# NTSB ERA19LA239: Cessna 210, N2362F, Chattanooga, TN, July 30, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 30, 2019, 16:00 local (20:00 UTC) - Place: Chattanooga, TN - Coordinates: 35.031665, -85.204719 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0317&lon=-85.2047&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - ADs cited in the narratives: [AD 76-14-07 R2](https://openairdocs.org/ad/76-14-07-R2) (OpenAirDocs) - NTSB case key (mKey): 99972 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA239 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99972/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99972 - Page: https://openairdocs.org/ntsb/ERA19LA239 ## Probable cause The improper maintenance of the airplane’s landing gear system, which resulted in a hydraulic fluid leak and insufficient pressure to extend and lock the landing gear during the accident flight. ## 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 210E, 1 case](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=2073416), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) - [Fluids: hydraulic fluid](https://openairdocs.org/ntsb-findings/01071015): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-findings/01071015/cases.md?model=2073416), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01071015/cases.md) - [Fluids: hydraulic fluid](https://openairdocs.org/ntsb-findings/01071015): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-findings/01071015/cases.md?model=2073416), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01071015/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2073416), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-events/330/sequence.md?model=2073416), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md) - [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=2073416), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=2073416), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna 210E, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073416), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis After takeoff on a cross-country flight, the pilot retracted the landing gear and noted that it would not remain in the up position. He placed the landing gear handle in the neutral position and continued the flight. Upon arrival at his destination, the pilot attempted to extend the landing gear, but the gear did not extend completely and lock even after he performed the landing gear malfunction procedures in the pilot operating handbook. Airport personnel observed that the nose gear was down, and the two main landing gear were partially extended; the airplane landed with the landing gear in that configuration. The airplane decelerated, veered to the right, impacted a taxiway sign, and slid to a stop in the grass, resulting in substantial damage to the right and left horizontal stabilizers. Postaccident examination of the hydraulic system revealed a low level of hydraulic fluid in its reservoir and evidence of hydraulic fluid seepage near both landing gear actuators and the emergency landing gear-extension handle. The landing gear was extended and retracted by hydraulic pressure; therefore, the low hydraulic fluid level likely prevented the system from developing adequate pressure for the electric pump and the manual gear handle to extend and lock the landing. The airframe manufacturer's service manual indicated that inspection and replenishment of the hydraulic reservoir should be performed every 25 hours and that all rubber parts in the landing gear system should be replaced every 5 years. A review of available maintenance records did not reveal that these recommended inspections and overhauls were performed. ## Factual narrative On July 30, 2019, at 1600 eastern daylight time, a Cessna 210E, N2362F, owned and operated by a private individual, sustained substantial damage while landing at Lovell Field Airport (CHA), Chattanooga, Tennessee. The private pilot and two passengers were 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 flight that originated from Destin Executive Airport (DTS), Destin, Florida, about 1120 central daylight time, and was destined for Mark Anton Airport (2A0), Dayton, Tennessee. According to the pilot, he performed a preflight inspection and did not note any anomalies with the airplane, nor did he notice any hydraulic leaks near the landing gear system. After takeoff from DTS, the landing gear would not lock into place on the first attempt to retract. The pilot cycled the landing gear with the same result. He placed the landing gear handle in the neutral position and continued the flight. The pilot reported that the enroute portion of the flight was uneventful. Upon arrival at 2A0, the pilot selected the landing gear handle in the "DOWN" position. The gear down-and-locked light did not illuminate, and visual inspection revealed that the landing gear was hanging under the airplane and was not locked. The pilot performed the landing gear malfunction procedures in the pilot operating handbook to no avail. He utilized the manual landing gear extension procedure; however, the landing gear would still not lock, and he observed hydraulic fluid on the floorboards near the passenger seat. Aerial observation of the landing gear by airport personnel indicated that the nose gear was extended, and the main gear was trailing and not fully extended. The pilot declared an emergency and diverted to CHA and landed on runway 20 with the nose gear down and locked and the two main landing gear partially extended. As the airplane decelerated it veered to the right, impacted a taxiway sign, and slid to a stop in the grass. Examination of the accident scene by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest upright on the right side of the runway resting on the right wingtip, fuselage, and nose wheel. Both main landing gear were collapsed. The right rear empennage was torn, and the right and left horizontal stabilizers were substantially damaged. The pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA first-class medical certificate was issued on June 7, 2017. According to pilot logbooks, the pilot had accrued 123.8 total flight hours at the time of the accident, of which 83.9 hours were in the same make and model as the accident airplane. The 1553 weather conditions at CHA included wind 150° at 8 knots, visibility 10 statute miles, light rain, few clouds at 2,000 ft, scattered clouds at 4,000 ft, broken cloud layers at 10,000 ftand 25,000 ft, temperature 23° C, dew point 18° C, and an altimeter setting of 30.05 inches of mercury. According to FAA records, the 4-seat, high-wing, retractable gear airplane, serial number 21058562, was manufactured in 1965. According to airplane maintenance records, the most recent annual inspection was completed on October 10, 2018, at a recorded airframe total time of 4,950.3 hours. The airplane was powered by a Continental IO-520-A, 285-hp engine. Engine maintenance records showed that at the time of the most recent annual inspection, the engine had accrued 2,996 total hours and 932.4 hours since overhaul. At the time of the accident, the engine had accrued 3,057 hours. Examination of the landing gear system by a mechanic and an FAA inspector at a maintenance facility revealed a low level of hydraulic fluid in the reservoir and evidence of hydraulic fluid seepage near both landing gear actuators and the emergency gear-extension handle. The left actuator was broken, and operation of the emergency gear handle did not feel "normal." A placard on the firewall stated, "Check fluid level every 25 hours;" however, the pilot stated that it had not been checked since the last annual inspection. According to the pilot, he purchased the airplane in 2017 after it had been sold at auction without its logbooks. The landing gear saddle was the subject of an Airworthiness Directive (AD), AD 76-14-07 R2. The AD required replacement of the landing gear saddle, and after 1,200 hours of service on the new part, annual dye penetration inspections. There were no records in the logbook to indicate that the AD had been complied with or that an annual inspection of the part had ever been performed. According to cockpit placards and the manufacturer's service manual, the hydraulic reservoir was to be inspected and replenished every 25 hours, the landing gear hydraulic system was to be checked for leaks and external damage to components or mounting structure every 100 hours, and all rubber parts in the landing gear system were to be replaced every 5 years. In addition, an overhaul of the landing gear system selector valve, emergency hand pump, and pressure switch was to take place every 5 years. Available maintenance records did not reveal that these recommended inspections and overhauls had been performed. ## Aircraft - Registration: [N2362F](https://openairdocs.org/deregistered/N2362F-2021-03-11), registration cancelled 2021-03-11, S/N 21058562 (OpenAirDocs) - Reported make and model: Cessna 210 (E) - Registry model: [Cessna 210E](https://openairdocs.org/model/cessna-210e) (registry code 2073416) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21058562 - Year built: 1965 - Airframe hours: 4950.3 - Engines: Continental IO 520-A 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 10, 2018, 80 hours before - Departed: DTS, Destin, FL - Destination: 2A0, Dayton, TN - Airport: CHA, Lovell Field Airport, runway 20, 7,400 × 150 ft, asphalt - Equipment: Stall warning system, Onboard weather, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: none; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review March 6, 2019; seat: left; restraint: lap only; flight hours: 123.8 total, 83.9 in this make and model, 57.5 as pilot in command, 40 in the last 90 days, 30 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 73 °F, dew point 64 °F - Altimeter: 30.04 inHg - Turbulence: Unknown - Observed at: CHA ## 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 20190730012929A](https://openairdocs.org/incident/20190730012929A), Jul 30, 2019: Cessna 210E, Chattanooga, TN, Substantial damage. On departure out of destin FL, pilot stated that the gear transit light stayed on when selecting the gear up. Pilot stated that he cycled the gear and left the… ## Other investigations on N2362F (1) 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. - [NTSB LAX69D0308](https://openairdocs.org/ntsb/LAX69D0308), Apr 4, 1969: Cessna 210 (N2362F), Yucca Valley, CA, substantial damage ## Docket (7 files) The files NTSB released with the investigation on October 7, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99972. 7.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 830 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476626&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statements (item 2, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476627&FileExtension=.PDF&FileName=Pilot%20Statements-Master.PDF - Pilot Logbook Excerpts (item 3, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476628&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Master.PDF - Service Manual Excerpts (item 4, .PDF, 604 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476629&FileExtension=.PDF&FileName=Service%20Manual%20Excerpts-Master.PDF - Maintenance Records (item 5, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476630&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Landing Gear Examination Notes (item 6, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476631&FileExtension=.PDF&FileName=Landing%20Gear%20Examination%20Notes-Master.PDF - Photos (item 7, .PDF, 7 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476633&FileExtension=.PDF&FileName=Photos-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. --- 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.