LAX90FA145

NTSB accident investigation · Cessna T207 · Grand Canyon, AZ · April 13, 1990

Accident · Serious injuriesField investigationFinal report
Date
April 13, 1990, 14:58 local (21:58 UTC)
Place
Grand Canyon, AZ
Injuries
7 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N91081Cessna T207
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 1992
Report
Approved by Office Director
FAA report
19900413008809A
Case key
26625

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 adjustment of the turbo-charger absolute pressure controller, and improper manipulation of the power plant controls by the pilot during the go-around. Factors related to the accident were: failure of company management to properly train the pilot in accordance with the approved company training program, and the pilot's lack of experience in turbo-charged engine operations.

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) - nonmechanicalGo-around (vfr)
Exhaust system,turbocharger - incorrectCause
Maintenance,adjustment - improperCause
Throttle/power control - improper use ofPilot in commandCause
Inadequate trainingCompany/operator managementFactor
Lack of familiarity with aircraftPilot in commandFactor
Forced landingDescent - emergency
In flight collision with objectLanding
Terrain condition - none suitableFactor
Object - tree(s)

Analysis

According to witnesses, the acft was about to touchdown from a normal apch to rwy 21, when it encountered varialble wind conds & ballooned to about 70' AGL. The plt initiated a go-around. Shortly thereafter, witnesses observed a puff of smoke emanate from the acft, then the plt transmitted that the flt was 'going down.' Subsequently, the acft collided with trees on wooded terrain about 1/2 mi from the dep end of the rwy. An exam revealed a lack of power signatures on the prop; evidence of sooting was found on the spark plugs (indicating a rich mixture). Testing of the turbo-controller revealed evidence that it had been adjusted to a low setting; the turbo would only produce a maximum air flow equal to high cruise power. The eng manufacturer rprtd that this situation could produce an over-rich mixture, particularily if the throttle and/or mixture controls were impropperly manipulated. The pilot lacked experience in acft with turbo-charged engs & he was not trained iaw the company training program.

Aircraft

Registration
N91081
Reported as
Cessna T207
Category
Airplane
Serial number
20700062
Airframe hours
5,325
Engine
Continental TSIO-520-HCG, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Part 135
Operator
Windrock Aviation
Registered owner
Charles B. Beagle
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · March 31, 1990 · 35 hours before
Departed
GCN
Destination
GCN
Flight plan
Company VFR
Airport
GCN · Grand Canyon, runway 21, 8,999 × 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
24
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
555 total · 9 in this make and model · 407 as pilot in command · 89 in the last 90 days · 43 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 11 knots
Visibility
50 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 28 °F
Altimeter
30.00 inHg
Observed at
GCN

FAA reports on this event · 1

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