ERA18LA111

NTSB accident investigation · Cessna 210 · Shelburne, VT · March 16, 2018

Accident · No injuriesLimited investigationFinal report
Date
March 16, 2018, 14:45 local (18:45 UTC)
Place
Shelburne, VT
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N761DVCessna 210
Defining event
Maneuvering: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report May 29, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20180316002799A
Case key
96906

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 inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation.

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 210M: 1 caseAll aircraft: 1,391 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna 210M: 1 caseAll aircraft: 1,695 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationCessna 210M: 1 caseAll aircraft: 176 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 stated that he did not visually check either fuel tank before takeoff because he had observed the airplane being fueled the day before; he assumed that the tanks were full (44.5 gallons of usable fuel per tank, 89 gallons total) and that he would have sufficient fuel (6.5 hours) for his estimated 5-hour aerial survey flight. He departed with the fuel selector positioned to the left tank; his normal routine was to switch fuel tanks every hour for the first 4 hours of flight. About 3 hours into the flight, the engine lost total power. The pilot switched the fuel selector to the right tank and attempted to restart the engine to no avail; he made a forced landing to a snow-covered field, which resulted in substantial damage to the fuselage, an engine mount, and the firewall. Postaccident examination revealed that the left- and right-wing fuel tanks were undamaged, that both fuel caps were secure, and that there was no evidence of leaks. The left tank was empty, and 33 gallons of fuel were drained from the right tank. Visual examination of the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot indicated that his typical routine was to switch fuel tanks every hour, given the amount of fuel remaining in the right tank, it is likely that the pilot did not adequately manage the fuel supply during flight, which resulted in the total loss of engine power due to fuel starvation.

Factual narrative

On March 16, 2018, about 1445 eastern daylight time, a Cessna 210M, N761DV, sustained substantial damage during a forced landing after a total loss of engine power near Shelburne, Vermont. The commercial pilot was not injured. The airplane was registered to and operated by GV Air, Medford, Oregon, as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at the Burlington International Airport (BTV), Burlington, Vermont, about 1140.The pilot stated that he conducted a preflight inspection of the airplane but did not visually check either fuel tank because he had observed the airplane being fueled the day before and he assumed the tanks were full (44.5 gallons usable per tank, 89 gallons total). The pilot said that the airplane burned about 13.5 gallons per hour and had a total fuel endurance of 6.5-hours, which was sufficient for his planned aerial survey flight of 5-hours. The pilot said he departed on the left tank and his normal routine was to switch fuel tanks every hour for the first 4 hours of flight. At 1435, almost 3 hours into the flight, with the fuel selector on the left tank, the engine abruptly stopped producing power. The pilot pushed the mixture control full forward and turned the fuel pump on. He then switched the fuel selector to the right tank and attempted to re-start the engine, but was unsuccessful , and he made a forced landing on a snow-covered field. The airplane came to rest upright and the nose wheel had separated, which resulted in substantial damage to the fuselage, an engine mount, and the firewall. The outboard section of the right wing was also damaged. Postaccident examination of the airplane revealed the left and right-wing fuel tanks were undamaged and both fuel caps were secure. The left-wing fuel tank was empty, and about 33 gallons of fuel were drained from the right tank. Further examination of the fuel system revealed no evidence of leaks and there was no staining on the airplane or area surrounding the airplane. Visual examination of the engine revealed no mechanical deficiencies. The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. He reported a total of 521 hours of flight experience, of which, 65 hours were in the same make and model as the accident airplane. His last Federal Aviation Administration (FAA) second-class medical certificate was issued on November 18, 2017. Weather reported at BTV at 1454 was wind from 290° at 11 knots, visibility 10 miles, scattered clouds at 3,600 ft, overcast clouds at 7,000 ft, temperature -3° C, dewpoint -12° C, and a barometric pressure setting of 29.69 inches Hg.

Aircraft

Registration
N761DV
Reported as
Cessna 210 (M)
Category
Airplane
Serial number
21062182
Built
1977
Airframe hours
10,030.7
Engine
Cont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · August 1, 2017
Departed
BTV · Burlington, VT
Destination
BTV · Burlington, VT
Equipment
ADS-B, Stall warning system

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
24
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 18, 2017
Seat
Left
Restraint
3-point
Flight hours
521.4 total · 65 in this make and model · 450 as pilot in command · 131 in the last 90 days · 60 in the last 30 days · 4.4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 11 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft overcast
Temperature
27 °F, dew point 10 °F
Altimeter
29.69 inHg
Observed at
BTV, 9 nm away

Docket · 6

The files NTSB released with the investigation on December 11, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 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.