# NTSB LAX90FA145: Cessna T207, N91081, Grand Canyon, AZ, April 13, 1990

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Field investigation · Final report
- Date: April 13, 1990, 14:58 local (21:58 UTC)
- Place: Grand Canyon, AZ
- Coordinates: 36.029575, -112.020545 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.0296&lon=-112.0205&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 7 serious
- Status: Completed, report April 13, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26625
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX90FA145
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26625/pdf
- Page: https://openairdocs.org/ntsb/LAX90FA145

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - nonmechanical, go-around (vfr)
  - exhaust system,turbocharger - incorrect (cause)
  - maintenance,adjustment - improper (cause)
  - throttle/power control - improper use of, pilot in command (cause)
  - inadequate training, company/operator management (contributing factor)
  - lack of familiarity with aircraft, pilot in command (contributing factor)
- Forced landing, descent - emergency
- In flight collision with object, landing
  - terrain condition - none suitable (contributing factor)
  - 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](https://openairdocs.org/deregistered/N91081-1990-07-11), registration cancelled 1990-07-11, S/N 20700062 (OpenAirDocs)
- Reported make and model: CESSNA T207
- Registry model: [Cessna T207](https://openairdocs.org/model/cessna-t207) (registry code 2073612) (OpenAirDocs)
- Category: Airplane
- Serial number: 20700062
- Airframe hours: 5325
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 24; 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 (OpenAirDocs).

- [Accident 19900413008809A](https://openairdocs.org/incident/19900413008809A), Apr 13, 1990: Cessna T207, Grand Canyon, AZ, Destroyed. Engine backfired on go around in gusty wind. Untrained pilot lost control. Struck trees. Fuel control maladjusted.

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.

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