CEN20LA162

NTSB accident investigation · Cessna T210 · New Braunfels, TX · April 28, 2020

Accident · Minor injuriesClass 2 · LimitedFinal report
Date
April 28, 2020, 09:58 local (14:58 UTC)
Place
New Braunfels, TX
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N210HHCessna T210
Defining event
Enroute: Fuel exhaustion
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Central Region
Parties
Federal Aviation Administration, Continental Motors, Textron Aviation, RAM Aircraft, LP
FAA report
20200428006519A
Case key
101215

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's inadequate preflight inspection and fuel planning, which resulted in the loss of engine power due to fuel exhaustion.

Findings · 5

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.

Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 210L: 1 caseAll aircraft: 551 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Inadequate inspectionCessna 210L: 2 casesAll aircraft: 1,695 casesProbable cause
Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomeCessna 210L: 1 caseAll aircraft: 97 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 210L: 2 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 210L: 2 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 pilot stated that he had performed a "standard" preflight check before departing for the 1.5-hour cross-country flight. He reported that he checked the fuel gauges and visually inspected the fuel levels in the tanks and estimated the airplane had about 70 gallons of fuel for the flight. Near the conclusion of the flight, the pilot was given a clearance to climb in preparation for an instrument approach to the destination airport. During the climb, the pilot noticed that the airspeed was bleeding off and the engine was not producing power. After descending below clouds, the pilot decided to land in a field at the end of a lake. However, the pilot realized that the airplane would not reach the field, and he elected to conduct a forced landing on the water, which resulted in substantial damage to the airframe. Postaccident examination of the fuel tanks revealed some fuel remained, but when the fuel manifold was disassembled, no fuel was observed under its diaphragm. Recovery personnel dried the magnetos and plumbed a fuel can to the airplane for a test run of the engine, which was successful. The airplane’s fuel tanks were topped off about 3.5 flight hours before the accident flight departed; no fuel had been added since that time. With full tanks, the accident airplane’s expected endurance was about 4.8 hours of flight time. Thus, it is likely that the engine lost power due to fuel exhaustion. Given the available information, it is likely the pilot did not adequately verify the quantity of fuel during the preflight inspection of the airplane or take into account the amount of fuel burned since the airplane was last fueled.

Factual narrative

The full cantilever wings have integral fuel tanks. The integral fuel tanks are formed by the forward spar, two sealing ribs, and an aft fuel tank spar forward of the main spar. The fuel system consists of two vented integral fuel tanks (one in each wing), two fuel reservoir tanks, a fuel selector valve, auxiliary fuel pump, fuel strainer, engine-driven fuel pump, fuel/air control unit, fuel manifold, and fuel injection nozzles. The fuel tanks have a total capacity of 90 gallons of which 89 gallons is usable. Fuel quantity is measured by four electrically operated capacitance type fuel quantity transmitters (two in each tank) and indicated by two electrically operated fuel quantity indicators on the right side of the instrument panel. The indicators are marked in gallons (top scale) and pounds (bottom scale) with a red line indicating an empty tank. When an indicator shows an empty tank, about 0.5 gallon remains in the tank as unusable fuel. The performance specification in the airplane owner's manual, in part, stated that at 10,000 ft, a power setting of 75%, the expected range of the airplane was 830 nautical miles with a time of 4.8 hours. The airplane's Pilot Safety And Warning Supplements, in part, indicated, "Poor fuel management is often the cause of aircraft accidents. ... The aircraft should be on level ground during all fueling operations, since filling the tanks when the aircraft is not level may result in a fuel quantity less than the maximum capacity. Rapid filling of a fuel tank, without allowing time for air in the tank to escape, may result in a lower fuel quantity. ... Some Cessna single-engine airplanes have long, narrow fuel tanks. If your airplane is so equipped, it may be necessary to partially fill each tank alternately, and repeat the sequence as required to completely fill the tanks to their maximum capacity. This method of fueling helps prevent the airplane from settling to a wing-low attitude because of increased fuel weight in the fullest wing tank. ... It is always the responsibility of the pilot-in-command to ensure sufficient fuel is available for the planned flight. ... A pilot should not begin a flight without determining the fuel required and verifying its presence onboard." The airplane owner's manual, in part, stated, "Prepare for ditching by securing or jettisoning heavy objects located in the baggage area and collect folded coats or cushions for protection of occupants' face at touchdown." According to the airplane owner and airport records, the airplane was topped of at Llano Municipal Airport (AQO) Llano, Texas, with 46.8 gallons of 100 low lead fuel on March 8, 2020, about 1743. The fuel farm ramp at AQO exhibited a level surface and the airplane owner stated that the airplane appeared level during the fueling service. He visually verified the fuel level as he filled each fuel tank and by the fuel gauges. The owner then flew the airplane to MDD and review of his logbook showed that flight time was 2 hours.On March 28, 2020, the owner flew the airplane locally at MDD for 1.5 hours of flight time. No struts or steps on the side of the fuselage were seen during a review of photographs of the recovered airplane. On April 28, 2020, about 0958 central daylight time, a Cessna T210L airplane, N210HH, was substantially damaged when it was involved in an accident near New Braunfels, Texas. The private pilot sustained no injuries and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and a passenger departed on a flight about 0830 from the Midland Airpark (MDD), near Midland, Texas, and were enroute to the New Braunfels Regional Airport, near New Braunfels, Texas, (BAZ). He stated that he had performed the "standard" pre-flight checks that included confirming the airplane had about 70 gallons of fuel based on 3 different factors. He and the airplane owner discussed the amount of fuel in the airplane when it was flown last and the owner thought it was full. During the preflight inspection, the pilot noted that the fuel gauges were showing about 70 gallons available. The pilot, in part, stated, "Additionally, I visually inspected both tanks and saw that they were about even and while not completely full, they were close to full." When further asked if he used a stick to verify the fuel level, he stated, "I did not 'stick' the tanks. They appeared to visually match the gauges." To verify the level of fuel the pilot stated, "I used the step on the airplane that is there to stand on and look into the tanks." He stated that the grade of the ramp surface during the preflight was flat. The flight cruised about 7,500 ft msl. The pilot started a descent to remain clear of the clouds and checked the weather at BAZ. There were broken clouds below 3,900 ft with a ceiling of about 3,500 ft. When the pilot called the BAZ air traffic control tower, he was advised that weather conditions required him to file an instrument flight rules (IFR) flight plan. The pilot filed a flight plan and subsequently discussed the approach type with an approach controller. The pilot elected an area navigation (RNAV) approach for runway 17, was cleared to fly to a fix on the RNAV 17 approach, and was cleared to climb to 3,000 ft. The pilot programed the RNAV 17 approach in the GPS and headed to the assigned fix. During the climb, the pilot noticed that the airspeed was decreasing and the engine was not producing normal power. The pilot performed an emergency checklist, and subsequently initiated a descent to an altitude where he could see the ground. The pilot continued with emergency checklists, which included selecting the fullest tank, and activating the auxiliary fuel pump. However, he was unable to increase engine power. The engine remained at 2,500 RPM. Upon exiting the clouds, the pilot reduced the airplane's descent rate and evaluated forced landing options. The pilot advisedapproach control of his decision to land in a field at the end of Canyon Lake. After he realized the flight would not reach the field, the pilot elected to land on the lake with the landing gear intentionally retracted. The pilot picked a spot in the lake that was clear of boats and trees. Upon reaching a few feet above the water, the pilot "killed the motor," flared to bleed off speed, and kept the airplane's nose up. The passenger, in part, stated, "During the landing, I hit my head on the yoke, fell back into my chair, and then tried [to] make my way out of the plane." The pilot and passenger exited through the windows and subsequently swam to the shore. According to the pilot's logbook, he accumulated 144.1 hours of total flight time between the accident flight and his flight review on November 5, 2019, of which 9.4 hours were in the accident airplane and the remainder of that total time was in a Cirrus SR22T. A Federal Aviation Administration inspector oversaw the recovery of the airplane from the lake and documented the condition of the airplane. The airplane exhibited wrinkled fuselage skins. There were no wing skin anomalies around the integral fuel tanks. Utilizing five-gallon containers, recovered liquid from one fuel tank filled about 2.5 inches of the bottom of one container and a liquid from the other fuel tank filled about 3.5 inches of the bottom of another container. The airplane's wings were removed, and the disassembled airplane was taken to a recovery yard. Subsequently the sparkplugs were removed by recovery personnel and the plugs did not exhibit any anomalies that could not be attributed to water submersion. About 1/2 gallon of liquid consistent with water was recovered from each header fuel tank. No debris was observed on the fuel screen when recovery personnel removed it. The fuel manifold was disassembled, and no liquid was observed under its diaphragm. There was a rivet head lodged in the turbocharger impeller. However, there was no damage to the impeller blades, nor any scoring to the sidewalls. Once removed, the turbocharger impeller rotated freely when recovery personnel rotated it by hand. The magnetos were dried out and a fuel can was plumbed to the airplane by recovery personnel for a test run of the engine. The engine was started, and it was operational during the test run.

Aircraft

Registration
N210HH
Reported as
Cessna T210 (L)
Category
Airplane
Serial number
21061462
Built
1976
Airframe hours
4,707.3
Engine
Continental IO-520-R, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 5, 2019
Departed
MDD · Midland, TX
Destination
BAZ · New Braunfels, TX
Equipment
Satellite tracking device, Electronic multifunction display, ADS-B, 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
43
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
November 5, 2019
Seat
Left
Restraint
3-point
Flight hours
2,256 total · 97 in this make and model · 2,256 as pilot in command · 11 in the last 90 days · 11 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 11 knots
Visibility
6 statute miles
Lowest ceiling
800 ft broken
Temperature
79 °F, dew point 72 °F
Altimeter
29.94 inHg
Observed at
KBAZ, 15 nm away

Docket · 24

The files NTSB released with the investigation on October 9, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 781 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1 - operatorItem 1 · PDF · 9 pages · 2.3 MBPilot/operator aircraft accident report, NTSB form 6120.1 - pilotItem 2 · PDF · 9 pages · 6.3 MBPilot's statement - replies to followup questions supplied by pilot's attorneyItem 3 · PDF · 3 pages · 103 KBWitness statement - passenger's statement supplied by his attorneyItem 4 · PDF · 2 pages · 99 KBMiscellaneous information - pilot logbook excerptsItem 5 · PDF · 2 pages · 137 KBMiscellaneous information - pilot logbook excerpts from the owner of N210HHItem 6 · PDF · 2 pages · 1.9 MBMiscellaneous information - pilot's time in 210S between his last flight review and the accident flightItem 7 · PDF · 1 page · 22 KBFlight data recorder - garmin SD cardsItem 8 · PDF · 1 page · 65 KBMiscellaneous information - T210L pilot's operating handbook excerptsItem 9 · PDF · 12 pages · 452 KBMiscellaneous information - pilot's operating handbook performance excerptItem 10 · PDF · 1 page · 84 KBMiscellaneous information - pilot safety and warning supplements excerptItem 11 · PDF · 3 pages · 774 KBMaintenance records - logbook excerptsItem 12 · PDF · 14 pages · 12.2 MBPhotos - supplied photos of the airplane recovery and fuel farm rampItem 13 · PDF · 13 pages · 13 photos · 12.9 MBPhotos - insurance company supplied photos from the engine runItem 14 · PDF · 16 pages · 16 photos · 2.3 MBVideo file - engine run conducted by recovery personnelItem 15 · MOV · 725 MBMemorandum for record a�� communication summary -- d jones in reference to engine runItem 16 · PDF · 1 page · 65 KBMiscellaneous information - fueling records from aqoItem 17 · PDF · 2 pages · 2.3 MBMiscellaneous information - N210HH flight time since fuel tanks top offItem 18 · PDF · 1 page · 53 KBMiscellaneous information - RNAV approach runway 17 bazItem 19 · PDF · 1 page · 220 KBMaps or charts of accident area - overlay of adsb flight path of N210HHItem 20 · PDF · 4 pages · 7.9 MBRelease of aircraft wreckage, NTSB form 6120.15Item 21 · PDF · 1 page · 2.7 MBEvidence control formItem 22 · PDF · 1 page · 60 KBStatement of party representatives to NTSB investigationItem 23 · PDF · 3 pages · 2.1 MBMiscellaneous information - Cessna pilots association articleItem 24 · PDF · 7 pages · 1.1 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.