LAX05FA026

NTSB accident investigation · Cessna T210M · Lomita, CA · November 5, 2004

Accident · FatalField investigationFinal report
Date
November 4, 2004, 17:34 local (Nov 5, 2004, 01:34 UTC)
Place
Lomita, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N732RWCessna T210M
Weather
Visual (VMC) · Night
Status
Completed · report February 28, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Teledyne Continental, Federal Aviation Administration
FAA report
20041104029929A
Case key
60508

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

A loss of engine power due to fuel starvation as a result of the pilot's mismanagement and inadequate preflight inspection.

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.

Loss of engine power(total) - nonmechanicalApproach - vfr pattern - final approach
Aircraft preflight - inadequatePilot in commandCause
Fluid,fuel - starvationCause
Fuel management - inadequatePilot in commandCause
Light condition - night
Forced landingDescent - emergency
In flight collision with objectEmergency descent/landing
Object - utility pole
Object - residence

Analysis

The engine lost power at night while the pilot was on short final for the runway during a 12-minute positioning flight between nearby airports, and the airplane collided with a house. Witnesses reported that the engine sound was quiet prior to impact with trees, power lines, and a house. The airplane came to rest inverted in the backyard of a residence. The total flight time since the last refueling of 40 gallons was 2.1 hours tachometer time. The owner estimated that when the 40 gallons were added, the fuel tanks would have been near empty. Fuel calculations based on charts in the Cessna Pilot's Operating Handbook indicated that approximately 30 gallons would have been used during the 2.1 hours. At the accident site, the intact right fuel tank contained about 8 ounces of fuel. The left fuel tank was breached but approximately 1 gallon was drained from the tank when it was moved for recovery and a strong odor of fuel was present in the soil beneath the airplane's left wing. The fuel selector was positioned to the right fuel tank. Prior to the airplane's departure on the accident flight, the owner noted that the fuel gauges were reading about 1/4 tank. The fuel line from the fuel pump to the engine was removed and a residual amount of fuel drained out. No control or operational anomalies were noted with the airplane, and the engine was test-run successfully. Interviews with friends of the pilot revealed that the pilot was to reposition the airplane over the previous days leading up to the accident, and that the owner had expressed his disapproval that the repositioning had not been done yet. According to the pilot's friends, the pilot had flown a twin engine Cessna earlier in the day. That evening, the accident pilot was delayed while waiting for a ferry airplane and pilot to arrive, in order to fly him to pickup the accident airplane. The certified flight instructor (CFI) that flew the accident pilot to pickup the airplane reported that immediately after dropping the pilot at the airplane, he began his return trip. The accident airplane was two airplanes behind the CFI during landing. As the CFI was taxiing to parking, he saw a flash of fire in the direction of the accident site. Besides the accident airplane, two other airplanes were for sale at the owners facility; one of these airplanes was the same make and model of the accident airplane. About 2 weeks prior to the accident, the owner of the aircraft sales company and the accident pilot refueled these two airplanes; however, the accident airplane was not refueled.

Factual narrative

History of flight

On November 4, 2004, at 1734 Pacific standard time, a Cessna T210M, N732RW, collided with a series of obstacles in Lomita, California, during a forced landing following a loss of engine power. The airline transport pilot, the sole occupant, sustained serious injuries. The airplane was destroyed. The pilot was positioning the privately owned airplane under the provisions of 14 CFR Part 91. Night visual meteorological conditions prevailed and no flight plan was filed. The airplane departed John Wayne Airport/Orange County (SNA), Santa Ana, California, at 1722, and the pilot's destination was Zamperini Field (TOA), Torrance, California. The pilot succumbed to his injuries on November 16.

The airplane was for sale by Chuck Smith Aircraft Sales. According to a personal schedule contained on the pilot's personal computer, the pilot positioned the airplane from Montgomery Field (MYF), San Diego, California, on September 28. The flight time recorded was 0.8 flight hour. On October 31, the pilot positioned the airplane to John Wayne Airport to have the airplane's electrical system serviced. The flight time recorded was 0.6 flight hour.

A witness located in a nearby residence noticed a white flash. Shortly thereafter, he heard what he initially thought was the sound of thunder and saw a "massive ball of fire." He ran to the airplane and observed another resident attempting to extinguish the fire with a garden hose. The witness further stated that small puddles of fuel were burning around the airplane. With the assistance of others nearby, the witness pulled the pilot from the airplane.

An additional witness located in a residence near an open window heard a sound he associated with an airplane, but noted that the engine sound was quiet. He saw the airplane's lights disappear below a tree line, which was not normal. He then heard a "crunch" sound, followed by a series of impact sounds. A fireball approximately 50 feet tall and 30 feet in diameter then erupted.

Another witness stated that he was standing at his front door, when he saw sparks at the location of the utility lines, and then heard a series of loud impacts. A large fire shot into the air and he ran to the backyard from where the fire was emanating. Once he reached the backyard, he realized that an airplane had crashed. The day following the accident, the witness looked toward the area of the accident from his front porch, which faces south/southwest. He could see a large tree across the street from the residence and it had a noticeable portion of branches missing from its center. The tree was positioned on the eastern side of the utility lines.

Personnel information

Federal Aviation Administration (FAA) records indicated that the pilot held an airline transport pilot certificate for multiengine land airplane. The pilot held commercial privileges for airplane single-engine land and sea. He also held a flight instructor certificate for airplane single-engine and multi-engine, instrument. The pilot held a ground instructor certificate for advanced and instrument ground instruction. The pilot was type rated in the Cessna Citation (CE-500).

The pilot held a second-class medical issued on December 1, 2003. It had the restriction that the pilot must wear corrective lenses.

The pilot was employed as a positioning pilot and corporate pilot at Zamperini Field. He was well known at the airport and described by those who knew him as a high-time pilot with good flying skills.

No recent logbooks for the pilot were recovered. The pilot's acquaintances indicated that the pilot did not keep a logbook. Rather, he recorded his flights using a calendar. On the pilot's last insurance application obtained from a friend of the pilot, the pilot reported the following flight times: 13,000 hours total flight time; 4,000 total hours in multiengine aircraft; and, 4,000 total hours in retractable gear aircraft. The pilot flew 200 hours from October 2003, until September 2004. His last flight review was on October 6, 2004.

Interviews with friends of the pilot revealed that the pilot was to reposition the airplane over the previous days leading up to the accident, and that the owner had expressed his disapproval that the repositioning had not been done yet. According to the pilot's friends, the pilot had flown a twin-engine Cessna earlier in the day. That evening, the accident pilot was delayed while waiting for a ferry airplane and pilot to arrive, in order to fly him to pickup the accident airplane.

A certified flight instructor (CFI) flew with the pilot to John Wayne Airport. The CFI reported that the flight to John Wayne was uneventful. The CFI dropped the pilot off at the airplane and immediately made the return trip back to Torrance. During the return flight, the accident pilot was two airplanes behind the CFI. As the CFI was taxiing to parking, he saw a flash of fire in the direction of the accident site.

Aircraft information

The single engine Cessna T210M (Serial Number (SN) 21061723) was manufactured in 1977. A review of maintenance records for the airplane revealed that the last annual inspection was completed on September 21, 2004. The tachometer recording was 2,200.8 hours and the Hobbs hour meter recording was 1,578.5 hours.

The Teledyne Continental engine (SN 294605-R), model TSIO-520-R9, was rebuilt/zero timed on March 2, 2002, by Teledyne Continental Motors. The last annual inspection was completed on September 15, 2003. However, the recorded Hobbs hour meter and tachometer hours recording were the same as those recorded in the airframe logbook for the annual inspection completed on September 21, 2004.

The three-bladed McCauley propeller, model D3A34C402, hub series 769452, was overhauled on April 3, 2002.

On October 27, 2004, an adjustment was made to the idle mixture at a tachometer time of 2,202.2. The adjustment changed the idle setting to 575-625 revolutions per minute (rpm). Based on interviews with the aviation maintenance technician (AMT) that performed the work, the purpose of the adjustment was to correct a loss of engine power at the idle setting. Interviews with the AMT revealed that he did not have the proper manual available to perform the work.

The airplane was last fueled on September 28, 2004, at Montgomery Field, with the addition of 40 gallons of fuel. The quantity of fuel onboard prior to the refueling was estimated through dialogue and correspondence with the airplane's owner, and was estimated close to empty when the 40 gallons of fuel were added.

The owner of the airplane submitted logbook entries and a signed statement describing the recent history of the airplane. The owner departed from La Paz, Mexico, with full fuel tanks to Montgomery Field and made two landings in between. He then flew from Montgomery Field to Gillespie Field Airport, El Cajon, California, for an annual inspection. After the completion of the annual inspection, the owner flew the airplane back to Montgomery Field. The total tachometer time was 4.8 hours. At Montgomery Field, he added 40 gallons of fuel.

The accident pilot ferried the airplane to Torrance on September 28. The airplane was then flown to John Wayne Airport for electrical work. The day of the accident, the pilot was returning the airplane to Torrance to be sold. The total tachometer time accumulated was 2.1 hours since the 40 gallons of fuel were added.

Montgomery Field to Torrance (0.8)

Estimated fuel burn calculations using generalized performance data and environmental conditions from the manufacturer's Federal Aviation Administration (FAA) approved Pilot's Operating Handbook indicated that using a 4,000-foot pressure altitude, 2,500 rpm, and 30 inches of manifold pressure at standard temperature, the airplane would burn about 106 pounds per hour (17.67 gallons). According to the Time, Fuel, and Distance to Climb C

Aircraft

Registration
N732RW
Reported as
Cessna T210M
Category
Airplane
Serial number
21061723
Airframe hours
2,200.8
Engine
Teledyne Continental TSIO-520-R9, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Jerry Hoke
Registered owner
Sakakibara, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 21, 2004 · 2.3 hours before
Departed
SNA · Santa Ana, CA
Destination
TOA · Torrance, CA
Airport
TOA · Zamperini Field, runway 29R, 5,001 × 150 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
68
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
October 1, 2004
Seat
Left
Toxicology
Performed
Flight hours
13,000 total

Weather

Conditions
Visual (VMC) · Night
Wind
230° at 7 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 45 °F
Altimeter
29.95 inHg
Observed at
TOA, 1 nm away

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 N732RW · 1

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