# NTSB ERA22LA317: Cessna T210F, N6195R, Monticello, NY, July 15, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 15, 2022, 12:45 local (16:45 UTC) - Place: Monticello, NY - Coordinates: 41.637113, -74.670615 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.6371&lon=-74.6706&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 105495 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA317 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105495/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105495 - Page: https://openairdocs.org/ntsb/ERA22LA317 ## Probable cause Maintenance personnel’s improper torque of the engine through-bolts during maintenance, which resulted in a bearing shift, oil starvation, and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2073422), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=2073422), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna T210F, 3 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073422), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna T210F, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073422), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=2073422), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna T210F, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073422), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Cessna T210F, 1 case](https://openairdocs.org/ntsb-events/170/sequence.md?model=2073422), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## Analysis The pilot was descending toward the destination airport when the engine began losing power and “making noises.” The pilot switched fuel tanks, but the power loss continued. He subsequently began looking for a place to land the airplane. The pilot then heard what sounded like an “explosion” from the engine. The oil service door blew open and began spewing oil and smoke from the service door opening, covering the windscreen. Smoke then began entering the cabin. The pilot landed on a road with the landing gear retracted, and the airplane slid to a stop. The airplane caught on fire, and the pilot egressed before the cockpit was consumed. Postaccident examination of the engine revealed that the Nos. 5 and 6 connecting rods were fractured. The No. 5 connecting rod was missing and the No. 6 connecting rod exhibited thermal discoloration consistent with a loss of lubrication. The crankshaft and camshaft were fractured at the No. 5 cylinder. Review of the engine logbook revealed that about 100 flight hours (5 months) before the accident flight, engine through-bolt nuts were removed and resealed for oil leaks. Given this information, it is likely that maintenance personnel did not properly torque the crankcase through-bolts, which allowed the No. 5 main bearing to shift, resulting in loss of lubrication to that area and subsequent engine failure. ## Factual narrative On July 15, 2022, at 1245 eastern daylight time, a Cessna T210F, N6195R, was destroyed when it was involved in an accident near Monticello, New York. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he conducted an uneventful flight earlier during the day from Maine to Sussex County Airport (FWN), Sussex, New Jersey, to fly a potential buyer in the airplane, which he was selling. After the short flight, the pilot dropped off the potential buyer at FWN and planned to fly to Sullivan County International Airport (MSV), Monticello, New York, for fuel before returning home to Maine. Upon beginning a descent into MSV, the engine began losing power and “making noises.” The pilot verified the fuel quantity and mixture setting, and estimated that 10 gallons of fuel remained in each tank. He switched fuel tanks, but the power loss continued. He subsequently began looking for a place to land the airplane. The pilot then heard what sounded like an “explosion” from the engine. The oil service door blew open and began spewing oil and smoke from the service door opening, covering the windscreen. Smoke then began entering the cabin. The pilot reported extending the wing flaps and landing gear, but did not have time to verify extension. He identified a field as an emergency landing location. As the airplane approached the field, about 200 ft above the ground, the pilot saw high voltage power lines crossing the field and he repositioned the airplane for a landing on a road. After landing, the airplane caught on fire, and the pilot egressed before the cockpit was consumed. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed that the landing gear did not extend, and that the engine had a large section of the crankcase missing from the forward left side. The No. 6 connecting rod was laying on top of the engine and the crankshaft and camshaft were fractured. Further examination revealed that the engine was thermally damaged. The spark plug wires were burnt. The oil filter was thermally damaged. When it was cut open, metal shavings were noted in the filter element. The fuel pump was thermally damaged; however, the shear shaft was unremarkable. The oil pump was impact damaged and could not be rotated. The turbocharger was thermally damaged but rotated freely. Both magnetos were thermally damaged and would not produce spark on any leads. The oil pan was melted away and missing. The crankshaft and camshaft were fractured at the No. 5 cylinder. The propeller, oil cooler, front section of the camshaft and crankshaft were fractured off the engine. The spark plugs exhibited normal wear. The cylinder skirts on cylinder Nos. 5 and 6 were damaged by the corresponding connecting rod failures and the cylinders could not be removed. The connecting rod for cylinder No. 5 was missing. The No. 6 connecting rod was thermally damaged and discolored.The fuel flow divider was thermally damaged, and the diaphragm was melted. The propeller was thermally damaged, and one blade tip was melted away. Review of the airplane’s maintenance logbooks revealed that 105 and 106 flight hours before the accident (about 5 months), engine through-bolt nuts were removed and resealed due to oil leaks. ## Aircraft - Registration: [N6195R](https://openairdocs.org/deregistered/N6195R-2023-04-16), registration cancelled 2023-04-16, S/N T210-0095, built 1966 (OpenAirDocs) - Reported make and model: CESSNA T210F - Registry model: [Cessna T210F](https://openairdocs.org/model/cessna-t210f) (registry code 2073422) (OpenAirDocs) - Registry engine: [Continental GTSIO-520-C](https://openairdocs.org/engine/continental-gtsio-520-c) (registry code 17035, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: T210-0095 - Year built: 1966 - Airframe hours: 4730.3 - Engines: Continental TSIO-520-C 285 hp reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Simmons Mark K Trustee - Registered owner: Simmons Mark K Trustee - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 28, 2022 - Departed: FWN, Sussex, NJ - Destination: MSV, Monticello, NY - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; medical: basicmed, with waivers/limitations; last flight review February 15, 2022; seat: left; restraint: lap only; flight hours: 15,000 total, 230 in this make and model, 12,000 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Temperature: 79 °F, dew point 52 °F - Altimeter: 30.20 inHg - Observed at: KMSV, 7 nm away - METAR: KMSV 151656Z AUTO VRB03KT 10SM FEW065 26/11 A3020 RMK AO2 SLP221 T02610106 PNO $ ## 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 20220715012279A](https://openairdocs.org/incident/20220715012279A), Jul 15, 2022: Cessna T210F, Thompson, NY, Destroyed. Approximately 12 minutes after takeoff from sussex county NJ airport aircraft N6915R a Cessna 210-T crash landed with landing gear retracted, on county rt 42… ## Other investigations on N6195R (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 FTW70D0212](https://openairdocs.org/ntsb/FTW70D0212), Sep 3, 1969: Cessna T210 (N6195R), Dalhart, TX, substantial damage ## Docket (6 files) The files NTSB released with the investigation on January 4, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105495. 23.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14652509&FileExtension=pdf&FileName=6120_1_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14651843&FileExtension=pdf&FileName=Record%20of%20Interview-pilot-Rel.pdf - Maintenance records (excerpts) (item 3, PDF, 6 pages, 14.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14705771&FileExtension=pdf&FileName=Maintenance%20Records_Redacted-Rel.pdf - Investigative photos (item 4, PDF, 7 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14656190&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 5, PDF, 1 page, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14656397&FileExtension=pdf&FileName=wreckage%20release_Redacted-Rel.pdf - Engine examination summary (item 6, PDF, 2 pages, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16486172&FileExtension=pdf&FileName=Engine%20examination%20report-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.