# NTSB WPR09LA237: Cessna U206E, N1457M, Oroville, CA, May 10, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 10, 2009, 13:10 local (20:10 UTC) - Place: Oroville, CA - Coordinates: 39.5825, -121.563331 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.5825&lon=-121.5633&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73802 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA237 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73802/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73802 - Page: https://openairdocs.org/ntsb/WPR09LA237 ## Probable cause A total loss of engine power during cruise flight due to an excessively lean mixture for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome - [Engine fuel and control](https://openairdocs.org/ntsb-findings/01057300): Aircraft › Aircraft power plant · Not specified (probable cause) ## Analysis The airplane owner/pilot departed for a personal flight with 55 gallons of fuel in the airplane's fuel tanks. After flying for nearly 40 minutes all engine power was suddenly lost. The pilot reported that, because he was only 1,100 feet above the ground, he had limited time to attempt an engine restart. Therefore, the pilot concentrated on performing the forced landing. The pilot landed in an open field. During rollout on the uneven terrain, the nose gear collapsed and the firewall was bent. Subsequently, the airplane was recovered and examined and no anomalies were found. The engine was test run and no evidence of any mechanical malfunction was noted. The airplane was equipped with an engine monitoring system that retained various engine related operating parameters. The extracted nonvolatile memory data revealed that the engine's exhaust gas temperature peaked a few seconds before the fuel flow decreased to zero and all power was lost. The data was consistent with an interruption of fuel flow to the engine due to an overly lean mixture; however, the investigation could not determine the cause of the excessively lean mixture. ## Factual narrative On May 10, 2009, about 1310 Pacific daylight time, a Cessna U206E, N1457M, experienced a total loss of engine power while cruising about 5 miles north of Oroville, California. The private pilot made a forced landing in an open field. The airplane's nose gear broke off as the airplane decelerated over uneven terrain, the firewall was bent, and the airplane was substantially damaged. The private pilot was not injured during the personal flight that was performed in the airplane, which he co-owned. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91, and it originated from Marysville, California, about 1230. The pilot reported to the National Transportation Safety Board investigator that when his flight initiated, the airplane's fuel tanks contained a total of 55 gallons of 100 LL fuel. After takeoff, he performed two uneventful touch-and-go landings. Thereafter, he climbed to a 2,600-foot mean sea level (msl) cruise altitude. There were no clouds in the sky, and the wind was calm. The visibility was 100 miles. According to the pilot, while cruising the engine suddenly "died, as if the [ignition] key were shut off." Immediately thereafter, engine power returned without his taking action, and then the engine died completely. The pilot stated that he responded to the emergency by switching fuel tanks and also activating the electric fuel pump. The propeller continued to windmill. Due to the airplane's low altitude, he then concentrated on executing the forced landing. His efforts at restarting the engine were not successful, and he landed the airplane on the nearby rough terrain, about 1,100 feet msl. Airplane recovery personnel reported to the Safety Board investigator finding evidence of fuel in all of the airplane's fuel tanks. The airplane was recovered from the accident site and examined by Federal Aviation Administration (FAA) personnel. In pertinent part, FAA personnel reported observing minimal propeller blade damage, which they opined was consistent with low or no engine power at impact. Control continuity between the cockpit's engine controls and the engine was confirmed. No anomalies were noted with the magnetos, examined spark plugs, cylinders, or internal engine components during rotation of the engine's crankshaft. The integrity of the fuel system was confirmed between the wings and the engine. The fuel vents in the wings and the bladder tanks were examined, and no blockages were noted. To ascertain the functionality of the powerplant, an FAA principal maintenance inspector test ran the engine. The FAA inspector reported that the electric fuel pump operated normally, and the engine properly started. Thereafter, it was test run for 12 minutes. No anomalies were noted. At the conclusion of the examination, the FAA inspector reported finding no evidence indicating why the reported power loss occurred. The accident airplane wasequipped with a J.P. Instruments, Inc. (JPI), engine data management (EDM-800) system that recorded various engine operating conditions. Following the FAA's engine test run, the EDM-800 was removed from the airplane. Under the Safety Board's supervision, its retained memory was downloaded by JPI's personnel at their manufacturing facility. JPI personnel reported to the Safety Board investigator that the instrument appeared undamaged, and the downloaded file contained data that did not appear corrupt. The downloaded file of the accident flight was reviewed by Safety Board personnel. A data graph showing the accident flight is included in the docket for this accident report. In pertinent part, the graph includes the following data for Time, Exhaust Gas Temperature (#1 cylinder, degrees Fahrenheit) Fuel Flow, and Revolutions Per Minute: *TIME EGT FF RPM NOTES 2117:54 1378 17.6 2465 (EGT remained bet. 1378 & less than 1417) 2124:12 1354 16.2 2345 (EGT rose to 1417 at 2124:24) 2124:24 1417 11.2 2339 (Peak EGT occurred here) 2124:30 1007 0.9 2130 2124:36 572 0.0 1937 2125:42 241 0.0 0 *See the docket for information regarding event times and all recorded data. JPI's Pilot's Guide indicates that retarding the mixture control changes the fuel/air ratio and hence the exhaust gas temperature. The Guide states: "As the mixture is leaned, EGT rises to a peak temperature, and then drops as the mixture is further leaned." ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) ## Aircraft - Registration: [N1457M](https://openairdocs.org/aircraft/N1457M), registered now, S/N U20601457, built 1970 (OpenAirDocs) - Reported make and model: CESSNA U206E - Registry model: [Cessna U206E](https://openairdocs.org/model/cessna-u206e) (registry code 2073350) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: U20601457 - Airframe hours: 4010 - Engines: Continental IO-550F 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 5, 2008, 4 hours before - Departed: MYV, Marysville, CA - Destination: MYV, Marysville, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review October 8, 2007; seat: left; flight hours: 339 total, 138 in this make and model, 244 as pilot in command, 3 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 100 statute miles - Lowest ceiling: none - Temperature: 64 °F - Altimeter: 29.79 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 20090510008729A](https://openairdocs.org/incident/20090510008729A), May 10, 2009: Cessna U206E, Marysville, CA, Minor damage. (-23) Aircraft departed Marysville calif (myv) at approximately 12:30 pm on 5/10/2009. The weather was VFR intended route of flight was sightseeing in the… ## Docket (9 files) The files NTSB released with the investigation on February 10, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73802. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 957 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325102&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Report (item 2, .PDF, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325103&FileExtension=.PDF&FileName=FAA%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325135&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 607 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325104&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Memo to File RE JPI Data, with 2 Attachments (item 5, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325122&FileExtension=.PDF&FileName=Memo%20to%20File%20RE%20JPI%20Data,%20with%202%20Attachments-Master.PDF - Memo Attachment 1. JPI Data Graph (item 6, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325105&FileExtension=.PDF&FileName=Memo%20Attachment%201.%20JPI%20Data%20Graph-Master.PDF - Memo Attachment 2. JPI Data Graph, Expanded View (item 7, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325106&FileExtension=.PDF&FileName=Memo%20Attachment%202.%20JPI%20Data%20Graph,%20Expanded%20View-Master.PDF - JPI EDM Data File (item 8, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325107&FileExtension=.PDF&FileName=JPI%20EDM%20Data%20File-Master.PDF - JPI Pilots Guide EDM-800 Extract (item 9, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325110&FileExtension=.PDF&FileName=JPI%20Pilots%20Guide%20EDM-800%20Extract-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.