CHI03LA305

NTSB accident investigation · Cessna T210N · Pine River, MN · September 9, 2003

Accident · Serious injuriesLimited investigationFinal report
Date
September 9, 2003, 14:40 local (19:40 UTC)
Place
Pine River, MN
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5360UCessna T210N
Weather
Visual (VMC) · Day
Status
Completed · report March 2, 2004
Report
Approved by Office Director
Parties
FAA -- Minneapolis FSDO
FAA report
20030909025019A
Case key
57917

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

An inadequate pre-flight inspection by the pilot due to his failure to visually confirm fuel quantity prior to flight, and the resulting fuel exhaustion. Contributing factors were the pilot's improper use of the fuel management computer installed in the aircraft, and the tree located in the middle of the emergency landing field.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerDescent - normal
Preflight planning/preparation - inadequatePilot in commandCause
Improper use of equipment/aircraftPilot in commandFactor
Fluid,fuel - exhaustionCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency landing
Terrain condition - ground

Analysis

The aircraft was substantially damaged during a forced landing following a complete loss of engine power. The pilot reported that during descent he "felt the plane slow up quite quickly." He reported he verified the position of the engine controls, however he was unable to restore power. The pilot stated that he selected an emergency landing field. He noted: "After I cleared the tree line I put down my wheels and ten degrees of flaps. … I had to turn pretty sharply to avoid a large tree that was in the middle of the field. When I felt I had cleared the tree I straightened out the plane and pulled the nose up to flare. The plane did not seem to flare and hit the ground very hard. The landing gear collapsed upon impact and the plane slid on the ground." The pilot reported no malfunctions with the aircraft or engine prior to the loss of engine power. The post-accident examination of the aircraft recovered approximately 8 ounces of fuel from the fuel tanks. No fuel was present in the fuel line running from the firewall to the engine. The fuel tanks and lines appeared to be intact and no evidence of fuel leakage was observed. The pilot stated that he did not visually confirm the fuel level before flight. He reported referencing remaining fuel quantity from a fuel management computer installed in the aircraft. The operating manual for the fuel management computer stated: "[The fuel management computer] is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."

Factual narrative

On September 9, 2003, at 1440 central daylight time, a Cessna T210N, N5360U, piloted by a private pilot, was substantially damaged during a forced landing following a complete loss of engine power about 10 miles east of the Pine River Regional Airport (PWC), Pine River, Minnesota. The personal flight was being conducted under 14 CFR Part 91 and was not on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The pilot sustained minor injuries and the passenger sustained serious injuries. The flight departed the Richard I. Bong Airport (SUW), Superior, Wisconsin, about 1400, with an intended destination of PWC.

In his written statement, the pilot reported that during descent into SUW he "felt the plane slow up quite quickly." He stated that he checked the landing gear and flap position, and they were both still up. He reported he verified the position of the engine controls, however he was unable to restore power.

The pilot reported that when he looked up he was getting close to a tower, which he immediately turned to avoid. At this point, the pilot stated that he selected an emergency landing field north of his position. He noted that the stall warning horn went off a couple of times during the approach. Each time he responded by reducing pitch.

Concerning the emergency landing, the pilot reported: "After I cleared the tree line I put down my wheels and ten degrees of flaps. ... I had to turn pretty sharply to avoid a large tree that was in the middle of the field. When I felt I had cleared the tree I straightened out the plane and pulled the nose up to flare. The plane did not seem to flare and hit the ground very hard. The landing gear collapsed upon impact and the plane slid on the ground."

The pilot reported no malfunctions with the aircraft or engine prior to the loss of engine power.

The post-accident examination of the aircraft recovered approximately 8 ounces of fuel from the fuel tanks. No fuel was present in the fuel line running from the firewall to the engine. The fuel tanks and lines appeared to be intact and no evidence of fuel leakage was observed.

The pilot stated that a Miniflo Digital Fuel Management System, manufactured by Shadin Company, was installed in the aircraft. On the morning of the accident, the pilot flew the aircraft from PWC to SUW. He noted that the fuel management computer indicated 54 gallons remaining and the fuel quantity gauges indicated at one-half tanks before departing PWC. Prior to the return flight, the pilot reported that the fuel management computer indicated 36 gallons remaining.

The pilot stated that he did not visually confirm the fuel level before flight. In addition, he noted that he conducted an abbreviated preflight inspection. He stated the abbreviated preflight was due to the fact that his wife was flying with him and he did not want to make her nervous.

The operating manual for the fuel management system stated that it is "designed to provide complete fuel management information under real flight conditions without any manual entry of data (after entry of the initial fuel on-board information)."

Under "Preflight Procedures", the manual went on to state: "Miniflo is a fuel flow measuring system and NOT a quantity-sensing device. A visual inspection and positive determination of the usable fuel in the fuel tanks is a necessity. Therefore, it is imperative that the determined available usable fuel be manually entered into the system."

Aircraft

Registration
N5360U
Reported as
Cessna T210N
Category
Airplane
Serial number
210-64878
Airframe hours
2,265
Engine
Continental TSIO-520R, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Radair Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 29, 2003 · 55 hours before
Departed
SUW · Superior, WI
Destination
PWC · Pine River, MN
Flight plan
Unknown
Airport
PWC · Pine River Regional

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
52
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
June 4, 2003
Seat
Left
Flight hours
233 total · 48 in this make and model · 197 as pilot in command · 50 in the last 90 days · 9 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 16 knots, gusting 24
Visibility
10 statute miles
Lowest ceiling
6,500 ft broken
Temperature
82 °F, dew point 57 °F
Altimeter
29.95 inHg
Observed at
PWC, 10 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.

Other investigations on N5360U · 1

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