ERA18LA103

NTSB accident investigation · Cessna T210 · Orlando, FL · March 13, 2018

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 13, 2018, 13:30 local (17:30 UTC)
Place
Orlando, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N5382ACessna T210
Defining event
Initial climb: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Continental Motors, FAA
FAA report
20180313002439A
Case key
96869

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The improper adjustment of the fuel pump by maintenance personnel, which resulted in an overly rich fuel/air mixture and a total loss of engine power.

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna T210N: 1 caseAll aircraft: 320 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · Maintenance personnelCessna T210N: 1 caseAll aircraft: 397 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Incorrect service/maintenanceCessna T210N: 5 casesAll aircraft: 1,695 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

On the morning of the accident, the pilot performed a 2-hour test flight with newly-installed camera equipment, during which the airplane performed normally. While taking off on the second flight of the day, the pilot felt that there was something wrong with the engine. There were no abnormal indications and the engine continued to produce power until the pilot leveled the airplane at cruise altitude; the engine then lost total power and the pilot subsequently conducted a forced landing onto a road, resulting in substantial damage to the wings. A test run of the engine revealed that the fuel pump was adjusted to an excessively rich fuel flow setting, which resulted in a loss of power when the throttle was increased past about 2,100 rpm. The fuel pump was readjusted and the engine performed nominally. When the fuel pump was reset to the as-received setting, the engine exhibited the same loss of power as during the first run. Bench testing of the throttle body and fuel pump revealed that both units failed to meet production standards. Review of the airplane's maintenance records indicated that a fuel system adjustment was performed almost 2 years before the accident. It is likely that the improper fuel pump setting resulted in an overly rich fuel/air mixture and the subsequent loss of engine power; however, the reason for the loss of engine power during the accident flight, and not during previous flights since the fuel pump was adjusted, could not be determined.

Factual narrative

On March 13, 2018, about 1330 eastern daylight time, a Cessna T210N, N5382A, was substantially damaged when it was involved in an accident near Orlando, Florida. The commercial pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and a coworker were conducting routine test flights with new camera equipment that had just been installed on the airplane. On the morning of the accident, the pilot performed a two-hour test flight with no issues. After starting the engine and waiting about 5 minutes to allow the camera system to boot up, the pilot taxied to the runway and was cleared for takeoff. As the airplane climbed, he felt there was something wrong with the engine, although it continued to produce power. He checked all the instruments and gauges and did not see any abnormalities. When the airplane reached cruise altitude, the pilot reduced power and the engine "quit." The pilot notified air traffic control of the engine failure and performed a forced landing on a road. Examination of the airplane by a Federal Aviation Administration inspector revealed that the empennage was separated from the fuselage. Both wings were buckled, and both wing assemblies were leaking fuel. The engine was removed and sent to the manufacturer for further examination and testing. After an examination, the engine was prepared and placed in an engine test cell. The engine ran normally up to about 2,100 rpm, then emitted black smoke from the exhaust and began to lose power when the throttle was increased, consistent with an overly rich fuel/air mixture. The fuel pump was leaned, and further test runs were completed with no anomalies. The unmetered pressure was at or slightly above the maximum pressure for full throttle. Upon completion of the standard run, the fuel pump was set back to the as-received setting and exhibited the same loss of power demonstrated during the first test. The throttle body and fuel pump were bench tested and both units failed to meet production standards. A review of the maintenance logbook entries revealed that on July 25, 2016, a fuel system adjustment was performed at a tachometer time of 9,854.4 hours. As of the last annual inspection on February 25, 2018, the engine had accumulated a total of 455.6 hours.

Aircraft

Registration
N5382A
Reported as
Cessna T210 (N)
Category
Airplane
Serial number
21063404
Built
1979
Airframe hours
10,310
Engine
Continental TSIO-520-R, 375 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 25, 2018
Departed
ISM · Orlando, FL
Destination
ISM · Orlando, FL
Airport
ISM · Kissimmee Gateway, runway 06, 5,001 × 100 ft, asphalt
Equipment
Stall warning system, Auto-pilot, ADS-B

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
25
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
330 total · 15 in this make and model · 225 as pilot in command · 35 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 32 °F
Altimeter
30.09 inHg
Observed at
ISM

Docket · 7

The files NTSB released with the investigation on May 25, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.9 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.