NYC02FA068

NTSB accident investigation · Cessna T210N · Teterboro, NJ · March 9, 2002

Accident · FatalField investigationFinal report
Date
March 9, 2002, 13:58 local (18:58 UTC)
Place
Teterboro, NJ
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N2BSCessna T210N
Weather
Visual (VMC) · Day
Status
Completed · report October 23, 2002
Report
Approved by Office Director
Parties
Federal Aviation Administration - FSDO, Cessna Aircraft Company, Brackett Aero Filters, Inc., Continental Motors
FAA report
20020309004739A
Case key
54318

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 maintenance by other maintenance personnel, which resulted in the air filter element being sucked into and blocking the turbocharger inlet, and a subsequent power loss. Factors in the accident were the pilot's failure to maintain airspeed and the tail wind.

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(partial) - mech failure/malfTakeoff - initial climb
Induction air control,air filter/screen
Maintenance,installation - improperOther maintenance personnelCause
Induction air ducting - blocked(total)
Loss of control - in flightTakeoff - initial climb
Weather condition - tailwindFactor
Airspeed - not maintainedPilot in commandFactor
Stall/mush - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled

Analysis

Several witnesses observed the Cessna T210N on initial climb, and then heard a reduction of engine power. Some witnesses thought the nose had pitched up after the power reduction, and prior to the airplane turning left and descending. The airplane banked left, descended, and struck the ground on airport property. A post-crash fire started within seconds after the airplane came to rest and consumed the cabin of the airplane. Examination of the engine revealed that the air filter element was lodged into the turbocharger air intake, and adjacent ducting. The single screen on the air filter was found on the air intake side. Installation instructions specify that with a single screen, the screen should be on the engine side of the air filter element. The air filter element had been changed during an annual inspection, about 2 1/2 months, and 30 hours prior to the accident. The specified change interval for the filter element was 12 months, 200 hours, or when the filter element was 50 % covered by foreign material. The initial emergency procedure for loss of engine power after takeoff was to maintain an airspeed of 85 knots.

Factual narrative

History of flight

On March 9, 2002, at 1358 eastern standard time, a Cessna T210N, N2BS, was destroyed when it impacted terrain at Teterboro Airport (TEB), Teterboro, New Jersey. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed for the personal flight destined for Montauk Airport (MTP), Montauk, New York. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

According to transcripts from the Federal Aviation Administration (FAA) air traffic control communications with the pilot:

At 1344:23, the pilot radioed the flight data/clearance delivery controller and advised, "november two bravo sierra, a cessna two ten at millionaire v f r to the northeast with sierra." The flight data/clearance delivery controller instructed the pilot to set his transponder to code 0332, and to contact the local controller when ready to taxi. The pilot acknowledged the transmission.

At 1350:01, the pilot contacted the local controller and advised, "tower, two bravo sierra at millionaire, taxi take off." The local controller instructed the pilot to taxi to runway 6 at intersection GOLF. The pilot responded, "six golf great."

At 1351:48, the pilot advised the local controller that he was ready for departure. The local controller instructed the pilot to hold short of the runway. The pilot acknowledged the transmission.

At 1355:09, the local controller cleared a Grumman Gulfstream IV for takeoff on runway 24.

At 1356:12, the local controller instructed the pilot to "taxi into position and hold" on runway 6 at intersection GOLF. The pilot advised "holding."

At 1357:10, the local controller cleared the pilot for takeoff from runway 6 at intersection GOLF. The pilot advised he was "rolling". No further communications were received from the pilot.

At 1357:40, the local controller cleared N65776, a Cessna 172, for takeoff on runway 6. The pilot acknowledged the instructions.

At 1358:09, a transmission of unknown origin stated, "I got an airplane down here at the end of the runway."

The pilot of the Cessna 172 advised the tower that he was aborting takeoff and stated, "an airplane just went down." Tower personnel immediately notified airport operations.

Several witnesses observed the airplane climbing on departure, and then noticed a reduction in engine noise. Most of the witnesses reported that the airplane turned to the left and descended. However, some witnesses reported the airplane pitched up prior to descending.

A pilot-rated witness reported:

"...I was distracted by the sound of a departing aircraft on runway 6. Looking through my windshield, I saw a single engine Cessna (the sound clearly indicated to me it was a Cessna 210) the aircraft was climbing, and [the] landing gear was retracted. The aircraft had just cleared the runway and had climbed to about 400 feet when the engine appeared to stop. The aircraft pitched up, followed with several steep rolls to the right and left. The aircraft banked to the left and descended nose down, at about 30 feet the aircraft came out of the steep dive and impacted the ground...Smoke was coming from the engine compartment, followed by a small fire [after the airplane came to rest] . After about 10 seconds the fire overwhelmed the aircraft...."

Another witness saw the airplane climbing in a nose high attitude, with the wings level, and it appeared slow. The nose remained up as the airplane initiated an "abrupt" left turn. The wings wobbled in the turn. He said, "I thought the airplane was in a stall. It was turning, but not under control." In the turn, the airplane banked left and descended. When he last saw the airplane, it had completed about 3/4 of its turn from runway heading to its heading at ground impact. He did not see the ground impact. He said the winds were strong, and the flags stood straight out.

A third witness, reported that he saw the airplane climbing, traveling from south to north. It appeared to be climbing normally when it suddenly pitched up about 30 degrees, and the left wing dropped about 70 or 80 degrees. The airplane turned 90 degrees and descended quickly. It hit the ground hard, flat, and slid to a stop. About 50 seconds after the airplane came to a stop, the witness saw flames. The flames were small at first, near the rear of the airplane, but then spread to the rest of the airplane.

The fire was extinguished by the airport emergency personnel.

The accident occurred during the hours of daylight, at 40 degrees, 51 minutes, 35 seconds north latitude, 74 degrees, 03 minutes, and 20 seconds west longitude.

Personnel information

The pilot held a private pilot certificate with airplane single engine land, single engine sea, and instrument airplane ratings. On June 27, 2000, when the pilot last applied for an FAA airman medical certificate, he reported that his total flight experience was 3,885 hours. The pilot's logbook was recovered; however, the bottom of the pages, which contained total hours, was burned. In addition, the logbook had been exposed to water, and the column with dates was faded and not readable. Based upon airplane logbook records, and incomplete pilot logbook records, the pilot was estimated to have a total flight experience of about 4,065 hours, about 3,950 hours as pilot-in-command, about 500 hours in make and model, and about 30 hours in the preceding 90 days. The date of the pilot's last flight review was not determined.

Aircraft information

The airplane was a 1979 Cessna T210N. The last inspection and maintenance listed in the airplane logbook was an annual inspection, which was completed on December 21, 2001. The airplane was estimated to have been flown about 30 hours since the annual inspection.

According to records from the FAA, the airplane had received several modifications which included, but were not limited to: a Brackett air filter; an auxiliary fuel tank in the aft fuselage; extended wing tips which held fuel, the installation of upper wing surface speed brakes, stall fences on the top side of the wings, and leading edge wing cuffs.

Airport information

Teterboro airport had two runways: 6/24, and 1/19. The runways crossed near the north end of the airport. Runway 6 was 6,013 feet long and 150 feet wide. From the intersection of taxiway GOLF, on runway 6, there was about 4,500 feet of runway remaining.

Meteorological information

Information SIERRA reported winds from 150 degrees at 7 knots. However, at 1351, the winds were recorded as being from 170 degrees at 16 knots with gusts to 20 knots. A witness who was watching airplanes at the airport reported that the winds started to increase about 10 minutes prior to the accident.

Radar data

Radar data was received from the New York TRACON (Newark Antenna), and reviewed. No targets were found that matched the pilot's assigned beacon code of 0332.

Wreckage and impact information

The wreckage was located in a grassy area on airport property, adjacent to the north airport boundary fence. A debris trail progressed along a magnetic heading of 340 degrees, and extended 245 feet from the first observed ground contact, to the cockpit of the airplane. The airplane came to rest on a heading of 260 degrees magnetic. Items associated with inside the cabin and engine compartment were found along the debris trail. No burn area was visible along the debris trail leading to the airplane.

Fire damage was observed on the right wing, and fuselage cabin. The fire extended forward to the aft portion of the engine compartment, and aft beyond the aft baggage compartment. The right wing was destroyed by fire. The right wing tip, which was found along the debris trail, had no fire damage.

Flight control continuity was verified to the ailerons, elevators, and rudder. The wing flap jackscrew was extended 3.5 inches, which

Aircraft

Registration
N2BS
Reported as
Cessna T210N
Category
Airplane
Serial number
21063095
Airframe hours
4,335
Engine
Continental TSIO-520-R, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
William L. Sonn
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 21, 2001 · 30 hours before
Departed
TEB · Teterboro, NJ
Destination
MTP · Montauk, NY
Airport
TEB · Teterboro, runway 6, 6,013 × 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
56
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
4,065 total · 500 in this make and model · 3,950 as pilot in command · 30 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 16 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
66 °F, dew point 50 °F
Altimeter
30.25 inHg
Observed at
TEB

Docket · 32

The files NTSB released with the investigation on October 4, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.1 MB in all.

Witness StatementsItem 1 · .PDF · 96 KBSummaries of InterviewsItem 2 · .PDF · 325 KBFAA Inspector StatementsItem 3 · .PDF · 140 KBATC 3 - Factual Report of Group ChairmanItem 4 · .PDF · 20 KBATC 3 - Attachment 1Item 5 · .PDF · 1.6 MBATC 3 - Attachment 2Item 6 · .PDF · 372 KBATC 3 - Attachment 3Item 7 · .PDF · 473 KBATC 3 - Attachment 4Item 8 · .PDF · 3.3 MBATC 3 - Attachment 5Item 9 · .PDF · 566 KBATC 3 - Attachment 6Item 10 · .PDF · 465 KBATC 3 - Attachment 7Item 11 · .PDF · 1.7 MBWreckage DiagramItem 12 · .PDF · 55 KBAirport DiagramItem 13 · .PDF · 115 KBLast Annual Inspection - N2BSItem 14 · .PDF · 982 KBMechanic StatementItem 15 · .PDF · 45 KBFAA Form 337 for Installation of Brackett Air FilterItem 16 · .PDF · 275 KBBrackett Air Filters - Original DocumentationItem 17 · .PDF · 157 KBBracket Air Filters - Original DecalItem 18 · .PDF · 66 KBBrackett Air Filters - Revised DocumentationItem 19 · .PDF · 169 KBStatement of Party Representatives to NTSB InvestigationItem 20 · .PDF · 140 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 21 · .PDF · 53 KBToxicological ReportItem 22 · .PDF · 65 KBPhoto 1. Initial ground impact point, looking in direction of airplane travelItem 23 · .PDF · 1.1 MBPhoto 2. Right wing tip, airplane in backgroundItem 24 · .PDF · 1.1 MBPhoto 3. Overview of airplaneItem 25 · .PDF · 960 KBPhoto 4. Turbocharger inlet paritally opened, filter element visible in ductItem 26 · .PDF · 915 KBPhoto 5. Filter element in turbocharger inletItem 27 · .PDF · 825 KBPhoto 6. Filter element removed from turbocharger inletItem 28 · .PDF · 799 KBPhoto 7. Rear of air filter installed on engineItem 29 · .PDF · 822 KBPhoto 8. Air filter removed from engineItem 30 · .PDF · 737 KBPhoto 9. Side of air filter that was next to engine cowlingItem 31 · .PDF · 804 KBPhoto 10. Side of air filter that was next to engineItem 32 · .PDF · 813 KB

FAA reports on this event · 1

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