ERA13LA053

NTSB accident investigation · Cessna 210 · Jasper, GA · November 11, 2012

Accident · No injuriesLimited investigationFinal report
Date
November 11, 2012, 17:40 local (22:40 UTC)
Place
Jasper, GA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9633TCessna 210
Defining event
Approach-VFR pattern final: Loss of engine power (total)
Weather
Visual (VMC) · Dusk
Status
Completed · report November 6, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20121111027459A
Case key
85558

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

A loss of engine power due to fuel starvation as a result of the pilot’s prolonged sideslip maneuvers during the descent to landing. Contributing to the accident was the airplane’s lack of a required placard advising pilots to avoid lengthy sideslip maneuvers with fuel tanks less than 1/2 full.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Related operating infoCessna 210: 6 casesAll aircraft: 1,695 casesProbable cause
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Related operating infoCessna 210: 1 caseAll aircraft: 809 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna 210: 6 casesAll aircraft: 1,695 casesProbable cause
Placards and markingsAircraft › Aircraft handling/service · Not serviced/maintainedCessna 210: 1 caseAll aircraft: 11 casesProbable cause
ActionPersonnel issues › Action/decision · PilotCessna 210: 1 caseAll aircraft: 111 cases

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

During a cross-country flight, the pilot elected to refuel at an intermediate airport. The pilot switched the fuel selector from the right tank to the left (which he reported contained fuel quantities of 1/4 tank and between 1/3 and 1/2 tank, respectively, according to the fuel gauges), and initiated a descent. The pilot circled the airplane over the airport until he reached traffic pattern altitude and then maneuvered for landing. The pilot stated that due to crosswind conditions at the airport, he had to “crab and slip the airplane” to maintain the proper final approach course. When the airplane was about 1 mile from the runway threshold, the engine experienced a total loss of power. The pilot was unsuccessful in his attempts to restart the engine and conducted a forced landing to a road. Postaccident examination of the airplane revealed that the right fuel tank contained about 14 gallons of fuel, and the left tank contained about 9 gallons. A postaccident test run of the engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. A service letter issued by the manufacturer about 47 years before the accident and a subsequent airworthiness directive issued by the Federal Aviation Administration required the installation of a placard on the instrument panel directly under the fuel quantity indicators which stated, “Avoid landing approaches in red arc and over 30 second slips under 1/2 tank.” The placard was not installed on the accident airplane at the time of the accident. Given the airplane’s fuel state at the time of the accident and the absence of mechanical malfunctions in postaccident examinations, it is likely that, while the pilot was descending and maneuvering for landing using a prolonged sideslip, the fuel tank outlet became unported, and that the subsequent lack of fuel flow resulted in a loss of engine power.

Factual narrative

On November 11, 2012, approximately 1740 eastern standard time, a Cessna 210, N9633T, sustained substantial damage during a forced landing following a total loss of engine power near Jasper, Georgia. The private pilot and passenger were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which departed Vero Beach Municipal Airport (VRB), Vero Beach, Florida, about 1430, and was destined for Upper Cumberland Regional Airport (SRB), Sparta, Tennessee. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot stated that the he filled the airplane’s fuel tanks to capacity at VRB prior to departure. Fuel samples taken from both tanks, as well as the gascolator, were free of water and contaminants, and pre-takeoff checks of the engine revealed no anomalies. The pilot departed VRB and climbed the airplane to a cruise altitude of 8,500 feet. After about 2.5 hours of flight, the pilot elected to land and obtain fuel at Pickens County Airport (JZP), Jasper, Georgia, after noting that the right tank fuel gauge indicated one-quarter full, and the left tank gauge indicated between one-third and one-half full. The pilot switched the fuel selector from the right tank to the left and initiated a descent by reducing engine power, extending the airplane’s wing flaps 10-15 degrees, and lowering the landing gear. The pilot circled the airplane over the airport until reaching traffic pattern altitude, and then maneuvered for landing on runway 16. The pilot stated that due to crosswind conditions at the airport, he had to “crab and slip the airplane” to maintain the proper final approach course. About one mile from the runway threshold, the engine experienced a total loss of power. The pilot was unsuccessful in his attempts to restart the engine, and subsequently conducted a forced landing to a road. During the landing, the airplane’s right wing contacted a fire hydrant, resulting in substantial damage. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the left fuel tank contained approximately 9 gallons of fuel, and the right tank contained approximately 14 gallons. The pilot held a private pilot certificate with a rating for airplane single-engine land. He reported 319 hours total flight experience, of which 24 hours were in the accident airplane make and model. His most recent flight review was conducted in September 2012 in the accident airplane. His most recent FAA third-class medical certificate was issued in April 2011. The airplane was manufactured in 1960, and registered to the pilot in October 2012. Its most recent annual inspection was conducted on January 2, 2012. The airplane was equipped with two 32.5-gallon fuel tanks, with one tank located in each wing. Each tank contained a usable fuel capacity of 27.5 gallons in all flight attitudes, but the usable capacity increased to 31 gallons pertank if the airplane maintained a level flight attitude. An examination of the engine was conducted in March, 2013. External inspection revealed no damage to the engine or its accessory components. The top and bottom spark plugs were removed, and exhibited normal wear. Borescope inspection of the cylinders revealed no anomalies. The crankshaft was rotated by hand, and valvetrain continuity was confirmed. The fuel lines were disconnected and checked for blockage, and no debris was found within the lines. An external fuel tank was connected to the fuel line leading to the fuel pump. The engine was started normally, accelerated smoothly, and operated for around 10 minutes throughout various power settings with no anomalies. In April 1965, Cessna Aircraft Company issued Service Letter 65-39, “Fuel System Placard and Owner’s Manual Sticker.” The letter advised operators that in low-fuel situations under certain flight attitudes, including prolonged sideslips or high rates of descent (1,000 feet per minute with flaps retracted, or 500 feet per minute with flaps extended), it was possible for a loss of fuel flow to occur due to the tank outlet port becoming uncovered. Cessna provided a placard to be installed on the instrument panel directly under the fuel quantity indicators that stated, “Avoid landing approaches in red arc and over 30 second slips under 1/2 tank (ref. owner’s manual).” Additionally, the manufacturer provided a sticker to be added to the owner’s manual emergency procedures section, outlining actions to be taken should a loss of power occur in such flight attitudes. In August 1966, the FAA issued Airworthiness Directive 66-19-02 requiring the installation of the placard on the instrument panel. Postaccident examination of the airplane revealed that the placard was not installed on the instrument panel, but the owner’s manual did contain the required sticker.

Aircraft

Registration
N9633T
Reported as
Cessna 210
Category
Airplane
Serial number
57433
Airframe hours
2,578
Engine
Continental Motors IO-470-E, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
William E Bowling
Registered owner
William E Bowling
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 2, 2012
Departed
VRB · Vero Beach, FL
Destination
SRB · Sparta, TN
Airport
JZP · Pickens County

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
58
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
September 15, 2012
Seat
Left
Flight hours
319 total · 24 in this make and model · 273 as pilot in command

Weather

Conditions
Visual (VMC) · Dusk
Wind
100° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 41 °F
Altimeter
30.31 inHg
Observed at
CNI, 8 nm away

Docket · 6

The files NTSB released with the investigation on August 7, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.7 MB in all.

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 N9633T · 2

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