WPR09LA214

NTSB accident investigation · Cessna T210M · Hanford, CA · April 24, 2009

Accident · No injuriesLimited investigationFinal report
Date
April 24, 2009, 14:25 local (21:25 UTC)
Place
Hanford, CA
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6584BCessna T210M
Defining event
Enroute-descent: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report September 10, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Fresno FSDO
FAA report
20090424004699A
Case key
73724

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

A loss of engine power during descent due to fuel starvation as a result of the pilot's improper fuel management. Contributing to the accident was the pilot's failure to use the correct fuel flow performance chart.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationCessna T210M: 1 caseAll aircraft: 176 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna T210M: 3 casesAll aircraft: 442 cases
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna T210M: 5 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna T210M: 7 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of manualPersonnel issues › Task performance · PilotCessna T210M: 1 caseAll aircraft: 15 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While the pilot was descending toward an alternate airport because his fuel level was becoming lower than he was comfortable with, the airplane experienced a total loss of engine power because the selected fuel tank ran dry. Although he tried to restart the engine, the pilot failed to switch tanks during the restart attempt and was therefore unsuccessful. He ultimately made a forced landing in an open field with rough terrain, and one wing came in contact with the surface during the landing roll. It was later determined that the other fuel tank contained about eight gallons of fuel. It was also determined that the pilot had been using the fuel flow charts provided with the airplane at the time of manufacture, instead of the updated charts that should have been used after the engine underwent a Supplemental Type Certificate (STC) performance modification that resulted in higher fuel flows.

Factual narrative

On April 24, 2009, about 1425 Pacific daylight time, a Cessna T210M, N6584B, impacted the terrain during a forced landing on rough terrain about five miles southeast of Hanford, California. The commercial pilot and his three passengers were not injured, but the airplane, which was owned and operated by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal pleasure flight, which departed North Las Vegas Airport about two and one-half hours prior to the accident, was being operated in visual meteorological conditions. The flight was en route to Vacaville, California. No flight plan had been filed. According to the pilot, while en route to Vacaville, he noticed that the fuel quantity was getting lower than he was comfortable with, so he elected to divert into Hanford Municipal Airport to take on some additional fuel. During his descent into Hanford, the engine lost power, and he was unable to get it restarted. He therefore executed an engine-out forced landing in an open field. During the landing roll the airplane's wing came in contact with the rough terrain. A post-accident inspection of the airplane by a Federal Aviation Administration (FAA) Inspector found that there was eight gallons of fuel in the left wing tank, but the right wing tank was empty. Further discussions with the pilot determined that he had the right tank selected when the engine quit, and although he attempted a restart sequence, he did not select the left tank at any time during the restart attempt. According to the pilot, prior to the time he purchased the airplane (about seven years before the accident) it underwent a RAM Aircraft Supplemental Type Certificate (STC) engine conversion, increasing its output to 310 horsepower, and changing its performance and fuel flow figures. The pilot further stated that until about two weeks before the accident, when his current maintenance provider gave him a copy of the RAM conversion performance charts, he did not realize there was a fuel flow difference between the original/standard engine and the RAM conversion. Although he had the RAM charts, the pilot continued to use the performance/fuel flow charts that came with the aircraft at the time of the aircraft's manufacture, and in so doing, on the accident flight he ended up with less fuel remaining than he expected for the time that he had been airborne.

Aircraft

Registration
N6584B
Reported as
Cessna T210M
Category
Airplane
Serial number
21062791
Airframe hours
4,397
Engine
Cont Motor TSIO-520 SER, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Preston Donald S
Registered owner
Preston Donald S
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 2, 2009
Departed
KVGT · North Las Vegas, NV
Destination
KVCB · Vacaville, CA

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
63
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 17, 2009
Seat
Left
Flight hours
8,000 total · 1,500 in this make and model · 7,000 as pilot in command · 17 in the last 90 days · 14 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 10 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F

Docket · 1

The files NTSB released with the investigation on July 21, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 829 KB in all.

FAA reports on this event · 1

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