# NTSB ERA18LA103: Cessna T210, N5382A, Orlando, FL, March 13, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 13, 2018, 13:30 local (17:30 UTC) - Place: Orlando, FL - Coordinates: 28.289722, -81.436943 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.2897&lon=-81.4369&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Continental Motors, FAA - NTSB case key (mKey): 96869 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA103 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96869/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96869 - Page: https://openairdocs.org/ntsb/ERA18LA103 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2073456), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2073456), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Cessna T210N, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073456), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=2073456), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T210N, 14 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073456), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N5382A-2019-12-06), registration cancelled 2019-12-06, S/N 21063404, built 1979 (OpenAirDocs) - Reported make and model: CESSNA T210 (N) - Registry model: [Cessna T210N](https://openairdocs.org/model/cessna-t210n) (registry code 2073456) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21063404 - Year built: 1979 - Airframe hours: 10310 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: none; 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 ## 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 20180313002439A](https://openairdocs.org/incident/20180313002439A), Mar 13, 2018: Cessna T210N, Kissimmee, FL, Destroyed. While on take off from kism, at approximate 400 feet PIC reported lost of partial power, while trying to compensate fuel controls, lost total engine power. PIC… ## Docket (7 files) The files NTSB released with the investigation on May 25, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96869. 13.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 7.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9078981&FileExtension=pdf&FileName=Karl%20NTSB%20Report_Redacted-Rel.pdf - Pilot's statement (item 2, PDF, 1 page, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9102649&FileExtension=pdf&FileName=Karl%20Verschuren%20Accident%20Report_Redacted%201-Rel.pdf - Memorandum of record FAA (item 3, PDF, 1 page, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9079395&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20FAA%20examination%20summary%20%20LA103-Rel.pdf - Maintenance records (item 4, PDF, 12 pages, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9079254&FileExtension=pdf&FileName=N5382A%20Logbook%20page%20excerpts_Redacted-Rel.pdf - NTSB engine examination summary (item 5, PDF, 7 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12298350&FileExtension=pdf&FileName=A_103_Engine%20Report_Redacted-Rel.pdf - Photo array (item 6, PDF, 2 pages, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9088463&FileExtension=pdf&FileName=Photo%20Array%20LA103-Rel.pdf - Statement of party representatives to NTSB investigation (item 7, PDF, 14 pages, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9079008&FileExtension=pdf&FileName=Certification-of-Party-Representation-Form-and-Guidance%2018LA103%20RD-Rel.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.