# NTSB WPR09LA170: Cessna T210L, N2445S, Madera, CA, March 28, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 28, 2009, 13:30 local (20:30 UTC) - Place: Madera, CA - Coordinates: 36.997222, -120.116386 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.9972&lon=-120.1164&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Cessna Aircraft, Fresno FSDO, Continental Motors - NTSB case key (mKey): 73570 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA170 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73570/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73570 - Page: https://openairdocs.org/ntsb/WPR09LA170 ## Probable cause A total loss of engine power during the initial climb due to fuel exhaustion as a result of the pilot's failure to properly monitor the airplane's fuel quantity and to correctly ascertain the fuel on board the airplane prior to takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna T210L, 1 case](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=2073449), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna T210L, 13 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073449), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Inadequate inspection (probable cause); cases with it: [Cessna T210L, 2 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=2073449), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210L, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2073449), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna T210L, 2 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=2073449), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192); cases with it: [Cessna T210L, 3 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073449), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna T210L, 12 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073449), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna T210L, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073449), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T210L, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073449), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis While entering the traffic pattern at his home base after a return flight, the pilot switched to the airplane's left tank. As he continued in the pattern he asked his passenger if he would like to make a landing for currency also. When the passenger said yes, the pilot changed his planned full-stop landing to a touch-and-go. During the initial climb after the touch-and-go, the engine lost all power and the pilot executed a forced landing into a grape orchard where the vegetation was supported by closely spaced posts. The investigation confirmed that both fuel tanks were empty at the time of the forced landing. It was further determined that the fuel tank dip tube that the pilot used to determine fuel levels prior to a flight earlier that day was not specifically designed for, or calibrated to, this specific airplane model. The investigation also determined that the pilot did not check the fuel quantity of the left tank when he switched to it upon entering the pattern, and that he switched to that tank only because after a previous momentary fuel flow interruption from the right tank, the owner had made switching to the left tank in the pattern a standard procedure for this airplane regardless of the fuel quantities in each tank. ## Factual narrative On March 28, 2009, about 1330 Pacific daylight time, a Cessna T210L, N2445S, impacted the terrain during a forced landing about one mile north of Madera Municipal Airport, Madera, California. The private pilot and his passenger received serious injuries, and the airplane, which was owned by the passenger, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal pleasure flight, which departed Harris Ranch Airport, Coalinga, CA, about 40 minutes prior to the accident, was being operated in visual meteorological conditions. No flight plan had been filed. According to the pilot, when he entered the traffic pattern at Madera, where he planned to make a full-stop landing, he asked his passenger if he would also like to make one landing for currency. Since the passenger replied that he would like to make a landing, the pilot changed his planned full-stop landing to a touch-and-go. During the initial climb after the touch-and-go, the airplane's engine began to sputter, and about five seconds later it lost all power while it was about 500 feet above ground level (AGL). The pilot checked to make sure the magneto switch was in the BOTH position, but because of the low altitude and the descent of the airplane, he did not make a restart attempt. Instead he decided to focus on making a power-off forced landing. He therefore turned toward a nearby open area, left the gear fully retracted, and concentrated on making a successful touchdown. After the touchdown, the airplane slid across a road and entered a grape orchard where the vegetation was supported by closely spaced posts. When a Federal Aviation Administration (FAA) Inspector responded to the scene about two hours after the accident, he found no fuel in either of the airplanes wings. He then confirmed that the fuel caps were on tight, and checked for any evidence of in-flight or on-ground fuel leakage, of which there was none. During the investigation, it was revealed that when the local fire department used a hydraulic cutting device to remove the injured occupants, they severed the fuel line that runs down the right forward door post. Because the airplane came to rest with the right wing higher than the left, this action would have allowed any remaining usable fuel from the right wing to drain out after it was cut. Therefore, the NTSB Investigator-In-Charge (IIC) contacted the on-scene commander from the Madera Fire department to determine if fuel had drained from that line. According to that individual, who confirmed that he had seen the door post being cut, and also observed the occupants being removed, no fuel drained from the line. An FAA-monitored post-accident inspection of the engine and the airframe did not reveal any evidence of malfunctions or anomalies that would have precluded the engine from producing rated horsepower, or would have allowed fuel to leak from the airplane. According to the pilot, earlier in the day, prior to the flight from Madera to Harris Ranch,he used a fuel tank dipping tube to measure the level of both fuel tanks. At that time he estimated each tank was about one-half full (about 22 gallons each), which would have provided a little over two hours flying time based upon his flight planning fuel flows. He then flew to Harris Ranch and back, for a total block-to-block time that he said could have been as much as one hour and twenty minutes. When questioned further by the IIC about his fuel measurement and fuel monitoring process, the pilot stated that the wing tank fuel dip tube was not one of the types that had been designed and marked specifically for use on the Cessna 210. He also confirmed that neither he nor the owner had put the tube through a calibrating process that would ensure its accuracy with this specific airplane. He also confirmed that although he had dipped the tanks prior to leaving Madera, he had not done so prior to the return flight from Harris Ranch. Upon further questioning, he also stated that he did not remember checking the fuel quantity in the left tank when he switched to it upon entering the pattern, nor did he check the left tank fuel level prior to asking the passenger if he would like to make a landing. When asked why he selected the left tank for landing, he said that it was standard procedure with this airplane because the owner had at some time in the past experienced a momentary interruption in fuel flow from the right tank while at altitude. Because of that event, both this pilot and the owner always switched to the left tank upon entering the pattern, regardless of which tank had the higher fuel level. ## Aircraft - Registration: [N2445S](https://openairdocs.org/deregistered/N2445S-2010-06-02), registration cancelled 2010-06-02, S/N 21061286, built 1976 (OpenAirDocs) - Reported make and model: CESSNA T210L - Registry model: [Cessna T210L](https://openairdocs.org/model/cessna-t210l) (registry code 2073449) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061286 - Airframe hours: 4230 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Davis David L - Registered owner: Davis David L - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2008 - Departed: 3O8, Coalinga, CA - Destination: KMAE, Madera, CA - Flight plan: Unknown - Airport: KMAE, Madera, runway 30, 5,400 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review March 29, 2008; seat: left; flight hours: 195 total, 85 in this make and model, 1 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F - Altimeter: 29.90 inHg ## 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 20090328003869A](https://openairdocs.org/incident/20090328003869A), Mar 28, 2009: Cessna T210L, Madera, CA, Substantial damage. (-23) The aircraft departed runway 30 at mae from what appears to be a "touch and go" landing according to a witness statement. The aircraft may also have been… ## Docket (4 files) The files NTSB released with the investigation on July 3, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73570. 836 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 748 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315012&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation (Fresno FSDO) (item 2, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315013&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Fresno%20FSDO)-Master.PDF - Record of Conversation (On-Scene Commander) (item 3, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315014&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(On-Scene%20Commander)-Master.PDF - Record of Conversation (Pilot) (item 4, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315015&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF 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.