ERA16LA252

NTSB accident investigation · Cessna 310 · Bartow, FL · July 11, 2016

Accident · Minor injuriesLimited investigationFinal report
Date
July 11, 2016, 11:00 local (15:00 UTC)
Place
Bartow, FL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N100CPCessna 310
Defining event
Approach-VFR pattern downwind: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, FAA/FSDO, Continental Motors
FAA report
20160711011939A
Case key
93591

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 failure to move the fuel selectors to the “main” position in accordance with the Before Landing checklist, which resulted in fuel starvation and the total loss of power of both engines.

Findings · 3

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 · Fluid managementCessna 310Q: 3 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotCessna 310Q: 1 caseAll aircraft: 336 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 310Q: 3 casesAll aircraft: 1,391 casesProbable cause

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

The commercial pilot climbed the multiengine airplane to 13,500 ft mean sea level and performed a 2-hour aerial photography flight before descending and returning to the departure airport. As the pilot maneuvered the airplane in the traffic pattern for landing, the right engine lost power, and then the left engine lost power. The pilot concluded that the airplane would not reach the airport, so he chose swampy terrain for a forced landing, during which the wings, fuselage, and tail section sustained substantial damage. Postaccident examination of the airplane and its engines revealed no preimpact mechanical anomalies that would have prevented normal operation. Both fuel selector handles were found in the "auxiliary" position. According to the airplane manufacturer's owner's manual, the first step in the Before Landing checklist was to move each fuel selector to the "main" position. Further, the auxiliary fuel system description stated, "Since the auxiliary fuel tanks are designed for cruising flight, they are not equipped with pumps and operation near the ground (below 1,000 ft [above ground level]), using auxiliary fuel tanks is not recommended." The pilot's failure to move the fuel selectors to the "main" position in accordance with the Before Landing checklist likely led to fuel starvation to both engines and their subsequent loss of power.

Factual narrative

On July 11, 2016, about 1100 eastern daylight time, a Cessna 310Q, N100CP, was substantially damaged during a forced landing near Bartow, Florida. The commercial pilot sustained minor injuries. Visual meteorological conditions prevailed, and no flight plan had been filed for the local aerial photography flight that departed from Bartow Municipal Airport (BOW), Bartow, Florida, at 0845. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.According to the pilot, the preflight inspection of the airplane revealed no anomalies; the fuel tanks were full, and no water or contaminants were visible in the fuel samples taken. The engine run-up, takeoff, and climb to 13,500 feet mean sea level (msl) were "normal," and the cruise power setting was 27" of manifold pressure at 2,200 rpm for the flight. After 2 hours, the pilot descended for landing at BOW. The airplane entered the traffic pattern, and as the left turn onto the base leg of the traffic pattern was completed, the right engine lost power. The pilot confirmed there was "available fuel," turned toward the runway threshold, and "recognized" that the left engine was also no longer producing power. The pilot concluded that the airplane would not reach the airport, selected a forced landing area, and completed the forced landing to swampy terrain. A Federal Aviation Inspector (FAA) inspector noted that the airplane came to rest in knee-deep water about 1 mile northwest of the airport. The airplane came to rest upright and there was substantial damage to the wings, empennage, and tail section. The inspector further noted that neither propeller appeared to be feathered, the right engine propeller blades appeared to be bent aft, and the left engine propeller blades were straight. Both fuel selector valve handles were found in the Auxiliary position. Examination of the auxiliary fuel tanks revealed an odor of fuel, but each tank appeared empty. Due to the swampy terrain conditions, the airplane could not be further examined on site, and was moved to a secure storage facility. During recovery of the airplane, it was noted that the fuel tanks on the right side of the airplane were damaged and voided by impact. The main tip tank was separated from the left wing, and several gallons of fuel were drained from the auxiliary left wing and the left wing-locker tank. A Shadin Fuel Flow Indicator was recovered from the instrument panel and retained for examination. A detailed examination of the airplane revealed control continuity from the flight controls to the flight control surfaces, and from the engine controls to each engine. A detailed examination of each engine revealed there were no anomalies that would have prevented normal operation. According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land and instrument airplane. He was issued an FAA second-class medical certificate on July 1, 2016. Thepilot reported 5,107 total hours of flight experience, of which 219 hours were in the accident airplane make and model. The airplane's most recent annual inspection was completed February 1, 2016, at 6637.6 total aircraft hours. At 1315, the weather reported at BOW included few clouds at 2,500 feet and variable winds at 4 knots. The temperature was 31° C, dewpoint was 21° C, and the altimeter setting was 30.13 inches of mercury. Interpolation of performance charts in the manufacturer's owner's manual revealed that the fuel consumption rate for the airplane was an estimated 27 gallons per hour at the power settings reported by the pilot. The Shadin Fuel Flow Indicator was a digital fuel management system designed to provide fuel management information under real-time flight conditions to the flight crew. The unit was connected to engine fuel flow transducers. The unit was capable of transmitting fuel information to certain GPS receivers for additional calculations and display of fuel management data. The unit can display engine fuel flow, fuel used, fuel remaining, and endurance. The unit does not interface with an aircraft's fuel quantity indicating system. The unit required the flight crew to enter the initial fuel on board the airplane. All calculations and data provided by the unit were based on fuel flow. Between power cycles, the unit retained the last fuel used and fuel remaining. When examined in the NTSB Recorders Laboratory, the unit displayed 62.3 gallons used, and 115 gallons remaining, which was consistent with the duration and profile of the accident flight as reported by the pilot. According to the Cessna 310 Owner's Manual: BEFORE LANDING Fuel Selectors – Left Engine – Left Main (feel for detent) Right Engine – Right Main (feel for detent) AUXILIARY FUEL SYSTEM "Since the auxiliary fuel tanks are designed for cruising flight, they are not equipped with pumps and operation near the ground (below 1000 feet AGL) using auxiliary fuel tanks is not recommended."

Aircraft

Registration
N100CP
Reported as
Cessna 310 (Q)
Category
Airplane
Serial number
310Q0219
Built
1971
Airframe hours
6,637
Engines
Cont Motor IO-470 SERIES, 280 horsepower, reciprocatingCont Motor IO-470 SERIES, 280 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 1, 2016 · 121 hours before
Departed
BOW · Bartow, FL
Destination
BOW · Bartow, FL
Airport
BOW · Bartow Municipal, runway 09L, 5,000 × 150 ft, asphalt
Equipment
Unknown

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
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
5,107 total · 219 in this make and model · 13 in the last 90 days · 13 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 70 °F
Altimeter
30.12 inHg
Observed at
BOW, 1 nm away

Docket · 7

The files NTSB released with the investigation on September 27, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 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.