# NTSB LAX08LA064: Cessna 210, N7337E, Willcox, AZ, February 23, 2008 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: February 23, 2008, 15:40 local (22:40 UTC) - Place: Willcox, AZ - Coordinates: 32.245277, -109.894447 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.2453&lon=-109.8944&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report January 22, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 67571 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08LA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67571/pdf - Page: https://openairdocs.org/ntsb/LAX08LA064 ## Probable cause A loss of engine power while on final approach due to multiple grounding faults in the ignition system as a result of poor ignition system maintenance. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ignition system](https://openairdocs.org/ntsb-findings/01057400): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/01057400/cases.md?model=2073402), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057400/cases.md) - [Ignition system](https://openairdocs.org/ntsb-findings/01057400): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/01057400/cases.md?model=2073402), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057400/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Other (probable cause); cases with it: [Cessna 210, 2 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=2073402), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Ignition system](https://openairdocs.org/ntsb-findings/01057400): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Cessna 210, 1 case](https://openairdocs.org/ntsb-findings/01057400/cases.md?model=2073402), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057400/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Cessna 210, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2073402), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 210, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073402), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The student pilot and passenger departed on the cross-country flight with both wing fuel tanks about 3/4 full. During the pilot's first attempt to land, the airplane was too high and he decided to perform a go-around. On his second attempt, the airplane was configured on final approach with the flaps fully extended and the landing gear down. As the airplane was approaching the runway at an altitude of 400 feet above ground level (agl), the engine experienced a loss of power. The airplane touched down short of the runway and the right wing collided with a small tree during the landing roll. An engine examination revealed that the spark plugs were heavily sooted, indicative of a rich mixture. Mechanical continuity was verified with rotation of the crankshaft. The ignition harnesses and the P-leads exhibited excessively worn insulation and shielding. Following an unsuccessful attempt to run the engine, both P-leads were found to be broken at a pass through hole in the engine baffling. The broken P-leads were spliced together and a second attempt to start the engine was made; the engine started and ran roughly at low power settings, smoothing out at higher ranges, though still notably rough. A magneto check revealed that the left magneto was not functioning. Troubleshooting the wiring revealed that only intermittent continuity could be established in the wiring between the ignition switch and the magnetos, resulting in intermittent grounding. ## Factual narrative HISTORY OF FLIGHT On February 23, 2008, about 1540 mountain standard time, a Cessna 210, N7337E, experienced a loss of engine power and collided with terrain while on final approach to runway 03 at Cochise County Airport, Willcox, Arizona. The pilot/owner, who held a student pilot certificate, was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The pilot was not injured and the passenger sustained minor injuries; the airplane sustained substantial damage. The personal cross-country flight departed from Ryan Field, Tucson, Arizona, about 1500, and was destined for Willcox. Visual meteorological conditions prevailed, and a flight plan had not been filed. During an interview with a National Transportation Safety Board investigator, the pilot stated that he was on a solo flight from Tucson to Willcox, where he planned to land. He recalled departing around 1500 with both wing fuel tanks about ¾ full, which he verified with a calibrated fuel stick gage. During his first attempt to land, the airplane was too high and he decided to perform a go-around. On his second attempt, the airplane was configured on final approach with the flaps fully extended and the landing gear down. As the airplane was approaching runway 03, at an altitude of 400 feet above ground level (agl), the engine experienced a loss of power. The pilot further stated that he attempted to troubleshoot the failure by turning the fuel boost pump to the "high" position and then he retracted the wing flaps to 10 degrees. He focused his attention to landing the airplane, as he realized that it was likely he would not make it to the runway surface. The airplane touched down short of the runway and the right wing collided with a small tree during the landing roll. The airplane came to rest adjacent to the airport perimeter fence. The pilot added that the fuel selector was positioned on the right tank. A Safety Board investigator spoke to a witness, who was a pilot, and was at his hangar located on the northeast end of the airport at the time of the accident. He recalled that he heard an airplane approaching the airport and watched it as it flew over the airport at an altitude well above the traffic pattern altitude. The airplane then continued to the southwest and made several maneuvers consistent with the pilot being confused about which runway to land on. The airplane then became aligned with the downwind leg for runway 03 and continued for an extended leg. He observed it turn onto base and then onto final approach. Around 50 feet agl, the airplane stalled and collided with the terrain. The witness recalled immediately driving to the wreckage and observing the pilot walking toward him. The witness noted that he did not smell or see fuel at the accident sight. The airport manager submitted a written statement reporting that the airplane came to rest about 0.25 to 0.5 miles from the runway. Following the accident he looked inside the wing fuel tanks and did not observe any fuel, but noticed the vent on the right wing had a small amount of liquid dripping from it; by the time he got a bucket to capture the liquid, it had quit dripping. He believed that the fuel tanks remained intact. Immediately following the accident, the pilot reported to a Safety Board investigator that there was a passenger on the flight. Later that day he stated that he did not have a passenger on the flight and was confused from the accident impact during the first conversation. He reported that following the accident, he called his cousin who resides in Willcox. His cousin was the first person on sight and sustained an injury getting to the wreckage by cutting himself on a fence. The witness from the airport stated that when he arrived at the accident site he saw the passenger still seated in the airplane with a laceration on his right arm. He transported the injured passenger to the airport's facilities and noted that he was very "shaken up" from the accident. The passenger indicated that the flight had originated from New Mexico. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed the pilot held a student pilot certificate. A Certified Flight Instructor (CFI) signed his initial cross-country solo endorsement for a Cessna 210 on February 18, 2008. The pilot held a third-class medical certificate that was issued on October 26, 2007, with no limitations. The Federal Aviation Administration inspector provided copies of the pilot's flight logbook. A review of the those copies revealed that he had about 68 hours total time, with 13 hours accrued in the accident airplane, and the remainder accrued in Cessna 172 and 150 models. The logbook spanned from September 2006 to the date of the accident, and indicated that the pilot had amassed about 15 hours in the capacity of pilot-in-command. AIRCRAFT INFORMATION The airplane data plate identified it as a Cessna 210, serial number 57037. The engine data plate identified it as a Teledyne Continental IO-470E, serial number 88502-0-E-R. The logbooks were not made available to Safety Board investigators. TESTS AND RESEARCH A Safety Board investigator examined the wreckage on March 27, 2008, at Air Transport, Phoenix, Arizona, accompanied by representatives from Teledyne Continental Motors (TCM) and the FAA. The wreckage had been recovered and placed into storage prior to the examination. The wings had been removed from the fuselage to facilitate transport from the accident site and for storage. The main aluminum fuel feed line located in the crushed area of the lower firewall was cracked, consistent with impact forces of the accident. When investigators introduced fuel into the airframe fuel system, fuel leaked at a significant rate from the crack. The fuel system within both wings was examined. Both fuel tanks, and the associated lines and fittings to the wing root connectors, were intact. Investigators plugged the lines and filled the tanks with water; no leaks were observed. The fuselage fuel lines, selector valve, and fittings were examined and were found to be intact up to the firewall. In preparation for an engine test run, straps and steel cables were used to reinforce the security of the bent and distorted engine mount. A temporary fuel tank was attached to the airframe fuel system at the left wing root fitting. The damaged propeller was removed and a serviceable McCauley 2A34C 201 propeller installed on the crankshaft flange. The top spark plugs were removed revealing that the plugs in cylinders number 1 and 2 exhibited a light gray coloration; the number 3 plug was sooted. The plugs for cylinders 4 and 5 were also sooted; the plug for cylinder number 6 was sooted, with an excessively worn and oval-shaped center electrode. All the cylinders were internally examined via the utilization of a lighted borescope. The intake and exhaust valves were intact. No foreign objects were observed. The pistons and cylinder head domes were normal in appearance. The combustion deposits were a white cream color. The crankshaft was then rotated, with mechanical continuity observed in the corresponding rotation of the accessory section, movement of the pistons, and the equal action of the valves. Most engine wiring was worn and frayed, with cracked and missing insulation apparent in some areas. The ignition harnesses and the P-leads had worn insulation and shielding. The first start attempt was unsuccessful, and the engine would not turn over. Detailed examination of the P-leads found that they were both broken at a pass through hole in the engine baffling. Using a magnifier, the ends of the broken strands exhibited a necked down appearance. The shielding and insulation in the immediate area of the break was worn through in some spots. The broken P-leads were spliced together and a second attempt to start the engine was made. The engine started an ## Aircraft - Registration: [N7337E](https://openairdocs.org/deregistered/N7337E-2013-02-21), registration cancelled 2013-02-21, S/N 57037, built 1959 (OpenAirDocs) - Reported make and model: CESSNA 210 - Registry model: [Cessna 210](https://openairdocs.org/model/cessna-210) (registry code 2073402) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 57037 - Engines: CONT MOTOR IO-470E 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: P33, Tucson, AZ - Destination: P33, Willcox, AZ - Airport: P33, Cochise County Airport, runway 03, 6,095 × 75 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; student; medical: class 3; seat: left; flight hours: 68 total, 13 in this make and model, 15 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 13 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: none - Altimeter: 30.04 inHg - Observed at: KSAD, 39 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 (OpenAirDocs). - [Accident 20080223012199A](https://openairdocs.org/incident/20080223012199A), Feb 23, 2008: Cessna 210, Willcox, AZ, Substantial damage. (-23) According to the student pilot, he was on a cross country flight from ryan airport, tucson, AZ, to Willcox, AZ. The student pilot stated he deviated from… 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.