DEN99LA070

NTSB accident investigation · Cessna T210L · Albuquerque, NM · April 30, 1999

Accident · Minor injuriesLimited investigationFinal report
Date
April 30, 1999, 13:13 local (19:13 UTC)
Place
Albuquerque, NM
Injuries
2 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N59235Cessna T210L
Weather
Visual (VMC) · Day
Status
Completed · report June 23, 2000
Report
Approved by Office Director
FAA report
19990430020469A
Case key
46185

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 improper mixture control use and the engine's subsequent power loss due to fuel starvation, and the lack of suitable terrain for the pilot to perform a forced landing. Factors were the pilot's lack of recent experience in type of airplane, the inadequate manufacturer's emergency engine airborne restart information in the Owner's Manual, and the pilot not performing the published emergency procedures for airborne engine restart.

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 power(total) - nonmechanicalApproach - vfr pattern - downwind
Fluid,fuel - starvationCause
Mixture - improper use ofPilot in commandCause
Lack of recent experience in type of aircraftPilot in commandFactor
Forced landingEmergency descent/landing
Emergency procedure - not followedPilot in commandFactor
Acft/equip,inadequate aircraft manualsManufacturerFactor
On ground/water encounter with terrain/waterEmergency descent/landing
Terrain condition - none suitableCause

Analysis

The pilot said that the takeoff was uneventful, and he began to level off at 1,000 feet agl to stay in the traffic pattern. He reduced the manifold pressure and began to lean the fuel mixture for cruise with the aid of the engine analyzer. After several communications with the tower, he turned the vernier mixture control further in the lean direction. The pilot said that the engine completely lost power without warning. The passenger stated that the engine fuel flow gauge 'was not indicating any fuel flow,' and the fuel mixture control was in the idle cut-off position. The pilot turned on the auxiliary fuel pump for an engine restart, but didn't move the mixture. The pilot performed a forced landing to 2 to 4 foot sand dune covered terrain. The manufacturer expanded the emergency procedure checklist, in later model T210's, to include 'mixture lean from full rich until restart occurs.' The pilot had 15 hours of flight experience in the airplane, and he had not flown it in the previous 90 days. The engine was placed on a engine run test stand, and it performed normally through its full operating range without difficulty.

Factual narrative

On April 30, 1999, at 1313 mountain daylight time, a Cessna T210L, N59235, was destroyed during a forced landing after takeoff from Albuquerque International Airport, Albuquerque, New Mexico. The commercial pilot and his passenger received minor injuries. The airplane was being operated by the Kirtland Air Force Base Aero Club, Albuquerque, New Mexico, under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the local maintenance test flight which originated 3 minutes prior to the accident. No flight plan had been filed.

The pilot said that the purpose of the flight was to perform a post maintenance evaluation of the airplane. The passenger in the right front seat was the chief mechanic and he was riding along to document the performance results. The pilot reported that the takeoff on runway 17 was uneventful, and that he leveled off at 1,000 feet above ground level (agl) to stay in the traffic pattern. He reduced manifold pressure and began to lean the fuel mixture for cruise with the aid of the GEM 603 engine analyzer. The pilot stated that the number 2 column on the GEM 603 began to blink, indicating that the number 2 cylinder had reached peak exhaust gas temperature (EGT). The pilot then had several communication exchanges with the control tower, and he began turning the airplane northbound for a traffic pattern downwind. He put his hand back on the vernier mixture control with the intention of enriching the fuel mixture, but "rotated the mixture control one and a half turns in the lean direction instead." The pilot said that the engine "completely lost power without warning." The passenger stated that the engine fuel flow gauge "was not indicating any fuel flow," and that the fuel mixture control lever was "in the idle cut-off position."

The pilot said that he "attempted an engine restart as the manual states while looking for a place to make a forced landing." The passenger stated that the pilot turned on the auxiliary fuel pump switch, but didn't move the engine mixture control forward. The passenger further stated that he pointed to the mixture control and said to the pilot, "it's all the way out!" The pilot said that he made an intentional gear up landing due to the rough terrain (2 to 4 foot high sand dunes).

The Cessna T210L Pilot's Checklist for Engine Failure During Flight states the following:

A. Airspeed-100 MPH; B. Fuel Selector Valve and Quantity-CHECK; C. Mixture-RICH; Auxiliary Fuel Pump-ON; D. Ignition Switch-BOTH (or START if propeller is stopped).

Cessna expanded this Emergency Procedures checklist in later model T210's (with the same engine) to include:

1. Airspeed---85 KIAS, 2. Auxiliary Fuel Pump---ON, 3. Fuel Selector Valve---OPPOSITE TANK (if it contains fuel), 4. Throttle---HALF OPEN, 5. Auxiliary Fuel Pump---OFF 6. Mixture---LEAN from full rich until restart occurs, 7. Mixture---ADJUST as required, 8. Throttle---ADJUST power as required, 9. Fuel Selector Valve---AS DESIRED after fuel flow is stabilized.

Additionally, the Owner's Manual published by the airplane's manufacturer states that leaning procedure is performed by leaning the mixture back to peak exhaust gas temperature (EGT) and enrich the mixture until the EGT is on the rich side of peak by an increment of 100 degrees Fahrenheit.

The pilot indicated on the National Transportation Safety Board's Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2) that he had not flown the Cessna T210L in the previous 90 days, but he had 15.2 hours in the airplane.

The airplane's engine was removed and shipped to the manufacturer for examination. The engine was put on a test stand on December 3, 1999, and ran through its full operating range with no abnormalities noted.

On December 14, 1999, the pilot wrote a letter to the safety investigator at Kirtland Air Force Base saying the following (see attached document): 1. He did enrich the mixture control sufficient to stop the GEM lights from flashing. 2. He did lean the mixture a second time (by an unspecified amount), but not enough, he believes, to cause the engine to quit.

The Investigator-In-Charge telephoned the passenger on December 21, 1999, and was told that this was accurate information, but the mixture was leaned the second time 3 to 3 1/2 inches out to idle cut-off position (see attached document).

Aircraft

Registration
N59235
Reported as
Cessna T210L
Category
Airplane
Serial number
2106171
Airframe hours
5,405
Engine
Continental TSIO-520-H, 265 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Kirtland Afb Aero Club
Registered owner
United States Air Force
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 25, 1999 · 94 hours before
Departed
ABQ

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
Certificates
Private, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
2,810 total · 15 in this make and model · 2,476 as pilot in command · 24 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 27 knots, gusting 37
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 12 °F
Altimeter
29.00 inHg
Observed at
ABQ, 2 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.