# NTSB CHI95FA337: Cessna T210R, N650GM, Iowa City, IA, September 28, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 27, 1995, 21:32 local (Sep 28, 1995, 02:32 UTC) - Place: Iowa City, IA - Coordinates: 41.650184, -91.570152 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.6502&lon=-91.5702&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious, 1 minor - Status: Completed, report May 9, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 9752 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95FA337 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9752/pdf - Page: https://openairdocs.org/ntsb/CHI95FA337 ## Probable cause fuel exhaustion as a result of the pilot's inadequate preflight and lack of familiarity with the airplane. Factors involved were the bright night, trees and transmission wires. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, approach - vfr pattern - downwind - fluid,fuel - exhaustion (cause) - preflight planning/preparation - inadequate, pilot in command (cause) - lack of familiarity with aircraft, pilot in command (cause) - Forced landing, emergency descent/landing - In flight collision with object, emergency descent/landing - light condition - bright night (contributing factor) - object - tree(s) (contributing factor) - object - wire,transmission (contributing factor) ## Analysis The day before the accident, the airplane had flown from Newton, KS to Oklahoma City, OK, then to Shawnee, OK, and return to Newton, KS. It was not refueled. That same day, the operator made a business arrangement with the passengers to have them flown round trip from Tulsa, OK, to Iowa City, IA. The operator contacted the pilot requesting that he fly the Cessna 210. The pilot accepted although he had never flown a Cessna 210. The next day, after a 1/2-hour checkout at Newton, KS, the pilot flew to Tulsa, OK to pick up the passengers. While approaching Tulsa, the pilot reported that the fuel gauges indicated empty. The refuelers were told to top off the fuel tanks. The refueler put on 48.8 gals of fuel; the airplane held 120 gals total fuel. A passenger paid for the fuel. The pilot did not see the fuel slip nor did he learn that 48.8 gals of fuel had been added. The pilot did not visually check the fuel level during preflight. The pilot reported that he did not believe the fuel gauges were reliable. After 2.6 hours of flight, the airplane impacted trees and power lines 1/2 mile north of Iowa City Airport. There was no indication of fuel on the airplane, nor were there indications of fuel siphoning or leaking. ## Factual narrative History of Flight On September 27, 1995, at 2132 central daylight time (CDT), a Cessna T210R, N650GM, was destroyed when it impacted trees after it had experienced a loss of engine power near Iowa City, Iowa. The commercial pilot received serious injuries. One passenger received fatal injuries and one passenger received minor injuries. The 14 CFR Part 91 flight departed Riverside Airport, Tulsa, Oklahoma, en route to Iowa City Municipal Airport, Iowa City, Iowa. Visual meteorological conditions prevailed and an instrument flight plan was filed. On September 26, 1995, the airplane was fueled and "topped off" with 81.1 gallons of fuel in Newton, Kansas. The lineman who fueled the airplane reported that he had filled the aircraft up to the top of the filler necks in both wings. The lineman reported that he did not know if anyone visually checked the level of the fuel after he had fueled the airplane. The operator reported that on September 26, 1995, he made a business flight in N650GM which required three flight legs. The operator reported that he had not visually checked the fuel level during preflight. He reported that the fuel gauges worked properly, and that the gauges indicated full tanks after the airplane had been refueled. The first leg of flight was from Newton, Kansas, to Sundance Airport, in Oklahoma City, Oklahoma. The second leg of flight went from Sundance Airport, to Shawnee Airport, Shawnee, Oklahoma. The third leg of flight was a return flight from Shawnee Airport to Newton, Kansas. No tach time or flight times were recorded for the flight. The airplane was not refueled when it returned to Newton, Kansas. A passenger of the accident airplane, N650GM, reported that the operator had made business arrangements with the passengers to provide an airplane and a pilot to fly them round trip from Riverside Airport, Tulsa, Oklahoma, to Iowa City, Iowa, on the night of September 27, 1995. The pilot reported that on the afternoon of September 26, 1995, he was offered an opportunity to fly, N650GM, for Ralph Lowry Aircraft Sales, Inc. Although the pilot had not flown a Cessna 210 or for the operator before, he reported that he was enthusiastic about the opportunity to fly the Cessna 210. The pilot reported that on September 27, 1995, he went to the airport to get checked out in the Cessna 210 by the operator. He arrived at about 1615 CDT. The pilot reported that the operator needed to make some phone calls so he used the time to look over the airplane. The pilot reported seeing the placard which was located below the fuel gauges which read: "FUEL GAUGES NOT CALIBRATED, BASE ALL FUEL CALCULATIONS ON VISUAL INSPECTION, TIME AND CONSUMPTION FIGURES. WITH FULL TANKS, MAX ENDURANCE IS 4 HOURS FOR FLIGHT PLANNING." The pilot reported that he did not consider the fuel gauges reliable after reading the warning on the placard. The operator reported that he and the pilot flew for about a half hour during the aircraft checkout. He reported that they climbed to about 2,500 feet, and also did some touch and go's in the traffic pattern. The operator reported that he discussed the aircraft systems with the pilot, and that he told the pilot that the fuel gauges worked fine. The pilot reported that at about 1700 CDT he dropped off the operator after the aircraft checkout, but did not shut down the airplane. He departed Newton, Kansas, en route to Riverside Airport, Tulsa, Oklahoma. He reported that he went direct to Tulsa using VFR flight following. He reported that he maintained 3,500 feet in order to stay below an overcast layer. He reported that the fuel gauges were indicating empty when he arrived at Riverside Airport at about 1800 CDT. The pilot reported that he radioed ahead to the fixed base operator (FBO) to request that the airplane be topped off with fuel. After the airplane was shut down, the refueler positioned the truck in front of N650GM. The pilot repeated to the refueler that he wanted the fuel tanks topped off. The pilot reported that he then went to the FBO's reception area to meet the passengers who were already waiting. After meeting the passengers, he went into the pilot flight planning area to obtain the weather and file an instrument flight plan. The refueler reported that he asked the pilot how many fuel tanks the airplane had. The refueler reported that the pilot indicated that he did not know. The refueler then proceeded to fuel the airplane. He reported that he topped off both wing tanks on the airplane. He reported that, "The shiny silver fuel caps stood out quite well against the darker painted surface of the wing." (N650GM's wings were painted white and the fuel caps were red) After putting in 48.8 gallons of fuel into N650GM, the refueler radioed the fuel sale back to his supervisor inside the FBO. He reported that after finishing the refueling process, he went back in and collected the payment for the fuel from one of the passengers. A passenger reported that he paid for the fuel for N650GM. While the pilot was getting the weather and filing the flight plan, the fuel bill was prepared and the passenger paid for it in cash. The pilot reported that when he finished flight planning he went out to preflight the airplane. He reported that he did not see the fuel slip, nor was he told that 48.8 gallons of fuel had been added to airplane. He reported that he had told the FBO twice to top it off. The pilot reported that he was unable to visually check the fuel tanks during the preflight. He reported that a ladder was not available, and that the Cessna 210 did not have any steps or dip sticks with which to check the fuel. The pilot reported that he remembered the gauges showing about 3/4 full. Records from the Riverside Air Traffic Control Tower indicate that the pilot of N650GM called for an IFR clearance and taxi instructions at 1857 CDT. Records indicate that he departed Riverside Airport at 1905 CDT and was advised to contact Tulsa Departure at 1906 CDT. The pilot reported that during the flight to Iowa City, Iowa, he climbed to 7,000 feet and later was cleared to 8,000 feet. He reported that he checked in the Pilot's Operating Handbook (POH) for performance limitations and emergency procedures, etc. He reported that he did not smell any fuel nor see any indications of fuel leaks. He reported that the engine ran well and sounded good. The pilot reported that he did not double check the fuel gauges because he considered them unreliable. The Cedar Rapids Air Traffic Control Tower reported that they advised N650GM to switch to advisory frequency at 2127 CDT. The pilot reported that he entered downwind for landing at Iowa City Airport. The airplane was at pattern altitude about one mile north of the airport when the engine quit. He reported that it was the first indication that he had of an engine problem. He reported that he checked the fuel flow and it was on "zero." The fuel tanks were on "Both." He turned the auxiliary fuel pump on and the engine regained power. The pilot reported that the fuel gauges were indicating "1/2." He reported that he turned base leg and final. While on final approach, the engine quit again and he did not regain power. The pilot establish the best glide speed of 88 knots and warned the passengers to prepare for a forced landing. At about 2132 CDT, approximately 2.6 hours takeoff, the aircraft hit trees. A witness who heard the airplane hit the tree near his house arrived at the accident site within 30 seconds of the aircraft impacting the ground. The witness reported that he remembered being worried about the possibility of downed powerlines and spilled fuel, so he looked for evidence of spilled fuel. He reported that he did not see or smell any fuel. The witness reported that he tried to assist the pilot and passengers. Police and paramedic help arrived ## Aircraft - Registration: [N650GM](https://openairdocs.org/deregistered/N650GM-2001-04-24), registration cancelled 2001-04-24, S/N 21064998 (OpenAirDocs) - Reported make and model: Cessna T210R - Registry model: [Cessna T210R](https://openairdocs.org/model/cessna-t210r) (registry code 2073459) (OpenAirDocs) - Category: Airplane - Serial number: 21064998 - Airframe hours: 1349 - Engines: Continental TSIO-520-CE 325 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Ralph Lowry Aircraft Sales - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 1995, 59 hours before - Departed: RVS, TULSA, OK - Destination: IOW - Flight plan: IFR - Airport: IOW, Iowa City Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 782 total, 4 in this make and model, 693 as pilot in command, 84 in the last 90 days, 81 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/bright - Wind: 160° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 54 °F - Altimeter: 30.00 inHg - Observed at: IOW, 1 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 19950928030419A](https://openairdocs.org/incident/19950928030419A), Sep 28, 1995: Cessna 210, Iowa City, IA, Substantial damage. Aircraft engine quit after aircraft was cleared for approach. (-4)the day before the accident, the airplane had flown from newton, KS to Oklahoma city, OK,… 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.