# NTSB CEN22LA018: Cessna 210, N1235U, Dallas, TX, October 20, 2021

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: October 20, 2021, 16:15 local (21:15 UTC)
- Place: Dallas, TX · Open field on airport property.
- Coordinates: 32.675028, -96.866772 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.6750&lon=-96.8668&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Fuel related](https://openairdocs.org/ntsb-events/190)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: FAA North Texas FSDO
- NTSB case key (mKey): 104143
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA018
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104143/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104143
- Page: https://openairdocs.org/ntsb/CEN22LA018

## Probable cause

A temporary loss of engine power during the takeoff due to a damaged fuel pump, which resulted in a forced landing and a runway excursion. The source of the damage to the fuel pump could not be determined.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 210N, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073453), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Cessna 210N, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=2073453), [All aircraft, 71 cases](https://openairdocs.org/ntsb-findings/01022822/cases.md)
- [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Unknown/Not determined (probable cause); cases with it: [Cessna 210N, 1 case](https://openairdocs.org/ntsb-findings/01022822/cases.md?model=2073453), [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.

- [Takeoff: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cessna 210N, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=2073453), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md)
- [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 210N, 4 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073453), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md)
- [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 210N, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073453), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md)

## Analysis

The airline transport pilot reported he felt and heard a fluctuation in the engine power during the initial climb. The fluctuation was followed by “dashes” on the fuel flow monitor. The pilot decided to abort the takeoff and during descent, noticed full power return to the engine. During the landing, the nosewheel impacted the runway, the airplane rolled off the runway, and impacted a ditch. The airplane sustained substantial damage to the fuselage, the left wing, and the empennage. A postaccident examination of the airframe and engine was performed. Both fuel tanks and the fuel lines appeared to be free of any contaminants. Fuel was drained from the airframe and appeared to be light blue in color and free of any contaminants. The fuel strainer was opened, and an unknown white substance was noted. Contaminants were also found in the gascolator. The fuel pump was removed and successfully bench tested. Following completion of the test, a disassembly examination of the fuel pump revealed damage to the pump’s internal components that was sustained some time before the accident flight. No containments were found inside of the fuel pump and the source of the internal damage to the fuel pump could not be determined. Based on the available evidence, the source of the engine power fluctuation was likely due to internal damage of the fuel pump.

## Factual narrative

On October 20, 2021, about 1615 central daylight time, a Cessna 210N airplane, N1235U, sustained substantial damage when it was involved in an accident near Dallas, Texas. The airline transport pilot sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. The pilot reported that during the takeoff, he felt and heard a fluctuation in the engine power. The fuel flow monitor showed about 148 pounds per hour and then showed only “dashes” on the monitor. The pilot initiated a descent to abort the takeoff at which time the engine returned to full power. He concluded that the engine power fluctuation had only been for a few seconds, and he did not notice a fluctuation on the cylinder head temperature monitor. During the landing, the nosewheel impacted the runway first, and the tire was blown. The airplane rolled off the runway, impacted a shallow ditch, and came to rest inverted on a grass field. The pilot performed an emergency shutdown and was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage, the left wing, and the empennage. A postaccident examination of the airframe and engine was performed. Both fuel tanks and the fuel lines appeared to be free of any contaminants. Fuel was drained from the airframe and appeared to be light blue in color and free of any contaminants. The fuel strainer was opened, and an unknown white substance was noted. Small specks of white contaminants were found in the gascolator. The fuel pump was removed, and bench tested normally. Teardown revealed internal damage to the pump rotor and the thrust plate. The diaphragm was found to be in a stiff condition. No containments were found inside of the fuel pump and the source of the internal damage to the fuel pump could not be determined. The pilot reported that the airplane had previous fuel fluctuation issues and the pilot found “very fine sand like material” in previous fuel samples. The pilot theorized that the previous contaminants found could have been from residue from previous maintenance work where the fuel tanks were sealed. During a previous inspection, a mechanic noted that, “inspection of the upper wing fuel tank access plates shows that improper sealant was used in their installation.” However, additional information of the type of sealant previously used in the fuel tanks was not available. Continental Motors has published Service Bulletin (SB) 08-4A Fuel Injection System Contamination. This document states in part: It is imperative that fuel injection system components be kept free from contamination during all installation and maintenance procedures. Fuel system contamination may lead to fuel system component damage, erratic engine operation, loss of power, or engine shutdown. A review of the airplane’s maintenance records showing recent maintenance work prior to the accident, did not show any annotation of SB 08-4A being compliedwith, even though the fuel injection system was worked on. The Federal Aviation Administration does not mandate compliance with service bulletins for 14 CFR Part 91 operations. Aircraft Maintenance Technology has published a magazine article titled, “Continuous Flow Fuel Injection Systems.” This article discusses Continental Motors fuel injection systems and states in part: Many TCM fuel system failures can be attributed to contaminates that have entered the system. These contaminants range from shaved “O” rings to fuel bladder material. “Foreign objects” always seem to migrate to the worst possible spots.

## Aircraft

- Registration: [N1235U](https://openairdocs.org/deregistered/N1235U-2022-07-30), registration cancelled 2022-07-30, S/N 21064677, built 1982 (OpenAirDocs)
- Reported make and model: CESSNA 210 (N)
- Registry model: [Cessna 210N](https://openairdocs.org/model/cessna-210n) (registry code 2073453) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 21064677
- Year built: 1982
- Airframe hours: 5315.5
- Engines: Continental Motors IO-520-L 300 horsepower reciprocating
- Damage: Substantial damage
- Flight: Business, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, September 2, 2021
- Destination: 88R, Spicewood, TX
- Airport: RBD, Dallas Exec, runway 17/35, 3,800 × 150 ft, concrete
- Equipment: Data recorder

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 67; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: helicopter, airplane; medical: class 3, without waivers/limitations; last flight review October 10, 2019; seat: left; restraint: 3-point; flight hours: 5,544.1 total, 1,716.6 in this make and model, 4,697.7 as pilot in command, 7.7 in the last 90 days, 3.6 in the last 30 days, 1.5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 210° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: 4,400 ft overcast
- Temperature: 81 °F, dew point 64 °F
- Altimeter: 30.04 inHg
- Observed at: KRBD
- METAR: KRBD 202053Z 21005KT 10SM OVC044 27/18 A3004 RMK AO2 SLP166 T02720183 56018

## 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 20211020022139A](https://openairdocs.org/incident/20211020022139A), Oct 20, 2021: Cessna 210N, Dallas, TX, Substantial damage. Aircraft was upside down with the nose pointing back up the runway approximately 100 feet past the end of runway 17 at Dallas Executive Airport (rbd). The…

## Docket (10 files)

The files NTSB released with the investigation on March 22, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104143. 25.7 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580777&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Redacted-Rel.pdf
- Accident photographs (item 2, PDF, 10 pages, 7.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13581046&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf
- Examination reports (item 3, PDF, 4 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580276&FileExtension=pdf&FileName=Examination%20Reports%20Redacted-Rel.pdf
- Various maintenance records (item 4, PDF, 7 pages, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13612776&FileExtension=pdf&FileName=Various%20Maintenace%20Records%20Redacted-Rel.pdf
- Additional documents (item 5, PDF, 17 pages, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580286&FileExtension=pdf&FileName=Additional%20Documents%20Redacted-Rel.pdf
- J.p. instruments, inc. edm 711 - engine data monitor factual report (item 6, PDF, 2 pages, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13581426&FileExtension=pdf&FileName=NTSB%20Factual%20Report%20JPI%20EDM711%20CEN22LA018-Rel.pdf
- J.p. instruments, inc. edm 711 - additional documents (item 7, PDF, 5 pages, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580296&FileExtension=pdf&FileName=NTSB%20JPI%20EDM711%20Download%20Addtional%20Documents-Rel.pdf
- J.p. instruments, inc. edm 711 - flight #57 tabular data (.csv file) (item 8, CSV, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580306&FileExtension=csv&FileName=Flight%2057%20Tabular%20Data-Rel.csv
- J.p. instruments, inc. edm 711 - flight #58 tabular data (.csv file) (item 9, CSV, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580827&FileExtension=csv&FileName=Flight%2058%20Tabular%20Data-Rel.csv
- J.p. instruments, inc. edm 711 - accident flight tabular data (.csv file) (item 10, CSV, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13581680&FileExtension=csv&FileName=Attachment%201%20-%20Accident%20Flight%20Tabular%20Data-Rel.csv

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.

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