# NTSB WPR09LA214: Cessna T210M, N6584B, Hanford, CA, April 24, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 24, 2009, 14:25 local (21:25 UTC) - Place: Hanford, CA - Coordinates: 36.215278, -119.588607 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2153&lon=-119.5886&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report September 10, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Fresno FSDO - NTSB case key (mKey): 73724 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA214 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73724/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73724 - Page: https://openairdocs.org/ntsb/WPR09LA214 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=2073451), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna T210M, 3 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=2073451), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210M, 5 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073451), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna T210M, 7 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073451), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of manual](https://openairdocs.org/ntsb-findings/02063020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210M, 1 case](https://openairdocs.org/ntsb-findings/02063020/cases.md?model=2073451), [All aircraft, 15 cases](https://openairdocs.org/ntsb-findings/02063020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna T210M, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2073451), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna T210M, 17 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073451), [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 T210M, 11 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073451), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N6584B-2010-09-01), registration cancelled 2010-09-01, S/N 21062791, built 1978 (OpenAirDocs) - Reported make and model: CESSNA T210M - Registry model: [Cessna T210M](https://openairdocs.org/model/cessna-t210m) (registry code 2073451) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21062791 - Airframe hours: 4397 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: none; 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 ## 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 20090424004699A](https://openairdocs.org/incident/20090424004699A), Apr 24, 2009: Cessna T210*, Hanford, CA, Substantial damage. (-23) Aircraft lost engine power at 5,000' MSL, approx 4 NM north of Hanford Municipal Airport (khjo). Pilot stated that he attempted restarts but was unable.… ## Docket (1 files) The files NTSB released with the investigation on July 21, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73724. 829 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 829 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314329&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.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.