal color and wear signatures. The cylinders were examined with a lighted boroscope. The cylinder valves were intact with normal combustion signatures. Thumb compression was achieved when the propeller was rotated by hand. Both magnetos produced spark at the ignition leads and the impulse couplers released normally. A temporary fuel supply was connected to the right-wing fuel supply port and a bucket was placed under the right tank fuel return port. The fuel inlet b-nut was removed from the fuel manifold and the boost pump was turned on. Fuel flow was verified at the fuel delivery hose. The fuel inlet hose was reinstalled on the fuel manifold. Cylinder No. 5 fuel line was removed from the injector. The fuel boost pump was turned on and fuel flow was verified through the line which was subsequently reinstalled. The fuel system wasprimed, and an attempt was made to start the engine. This was performed twice and both times the engine did not start. The No.6 injector nozzle was removed, the boost pump turned on and it was verified that fuel was flowing to the injector nozzle. A third attempt to start the engine was successful and the engine was run at idle for several minutes to warm up. The throttle was then advanced, and the engine rpm responded accordingly. The fuel mixture was leaned to account for the high elevation. The rpm increased by 150 rpm and the engine began to run more smoothly. A magneto check was performed at 1,700 rpm and a 100-rpm drop was noted with each magneto. Engine power was increased, and the engine ran smoothly until the mixture was enriched at which time it began to run rough, although it continued to run. The engine power was then decreased to idle, the mixture control was moved to the cutoff position, and the engine stopped. It was noted that the exhaust gas temperature gauge was inoperative, and the cylinder head temperature gauge indicated a single cylinder value. The fuel gauge operated normally. The manifold gauge indicated atmospheric pressure prior to the engine start but did not operate during the engine run. The examination did not reveal any preimpact failures/malfunctions that would have precluded normal operation of the engine.

Aircraft

Registration
N9589T
Reported as
Cessna 210
Category
Airplane
Serial number
57389
Built
1960
Airframe hours
4,621.08
Engine
Continental IO-470-E, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 10, 2017 · 10 hours before
Departed
PGA · Page, AZ
Destination
ANK · Salida, CO
Airport
ANK · Harriet Alexander Field Airpor
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
34
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
April 6, 2017
Seat
Left
Restraint
4-point
Flight hours
264.3 total · 3.7 in this make and model · 189.3 as pilot in command · 76.5 in the last 90 days · 16.8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 23 °F
Altimeter
30.20 inHg
Observed at
ANK, 1 nm away

Docket · 6

The files NTSB released with the investigation on May 10, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 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.

Other investigations on N9589T · 1

Matched to the same aircraft by N-number and date.