# NTSB CEN18LA229: Cessna T210F, N6107R, Desdemona, TX, June 17, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 17, 2018, 08:30 local (13:30 UTC) - Place: Desdemona, TX - Coordinates: 32.219444, -98.510002 - Nearby events: https://openairdocs.org/map.md?lat=32.2194&lon=-98.5100&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed, report April 30, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 97492 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA229 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97492/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97492 - Page: https://openairdocs.org/ntsb/CEN18LA229 ## Probable cause The total loss of engine power due to the fuel pump’s fuel flow setting being set too high, which resulted in an excessive fuel flow to the engine. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=2073422), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna T210F, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073422), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073422), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The private pilot was conducting a personal cross-country flight. He stated that the engine began running roughly during cruise flight. He leaned the mixture, and the engine roughness subsided; however, a few minutes later, the engine began running roughly again. He switched fuel tanks, but the engine continued running roughly. Shortly thereafter, the engine lost all power. The pilot subsequently conducted a forced landing in a soft, sandy field, and the airplane nosed over. A postaccident engine test-run revealed that the engine would not maintain power and that the fuel flow was excessive. A subsequent bench test of the fuel pump revealed that the pump was set to a high fuel flow setting, beyond the engine’s normal limits. The fuel pump was adjusted and reinstalled on the engine for another test-run. During the second test-run, the engine operated smoothly at a stabilized fuel flow within the operating limits for the engine. Given this evidence, it is likely that the engine lost power due the fuel pump’s flow setting being set to high, which resulted in an excessive fuel flow to the engine. ## Factual narrative On June 17, 2018, at 0830 central daylight time, a Cessna T210F airplane, N6107R, nosed over during an off airport forced landing in Desdemona, Texas. The private pilot and one passenger received minor injuries, and a second passenger was seriously injured. The airplane was substantially damaged. The airplane was registered to the pilot and operated as a personal flight under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions existed near the accident site at the time of the accident, and a flight plan had not been filed for the flight. The airplane departed the Dublin Municipal Airport (9F0), Dublin, Texas, about 0820, en route to the Gregory M. Simmons Memorial Airport (GZN), Cisco, Texas.The pilot stated that the engine began running rough during cruise flight at 2,400 ft above mean sea level. He leaned the fuel mixture and the engine roughness subsided. A few minutes later, the engine began running rough once again. He switched fuel tanks and there was no change in the engine operation. Shortly thereafter, the engine lost power. The pilot made a forced landing in a soft, sandy field and the airplane nosed over. The initial postaccident engine examination revealed the engine remained attached to the airframe. Various wires, cables, and hoses remained attached to the engine. The top spark plugs exhibited normal wear but were dark in color and oily. The cylinders were examined using a boroscope were unremarkable. The engine was then removed from the airframe and shipped to the manufacturer for a test run. The engine was placed in the test cell and started without hesitation. The engine ran at 1,200 rpm and 1,600 rpm with the fuel pump mixture control at full. After 2 minutes of run time, the engine power started to oscillate. The engine was shut down and the mixture control was adjusted to about half of where it was originally set. The engine was started again and after 1 minute and 20 seconds the engine power again began to decrease, with the fuel pressure reaching 40 psi, which was 8 psi higher than the maximum unmetered flow limit of 32 psi. The fuel pump was removed and placed on a test bench. At full power, 2,700 rpm, the fuel flow was about 170 pounds per hour with a fuel pressure of 92 psi. According to the engine manufacturer, the fuel pressure should have been between 29 and 32 psi. The adjustment screw was set to a fuel pressure of 30 psi and the pump was reinstalled on the engine for another test run. The engine was restarted and run up to 1,600 rpm. The rpm slowly dropped to 1,498 rpm. The engine power was increased to 2,552 rpm and the fuel pressure stabilized at 30.18 psi with smooth engine operation. During the initial engine run the engine was observed to have excessive manifold pressure. During the second engine run the turbocharger controller was adjusted to maintain normal manifold pressures. ## Aircraft - Registration: [N6107R](https://openairdocs.org/deregistered/N6107R-2018-10-18), registration cancelled 2018-10-18, S/N T210-0007, built 1965 (OpenAirDocs) - Reported make and model: CESSNA T210F (F) - Registry model: [Cessna T210F](https://openairdocs.org/model/cessna-t210f) (registry code 2073422) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: T210-0007 - Year built: 1965 - Airframe hours: 5315 - Engines: Continental TSIO-520C 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 22, 2017, 35 hours before - Departed: 9F0, Dublin, TX - Destination: 3F2, Cisco, TX - Equipment: Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Onboard weather, Electronic flight bag or handheld device, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review October 3, 2017; seat: left; flight hours: 332 total, 276 as pilot in command, 42 in the last 90 days, 11 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 3,400 ft broken - Temperature: 79 °F, dew point 68 °F - Altimeter: 30.02 inHg - Observed at: SEP, 22 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 20180617024859A](https://openairdocs.org/incident/20180617024859A), Jun 17, 2018: Cessna T210F, Desdemona, TX, Substantial damage. On June 17, 2018 at approximately 0945 central daylight time, a Cessna T210F landed in a field due to loss of power. The plane touched down in a sandy field… ## Other investigations on N6107R (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 DEN71DQA45](https://openairdocs.org/ntsb/DEN71DQA45), Jan 25, 1971: Cessna 210 (N6107R), Los Alamos, NM, substantial damage - [NTSB CHI68D0071](https://openairdocs.org/ntsb/CHI68D0071), May 18, 1967: Cessna T-210 (N6107R), Wooster, OH, substantial damage ## Docket (5 files) The files NTSB released with the investigation on December 10, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97492. 1.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 406 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469115&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - NTSB Engine Examination (item 2, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469116&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination-Master.PDF - Record of Conversation (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469117&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469118&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Engine Operational Test Log (item 5, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469119&FileExtension=.PDF&FileName=Engine%20Operational%20Test%20Log-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.