SEA07FA061

NTSB accident investigation · Cessna T210R · Rexburg, ID · February 8, 2007

Accident · FatalField investigationFinal report
Date
February 8, 2007, 15:44 local (22:44 UTC)
Place
Rexburg, ID
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N6390UCessna T210R
Weather
Visual (VMC) · Day
Status
Completed · report November 29, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration, Teledyne Continental Motors, Cessna Aircraft Company
FAA report
20070208001289A
Case key
65273

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The loss of engine power due to the contamination of the fuel manifold valve, and the pilot's continued operation of the airplane with known maintenance discrepancies.

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) - nonmechanicalTakeoff - initial climb
Operation with known deficiencies in equipment - continuedPilot in commandCause
Fuel system,fuel flow divider/distributor - blocked(partial)Cause
On ground/water collision with objectEmergency landing after takeoff
Object - vehicle
Object - other

Analysis

The airplane collided with the ground and obstacles following a loss of engine power during takeoff. Witnesses reported the engine losing power during takeoff and the airplane entered a sharp right bank. The airplane then collided with obstacles and terrain. Post accident examination of the engine showed that debris coated the inlet side of the fuel manifold valve which is separated from the outlet side by a screen. When fuel enters the manifold valve, it comes through the screen, and eventually out to the fuel injector nozzles. Due to the amount of debris on the inlet side of the manifold valve, injector fuel pressure could not be obtained above 213 psi (specifications were for 250 psi). With the fuel pump pressure at 83 psi (specifications were for 32.5 psi), at RPMs above 1,500, the fuel pressure may have been excessive, dependent upon the distribution of the debris within the valve. An aviation maintenance technician and a family member reported that the pilot had been experiencing engine trouble during takeoff, similar to the circumstances surrounding the accident, and to correct the problem he would adjust the mixture setting. This adjustment was most likely due to the excessive fuel pressure at the pump, set as a result of the low fuel pressures due to the contaminated manifold valve. As the system pressure increased, the debris generally limited the fuel flow pressure. However, because the debris could move within the valve, the pilot most likely experienced erratic fuel flow pressures. There was no maintenance entry for the adjustment of the fuel pump, nor was any maintenance of the manifold valve noted. Both of these components were remanufactured during the engine overhaul approximately 6.5 years prior to the accident.

Factual narrative

1.1 History of the Flight

On February 8, 2007, at 1544 mountain standard time, a Cessna T210R, N6390U, collided with terrain and farm equipment during the takeoff-initial climb from runway 17 at Rexburg-Madison County Airport, Rexburg, Idaho. The pilot, who was also the registered owner of the airplane, was operating it under the provisions of 14 CFR Part 91. The private pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. Visual meteorological conditions prevailed and an instrument flight plan was filed. The flight was originating at the time and destined for Lincoln Regional Airport/ Karl Harder Field, Lincoln, California.

According to a family member of the pilot, the pilot traveled to Rexburg every 2 to 3 weeks to visit family members and oversee his private businesses in the area. He rented a hangar at Rexburg.

One witness reported seeing the airplane depart normally, and then he heard a "popping" sound and saw a trail of black smoke. The engine then lost power and the airplane began turning to the right. It appeared to the witness that the pilot was attempting to turn back to the runway. The airplane then dove down to the right, with the right wing impacting the ground. Flames quickly consumed the airplane.

Another witness, who was standing outside, stated that the airplane had just departed. He heard a pop noise from the airplane and then saw black smoke. The airplane began to lose airspeed and it turned to the right. The airplane then dove down to the right and the right wing impacted the ground first.

A witness was standing outside of his house and noticed the airplane because it appeared lower than normal. As he looked up, he noted smoke emitting from the airplane. The witness then stated that he "…heard the pilot shut off the engine and he was gliding into the wind." A few moments later he heard the airplane impact farm equipment machinery and saw smoke immediately.

1.2 Personnel Information

1.2.1 Pilot Information

The pilot held a private pilot certificate and was certified to fly in instrument conditions. His last medical was issued on December 5, 2006, and it was a third class. It held the limitation that the pilot must wear corrective lenses. The pilot reported 1,258 flight hours on his last medical application. The pilot's logbook was obtained from his family. It showed that the last entry was dated February 2, 2007. The pilot had accrued approximately 1,333 hours total flight time with 938 hours in the accident airplane. He logged about 60 hours over the 90 days preceding the accident.

1.3 Aircraft Information

1.3.1 General Aircraft History

The Cessna T210R was manufactured in 1986. The airplane had been involved in an accident on June 7, 1988, in Tampa, Florida. During a forced landing following a loss of engine power, the airplane impacted the top of an office trailer and guy wire before coming to rest on a roadway. A FAA Form 337 was filed on November 1, 1990, that showed repairs to the fuselage, wings, horizontal stabilizer, and elevators. According to Federal Aviation Administration aircraft registration records, the airplane was sold to the accident pilot on April 3, 2003.

The airplane was powered by a Teledyne Continental Motors TSIO-520-CE engine that was equipped with a McCauley D3A34C 410B three-bladed propeller. The engine was overhauled on July 29, 1999.

Following the pilot's purchase of the airplane in 2003, the annual inspections were completed by a local aviation maintenance technician (AMT) with inspection authorization, who lived near the pilot's California residence. The California AMT was interviewed regarding the maintenance that he performed on the airplane. The last annual inspection was completed in April of 2006. The California AMT had completed two other annual inspections on the airplane. Other than the annual inspections, the California AMT did not perform any maintenance on the airplane.

On April 30, 2004, the cylinders were replaced with cylinder kit 655470A4 at Lincoln Skyways, Lincoln, California, at a total tachometer time of 2,193.8 hours. According to the engine manufacturer, this was an incorrect installation for the TSIO-520-CE engine. The difference between this cylinder kit and the correct cylinder kit were the intake inserts and the machining on the cylinder heads. The intake inserts were tapered on the ordered kit. According to the engine manufacturer's representative, the tapered cylinders would allow for an increase in horsepower.

The last annual inspection was completed on April 18, 2006, at a total airframe time of 2,699.2 hours. During the last annual inspection, the California AMT noted in the engine logbook that cylinders 3, 2, 4, and 6 were at the minimum allowable compression and would be sent in for rework.

The California AMT noted that he had heard that the cylinders were replaced later in 2006. In the logbook endorsements, the California AMT noted that the fuel screens were cleaned. The California AMT stated that he pulled the fuel control valve/throttle body screen and the airframe fuel system screen located at the lowest point in the fuel system. Based on his recollection, he said that he did not find any major contamination in the screens.

On an aircraft owner's group website forum, the pilot expressed frustration regarding the maintenance that had been performed on the airplane's engine. In October of 2006, he noted that the incorrect cylinders had been installed on the engine (approximately 600 hours prior in April, 2004).

On November 12, 2006, at an airframe total time of time of 2,824.5, the cylinders were replaced with the correct cylinders by a maintenance facility in Rexburg.

The pilot requested that the Rexburg AMT change the airplane's engine cylinders due to oil consumption and low compression. The pilot left the airplane with the AMT for 5 days while he completed the work. During this time, the Rexburg AMT noted that the linkage for the fuel injection system was badly worn and loose, and that it needed to be repaired and calibrated. The pilot told the Rexburg AMT that he was aware of the problem and would look into it at a later date.

According to the Rexburg AMT, the pilot had experienced two other power loss events at Rexburg within the past 18 months. The first event occurred when the pilot departed and was in the initial climb out phase of his departure. During the initial climb, the airplane began trailing smoke and descending like it had lost engine power. At some point, power was restored and the pilot continued to California. When the pilot returned to Rexburg several weeks later, the Rexburg AMT asked him about the power interruption. The pilot told him that if he did not warm up the engine enough, or lean the mixture for takeoff, the engine would lose power because the mixture was too rich.

The Rexburg AMT further stated that in September of 2006, the pilot was taking several people, including a family member, for an airplane ride. The temperature was near freezing. During the takeoff roll, near the airplane's rotation point, the engine lost power. The engine then regained power and then it lost power again. At this point, the pilot was more than half way down the runway so he aborted the takeoff. He taxied back to runway 17 and departed normally.

The Rexburg AMT completed various routine maintenance items on the airplane. About two weeks prior to the accident, he changed the right vacuum pump and again advised the pilot about the worn fuel injection linkages. The pilot told him that the problem would be addressed at a later time.

A family member of the pilot was interviewed by the NTSB investigator. He reported that the engine had lost power on several occasions in the past, just following takeoff. The first time it happened was during takeoff, right after the landing gear lifted from the runway. The f

Aircraft

Registration
N6390U
Reported as
Cessna T210R
Category
Airplane
Serial number
21064950
Airframe hours
2,699.2
Engine
Teledyne Continental TSIO-520-CE, 325 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2006 · 170 hours before
Departed
RXE · Rexburg, ID
Destination
LHM · Lincoln, CA
Flight plan
IFR
Airport
RXE · Rexburg-Madison Cty Airport, runway 17, 4,200 × 75 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
52
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
1,333 total · 938 in this make and model · 1,207 as pilot in command · 60 in the last 90 days · 15 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 34 °F
Altimeter
30.04 inHg
Observed at
RXE, 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 N6390U · 1

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