# NTSB LAX04LA328: Cessna 210B, N9757X, Flagstaff, AZ, September 22, 2004 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 22, 2004, 15:48 local (22:48 UTC) - Place: Flagstaff, AZ - Coordinates: 35.13861, -111.671112 - Nearby events: https://openairdocs.org/map.md?lat=35.1386&lon=-111.6711&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report January 31, 2006 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 60209 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04LA328 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60209/pdf - Page: https://openairdocs.org/ntsb/LAX04LA328 ## Probable cause the pilot's improper leaning procedures and delayed decision to abort the takeoff when it became obvious that the engine was not developing full power. A factor in the accident was the pilot's decision to use a runway with a quartering tailwind. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - roll/run - procedures/directives - not followed, pilot in command (cause) - weather condition - high density altitude - mixture - improper use of, pilot in command (cause) - Overrun, takeoff - aborted - wrong runway - selected, pilot in command (contributing factor) - weather condition - tailwind - aborted takeoff - delayed, pilot in command (cause) - On ground/water encounter with terrain/water, takeoff - aborted - terrain condition - drop-off/descending embankment ## Analysis The airplane went over an embankment at the departure end of the runway and nosed over after the pilot aborted the takeoff. The pilot elected to takeoff with a quartering tailwind on the 6,900-foot-long runway in spite of the tower controller offering the pilot the use of the opposite runway. Witnesses indicated that the airplane lifted off the ground with 2,000 feet of runway remaining. The engine sounded as if it was not producing full power and was heard to be surging or revving up and down. The pilot noted that after liftoff the airplane would not climb over 20-25 feet above the runway and he elected to abort the takeoff and touched down with approximately 500 feet of runway remaining. According to the pilot, he adjusted the mixture for peak engine revolutions per minute before takeoff. The fuel flow indicator has white radial markings denoting the best power fuel flow for different field elevations. The recommended procedure noted in the airplane's owner manual informs the pilot that he/she should utilize the fuel flow indicator and adjust the fuel flow to that which corresponds to the field elevation marked on the face of the dial. However, the owner's manual was not in the airplane, and the pilot was utilizing a checklist that did not have the information for a high performance takeoff. The airport elevation was 7,001 feet mean sea level. The density altitude was calculated as 8,461 feet. Post-accident examination of the engine revealed that its spark plugs were dark black in color, which is consistent to an excessively rich mixture setting. Following installation of a serviceable propeller, the engine was started and exercised through out it's normal power range with no anomalies noted. ## Factual narrative HISTORY OF FLIGHT On September 22, 2004, at 1548 mountain standard time, a Cessna 210B, N9757X, nosed over during an aborted takeoff from the Flagstaff Pulliam Airport, Flagstaff, Arizona. The commercial pilot was not injured, and his pilot-rated passenger sustained minor injuries. The airplane sustained substantial damage. The airplane was registered to a private individual, and the pilot operated it under the provisions of 14 CFR Part 91 as a personal flight. The cross-country flight was destined for the Phoenix Deer Valley Airport, Phoenix, Arizona, and was originating at the time of the accident. Visual meteorological conditions prevailed, and a flight plan had not filed for the flight. During a telephone interview conducted by the National Transportation Safety Board investigator, the pilot reported that he taxied the airplane to the departure runway (runway 21), conducted an engine run-up, leaned the mixture for "better performance," and applied full power for takeoff. The pilot reported that shortly after liftoff, the airplane "could barely get 25 feet above the runway." He increased the pitch attitude to obtain the best angle of climb speed of 64 miles per hour; however, the airplane would not climb. The pilot observed trees near the end of the 6,999-foot-runway and elected to abort the takeoff. The airplane landed with less than 1,000 feet of runway remaining, went off the end of the runway, down an embankment, and nosed over coming to rest inverted. According to the pilot's written statement, he performed a run-up at the end of the runway and "made sure the mixture was leaned out for peak performance to give maximum power." The pilot applied power with all the instruments providing "normal indications." The airplane accelerated down the runway; however, after rotating the airplane would not climb any higher than 20-25 feet above the runway. As the airplane neared the end of the runway, he aborted the takeoff, closed the throttle, and pitched "down towards the runway." The airplane touched down on the runway and continued off the end down a grassy hill. The Federal Aviation Administration (FAA) inspector, who responded to the accident site, obtained witness statements. One of the witnesses, who was a flight instructor operating an aircraft at the time of the event, reported that he was given a clearance to enter a "straight in final" behind two larger aircraft for runway 21. On a 3-mile final the flight instructor requested to land on runway 03 instead since the winds were out of the northeast at 10 knots. The flight instructor was given a clearance to enter a downwind leg for runway 03. While the instructor was approaching to land, the accident airplane held short of runway 21, and was given an option to takeoff from runway 03, which the accident pilot denied. In the interim, the flight instructor landed and observed the accident airplane takeoff from runway 21 with a tailwind. The instructor observed the airplane liftoff and stay in ground effect. He then diverted his attention to his airplane, and was later informed that the airplane wrecked off the end of runway 21. The instructor indicated that the accident pilot had a "long time to do a run-up for it was holding short for three arriving aircraft." Two additional witnesses, both airframe and powerplant mechanics, reported hearing the engine "surging" or "revving up and down." Both mechanics reported that the engine sounded as if it was not producing full power. One mechanic reported that the airplane did not become airborne until the 2,000-foot remaining runway marker. Both mechanics reported that once the airplane became airborne, it remained 20 feet above the ground. The airplane touched down "hard," left wing low, with approximately 500 feet of runway remaining. The airplane then disappeared over the embankment at the end of the runway. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with single engine land, multiengine land, and instrument airplane ratings. He also held a flight instructor certificate for the same ratings. He was issued a first-class medical certificate on November 17, 2003, with no limitations. Review of his pilot logbook revealed that he accumulated a total of 578.2 hours, of which approximately 7.6 hours were accumulated in the accident airplane. The pilot obtained his complex airplane endorsement on May 31, 2004, and his high performance airplane endorsement on June 11, 2004. According to the pilot, he obtained training in the accident airplane from the owner. The FAA inspector asked the pilot how he adjusted the power for maximum engine performance. The pilot responded by stating that he adjusted the mixture for peak engine revolutions per minute (rpm). The inspector asked if the pilot utilized any additional instruments for a power reference, and the pilot responded in the negative. AIRCRAFT INFORMATION The airplane (serial number 21058057) was equipped with a 260-horsepower Continental IO-470-S engine (serial number 102216-2-S) and a constant-speed, two-blade McCauley propeller. The airplane and engine underwent an annual inspection on September 03, 2003, at an airplane and engine total time of 3,356 hours. At the time of the annual inspection, the engine accumulated 1,252 hours total time since its last major overhaul. According to the airplane's owner manual, under the section titled, DESCRIPTION, the "fuel flow indicator used with the Continental fuel injection system is a fuel pressure gage calibrated to indicate the approximate gallons per hour of fuel being metered to the engine." The fuel flow indicator is marked with white radial lines near the high fuel flow area for takeoff and climb settings for full power at various altitudes. The "full power markings represent maximum performance mixtures for the altitudes shown, making it practical to lean the mixture on a high altitude takeoff and during full power climbs for maximum power and performance." In the section titled, OPERATING DETAILS, during a takeoff, "it is important to check full-throttle engine operation early in the takeoff run. Any signs of rough engine operation or sluggish engine acceleration is good cause for discontinuing the takeoff. For maximum engine power, the mixture should be adjusted during the initial takeoff roll to the fuel flow corresponding to the field elevation. The power increase is significant above 3,000 feet and this procedure always should be employed for field elevations greater than 5,000 feet above sea level." The owner's manual OPERATION LIMITATIONS section indicates that the fuel flow for a maximum performance takeoff at an altitude of 8,000 feet should be "15.8 gallons/hour (white radial)." The takeoff checklists provided in the owner's manual indicate that for a maximum performance takeoff, 20 degrees of flaps should be used, and the power should be set at full throttle with 2,625 rpm. The mixture should then be "leaned for field elevation." It should be noted that the owner's manual was not in the airplane. The airplane owner kept the original copy. The pilot informed the FAA inspector who responded to the accident site that he used a checklist located within the airplane to conduct his before takeoff checks. The checklist found in the airplane did not indicate how to set up the mixture, throttle, and propeller for maximum power on takeoff during high altitude operations. METEOROLOGICAL INFORMATION At 1556, the Flagstaff Pulliam Airport weather observation facility reported the wind from 080 degrees at 9 knots; visibility 10 statute miles; clear sky; temperature 16 degrees Celsius; dew point -01 degrees Celsius; and altimeter setting 30.23 inches of mercury. The Flagstaff Pulliam Airport elevation is 7,001 feet mean sea level (msl). The pilot stated that during takeoff the density altitude sign (located at run-up end of the runway) indicate ## Aircraft - Registration: [N9757X](https://openairdocs.org/deregistered/N9757X-2007-07-20), registration cancelled 2007-07-20, S/N 21058057, built 1962 (OpenAirDocs) - Reported make and model: Cessna 210B - Registry model: [Cessna 210B](https://openairdocs.org/model/cessna-210b) (registry code 2073410) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21058057 - Airframe hours: 3388.4 - Engines: Continental IO-470-S 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Brett M. Waisnor - Registered owner: Douglas Holmes - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 3, 2003, 32.4 hours before - Departed: FLG, Flagstaff, AZ - Destination: DVT, Phoenix, AZ - Airport: FLG, Flagstaff Pulliam Airport, runway 21, 6,999 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review November 1, 2003; seat: left; flight hours: 578 total, 8 in this make and model, 404 as pilot in command, 37 in the last 90 days, 10 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 34 °F - Altimeter: 30.22 inHg - Observed at: FLG ## 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 20040922029879A](https://openairdocs.org/incident/20040922029879A), Sep 22, 2004: Cessna 210B, Flagstaff, AZ, Substantial damage. (-23) The accident flight originated at flg after arriving from dvt. The aircraft was not refueled, however the pilot stated that he drained the sump and… 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.