# NTSB ERA13LA398: Cessna 210J, N210WS, Fort Myers, FL, September 5, 2013

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: September 5, 2013, 11:30 local (15:30 UTC)
- Place: Fort Myers, FL
- Coordinates: 26.586389, -81.863052 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=26.5864&lon=-81.8631&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report August 14, 2014
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 87982
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA398
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87982/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87982
- Page: https://openairdocs.org/ntsb/ERA13LA398

## Probable cause

The failure of the landing gear hydraulic power pack system to provide sufficient pressure to lock the main landing gear in the down position. Contributing to the accident was the improper maintenance and inspection of the landing gear system, the pilot’s continued operation of the airplane with a known mechanical problem with the landing gear system, and the pilot’s failure to visually verify that the landing gear were down.

## Findings

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

- [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 210J, 2 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=2073439), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md)
- [Landing gear system: main landing gear](https://openairdocs.org/ntsb-findings/01023210): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 210J, 2 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md?model=2073439), [All aircraft, 241 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md)
- [Landing gear system: main landing gear](https://openairdocs.org/ntsb-findings/01023210): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Cessna 210J, 2 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md?model=2073439), [All aircraft, 241 cases](https://openairdocs.org/ntsb-findings/01023210/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Cessna 210J, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073439), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 210J, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073439), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 210J, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073439), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094) (defining event); cases with it: [Cessna 210J, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=2073439), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md)
- [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 210J, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot stated that the airplane had been experiencing landing gear problems before the most recent annual inspection in April 2013 but that he thought that the landing gear problems had stopped after that inspection and maintenance. During departure, the landing gear failed to retract, and the amber light indicating that the landing gear fully retracted did not illuminate. After the pilot cycled the landing gear, the landing gear retracted, the amber light illuminated, and he continued the flight. The pilot stated that, as he neared his destination, he placed the landing gear handle in the "down" position and felt the "clunk" associated with the landing gear locking into place. He added that he quickly checked his wing mirror and confirmed that the landing gear were down before landing and that the green landing gear down-and-locked light "appeared" to be illuminated on the landing gear console. (The wing mirror can only show the position of the nose landing gear.) The airplane subsequently landed without the main landing gear down-and-locked, slid down the runway, and departed its left side. The left main landing gear hydraulic down lock was not in the locked position. A witness, who was also a mechanic, stated that, when the airplane arrived at the airport, he saw the main landing gear trailing aft during landing but that the nose landing gear were down-and-locked. He asked the pilot if he had looked out his left window to visually inspect the left main landing gear and verify that it was down. The pilot replied that he did not think of that and that no one had ever showed him that. Examinations determined that the hydraulic power pack that operates the functions of the landing gear was past its useful life and needed to be overhauled. The O-rings within the apparatus were malfunctioning and not providing the pressure needed to lock the main landing gear in the down position. If the pilot had looked out the window to visually verify the position of the main landing gear, he likely would have noticed that it was not in the correct position, and he could have accomplished emergency checklists that might have allowed the main landing gear to lock in the down position.

## Factual narrative

On September 5, 2013, about 1130 eastern daylight time, a Cessna 210J, N210WS, owned and operated by a private individual, was substantially damaged during landing at Page Field Airport, (FMY) Fort Myers, Florida. The private pilot was not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight that departed Opa-Locka Executive Airport (OPF) Miami, Florida about 1100. The pilot stated that after takeoff from OPF, the landing gear would not lock into place on the first attempt to retract, the amber light did not illuminate on the landing gear console, and that he had to recycle the landing gear handle to get the landing gear to retract and lock. The pilot stated that the remainder of the flight was "uneventful" to FMY. While on final approach for runway 5 at FMY, the pilot configured the airplane for landing with a "notch" of flaps and by placing the landing gear handle in the "DOWN" position. He stated that he felt the associated "clunk" of the landing gear locking into place, set the elevator trim for landing, and adjusted for a right crosswind. For further confirmation, the pilot stated that he looked out the window and at the mirror mounted on the right wing and confirmed that the landing gear were down. The pilot also stated that the green landing gear "LOCKED" light "appeared" to be illuminated. The pilot stated that upon touchdown at FMY, the plane "took flight again." As this transpired, the pilot leveled his attitude and "held steady." The stall warning horn sounded, the tail lowered and the airplane "took flight again." The airplane then settled to the tarmac and exited the left side of the runway. A witness to the accident stated that he observed the airplane during landing, and that the main landing gear was trailing aft upon landing. He added that the nose landing gear was down and locked and that the airplane was "being cushioned by the partially extended main landing gear tires". He watched the airplane slide down the runway until it exited into the dirt. The witness asked the pilot if he looked out his left window to visually inspect the left main landing gear and the pilot stated that no one had ever showed him that. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the right wing, aileron, horizontal stabilizer; and elevator. The left main landing gear hydraulic down lock was not in the locked position. The pilot, age 41, held a private pilot certificate with a rating for single-engine land that was issued on August 31, 2004. According to pilot logbooks, the pilot had accrued 772 total flight hours of which 301 hours were in the same make and model as the accident airplane. FAA records indicate that the pilot's third-class medical was issued on April 3, 2013, with no restrictions. The 1142 recorded weather observationat FMY included wind 120 degrees at 7 knots, visibility 10 statute miles, few clouds at 1,900 feet mean sea level, temperature 28 degrees C, dew point 26 degrees C, and an altimeter setting of 30.08 inches of mercury. The 6 seat, high-wing, retractable gear airplane, serial number 21059135, was manufactured in 1969. According to airplane maintenance records, the most recent annual inspection was completed on April 1, 2013 at a recorded airframe total time of 6066.4 hours. At the time of the accident, the airplane hour meter read 6,081 hours. The airplane was powered by a Continental IO-520-F, 290-hp engine. Engine maintenance records showed that the engine had accrued 3,583 total hours, 1,249 hours since overhaul, and 11 hours since its most recent recorded inspection. The engine was equipped with a McCauley, model number E-01, three-bladed, controllable pitch propeller. Propeller maintenance logs showed that the last annual inspection was completed on April 1, 2013 at that time had 546.7 hours total time in service since new. According to maintenance records, during the airplane's most recent annual inspection, hydraulic fluid was added, a hydraulic filter, and a hydraulic hose fitting was replaced. A landing gear inspection with normal and emergency extension operations was also completed by the maintenance facility, in Orlando, Florida. According to a written statement by the pilot, the airplane was experiencing landing gear problems prior to the most recent annual inspection in April 2013, and perceived that the landing gear problems had ceased after that inspection and maintenance. Further examination of the landing gear system by an FAA inspector at a maintenance facility revealed that the hydraulic level was normal but needed about one pint to completely service the fluid quantity. The down locks and main landing gear linkages were void of any lubrication, would not move freely, and covered with rust. The maintenance facility stated that the landing gear would only fully extend and lock two or three times out of 10 attempts, and the green down and locked light would illuminate with the gear unlocked. The mechanic's list of discrepancies is located in the public docket.

## Aircraft

- Registration: [N210WS](https://openairdocs.org/aircraft/N210WS), registered now, S/N 21059135, built 1969 (OpenAirDocs)
- Reported make and model: CESSNA 210J
- Registry model: [Cessna 210J](https://openairdocs.org/model/cessna-210j) (registry code 2073439) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 21059135
- Year built: 1969
- Airframe hours: 6081
- Engines: CONT MOTOR IO 520 SERIES 290 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Olin David G
- Registered owner: Olin David G
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 15, 2013
- Departed: OPF, Opa Locka, FL
- Destination: FMY, Fort Myers, FL
- Airport: FMY, Page Field Airport, runway 05, 6,406 × 150 ft, asphalt
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 41; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review October 11, 2012; seat: left; restraint: lap only; flight hours: 772 total, 301 in this make and model, 732 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 120° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 82 °F, dew point 79 °F
- Altimeter: 30.07 inHg
- Observed at: FMY

## 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 20130905019339A](https://openairdocs.org/incident/20130905019339A), Sep 5, 2013: Cessna 210J, Fort Myers, FL, Substantial damage. On September 5, 2013, at 1135 EDT a Cessna 210J, N210WS, [privacy data omitted], was cleared to land on runway 5 at Page Field (fmy) Fort Myers Florida.…

## Docket (11 files)

The files NTSB released with the investigation on March 14, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87982. 4.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409574&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Mr. Marler Interview. (item 2, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40402971&FileExtension=.PDF&FileName=Mr.%20Marler%20Interview.-Master.PDF
- Mr. Switlik Interview. (item 3, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409564&FileExtension=.PDF&FileName=Mr.%20Switlik%20Interview.-Master.PDF
- FAA Damage Assessment. (item 4, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401442&FileExtension=.PDF&FileName=FAA%20Damage%20Assessment.-Redacted.PDF
- Exceprts from Maintenance Logs. (item 5, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409570&FileExtension=.PDF&FileName=Exceprts%20from%20Maintenance%20Logs.-Redacted.PDF
- Mr. Switlik Inspection and Statement. (item 6, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401445&FileExtension=.PDF&FileName=Mr.%20Switlik%20Inspection%20and%20Statement.-Redacted.PDF
- Photo 1: Damage to the right elevator. (Courtesy of the FAA) (item 7, .PDF, 728 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401444&FileExtension=.PDF&FileName=Photo%201%3A%20Damage%20to%20the%20right%20elevator.%20(Courtesy%20of%20the%20FAA)-Master.PDF
- Photo 2: Picture of damage to the left elevator. (Courtesy of the FAA) (item 8, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401446&FileExtension=.PDF&FileName=Photo%202%3A%20Picture%20of%20damage%20to%20the%20left%20elevator.%20(Courtesy%20of%20the%20FAA)-Master.PDF
- Photo 3: Airplane at rest. Courtesy of the FAA. (item 9, .PDF, 899 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409573&FileExtension=.PDF&FileName=Photo%203%3A%20Airplane%20at%20rest.%20Courtesy%20of%20the%20FAA.-Master.PDF
- Photo 4: Left Main Gear Tab and Switch. Courtesy of the FAA. (item 10, .PDF, 623 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409575&FileExtension=.PDF&FileName=Photo%204%3A%20Left%20Main%20Gear%20Tab%20and%20Switch.%20Courtesy%20of%20the%20FAA.-Master.PDF
- Photo 5: Right Main Gear Tab and Switch. Courtesy of the FAA. (item 11, .PDF, 679 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40409576&FileExtension=.PDF&FileName=Photo%205%3A%20Right%20Main%20Gear%20Tab%20and%20Switch.%20Courtesy%20of%20the%20FAA.-Master.PDF

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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