IAD01LA035

NTSB accident investigation · Cessna 210 · Newark, OH · March 1, 2001

Accident · No injuriesLimited investigationFinal report
Date
March 1, 2001, 12:55 local (17:55 UTC)
Place
Newark, OH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3738YCessna 210
Weather
Visual (VMC) · Day
Status
Completed · report May 13, 2003
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20010301038209A
Case key
51871

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

Improper maintenance, which resulted in the failure of the instrument panel shock mounts.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionDescent - normal
Flight control,elevator - obstructed
Flight/nav instruments - shifted
Maintenance - improperOther maintenance personnelCause
Hard landingLanding - flare/touchdown
Flare - not possible

Analysis

During a descent the pilot noted "extreme pressure" was required to pull back on the controls to level the airplane. The pilot was unable to maintain altitude and continued on a straight-in approach for the airport. During the landing flare, the pilot could not pull the control yoke "far enough to roundout," and the airplane landed hard on the nosewheel, and came to rest off the side of the runway. A flight control check after the accident revealed that the flight controls could only be deflected aft to the "level flight" position. The horizontal situational indicator (HSI) was then removed from the instrument panel, and the flight controls could be deflected to their full aft position. Examination of the control stop on the control column tube, revealed significant chaffing marks and black paint transfer on its upper surface. Examination of the rear casing of the HSI revealed similar chaffing marks and an indentation consistent with the shape of the control column stop, on the lower edge of the instrument. Additionally, five shock mounts were installed on the instrument panel, of which the lower right and lower center shock mounts were broken, and the upper left shock mount was not attached. Examination of the shock mounts revealed they were fractured through their elastomeric center sections on one end of the mount, and large gaping cracks were noted on the opposite end of the mounts. A large number of smaller circumferential cracks were also observed through the center section of the mounts. The maintenance logbooks revealed that the HSI was installed in the airplane on August 17,1994, by an avionics facility, to replace the original directional gyro (DG) instrument. According to the Cessna 210 Service Manual, "The service life of shock-mounted instruments is directly related to adequate shock-mounting of the panel. If removal of the shock-mounted panel is necessary, check mounts for deterioration and replace as necessary." Detailed examination of the shock mounts revealed they were the original shock mounts installed in the airplane in December 1963.

Factual narrative

On March 1, 2001, at 1255 eastern standard time, a Cessna 210, N3738Y, was substantially damaged during landing at the Newark-Heath Airport (VTA), Newark, Ohio. The certificated private pilot and passenger were not injured. Visual meteorological conditions prevailed for the personal flight which originated from the Ronald Reagan Washington National Airport (DCA), Washington, D.C., at 0930. No flight plan was filed for the flight conducted under 14 CFR Part 91.

In a written statement, the pilot stated:

"I departed DCA, VFR, at approximately 9:30 EST on March 1, 2001. I was cleared to 8,500 feet, eventually on course to KVTA. At 8,500 feet the air was smooth. I had VFR flight following until approximately 35 miles out of KVTA, I was told to squawk 1200, and change to the local frequency."

"I started to reduce power in anticipation of going to a lower altitude, and eventually to land. I descended to 6,500 feet and we were feeling some occasional turbulence. I continued to reduce my power to continue the descent. When I reached 4,500 feet, I started to level off. When I leveled off, the plane felt somewhat nose heavy, and it seemed to me that no matter what I would do, I could not make the plane climb. It was taking two hands to pull on the yoke to stop the descent. I turned the trim tab to full nose up, and that seemed to help relieve the control pressures a little bit, but it was still taking extreme pressure to try and stop the descent."

"I monitored the ASOS for VTA and found that the winds were from 250, at approximately 15 knots. With the controls not feeling exactly right, I decided to come straight in for runway 27, instead of flying a pattern. I called out my intentions for a straight in approach when I was approximately 7 miles out..."

"As we got closer to the runway, I was descending faster than normal due to the controls not feeling correct. As we approached trees on final it appeared that we would not clear them, so I added power to stop the descent and we leveled off above the treetops. Once we were beyond the trees, I reduced power in anticipation of landing. When we were above the runway, and it was time to flare, I could not get the yoke to come back far enough to roundout. We hit the runway very hard on the nose wheel, porpoised back into the air approximately 30 feet, at that point, I tried applying power to make the next impact less, but the plane did not respond, it came back down, bounced again, we bounced one more time on the grass between the runway and taxiway, at which point the nose wheel broke off, and we skidded across the taxiway until we stopped on the grass at the other side, nose down."

The airplane was examined by a Federal Aviation Administration (FAA) inspector. A flight control continuity check performed by the inspector revealed that the control column could only be deflected aft to the "level flight" position.

The inspector removed the horizontal situational indicator (HSI) from the instrument panel, and was then able to deflect the flight controls to their full aft position. Examination of the control stop on the control column tube, revealed significant chaffing marks and black paint transfer on its upper surface. Examination of the rear casing of the HSI revealed similar chaffing marks and an indentation consistent with the shape of the control column stop, on the lower edge of the instrument. Additionally, the inspector reported that five shock mounts were installed on the instrument panel, of which the lower right and lower center shock mounts were broken, and the upper left shock mount was not attached.

The lower right and lower center shock mounts were examined at the Safety Board Materials Laboratory, on August 31, 2001. According to the Materials Laboratory factual report, each mount consisted of an elastomeric center section bonded to a stub plate with an attached threaded rod. Both mounts were fractured through their elastomeric center sections in a crescent-shaped region. The crescent region on both mounts intersected the exterior surface of the elastomeric section on multiple planes adjacent to the stub plate and progressed into the elastomeric section at an angle of about 80 degrees. Additionally noted on both mounts was a large gaping crack located on the end of the mount opposite from the fracture. Detailed examination also revealed the presence of a large number of smaller circumferential cracks located throughout the center section.

Examination of the maintenance logbooks revealed that the HSI was installed in the airplane on August 17, 1994, by an avionics facility, to replace the original directional gyro (DG) instrument. The HSI was installed about 3/4-inch above the control column, and was measured to be 9-inches long.

The distance between the HSI and the control column measured after the accident was about 1/2-inch.

According to the Cessna Model 210 Service Manual, "The service life of shock-mounted instruments is directly related to adequate shock-mounting of the panel. If removal of the shock-mounted panel is necessary, check mounts for deterioration and replace as necessary."

Detailed examination of the shock mounts revealed they were the original shock mounts installed in the airplane in December, 1963.

The pilot reported 736 hours of total flight experience, 250 of which were in make and model.

Aircraft

Registration
N3738Y
Reported as
Cessna 210
Category
Airplane
Serial number
21058238
Airframe hours
3,304
Engine
Continental IO-520, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Julianne Hartlaub
Registered owner
Lighthouse Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 2, 2001 · 12 hours before
Departed
DCA · Washington, DC
Destination
VTA · Newark, OH
Airport
VTA · Newark Heath Airport, runway 27, 4,648 × 75 ft, asphalt

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
42
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
September 25, 2000
Seat
Left
Flight hours
736 total · 250 in this make and model · 639 as pilot in command · 14 in the last 90 days · 9 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 17 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 19 °F
Altimeter
29.93 inHg
Observed at
VTA

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N3738Y · 1

Matched to the same aircraft by N-number and date.