# NTSB WPR14LA118: Cessna P210N, N18DP, Bountiful, UT, February 23, 2014

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: February 23, 2014, 14:05 local (21:05 UTC)
- Place: Bountiful, UT
- Coordinates: 40.868057, -111.922775 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.8681&lon=-111.9228&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report May 13, 2015
- Report: Approved by Office Director
- NTSB office: Western Pacific Region
- Parties: Federal Aviation Administration, Continential Motors
- NTSB case key (mKey): 88830
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA118
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88830/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88830
- Page: https://openairdocs.org/ntsb/WPR14LA118

## Probable cause

Fuel starvation due to the in-flight loosening of the fuel lines attached to the fuel flow indicator as a result of inadequate maintenance.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Engine fuel and control: fuel flow indicating](https://openairdocs.org/ntsb-findings/01057331): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/01057331/cases.md?model=2073454), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01057331/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2073454), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)
- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Cessna P210N, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073454), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Maintenance/inspections: time limits](https://openairdocs.org/ntsb-findings/01010510): Aircraft › Aircraft handling/service · Not serviced/maintained; cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/01010510/cases.md?model=2073454), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/01010510/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 starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna P210N, 4 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2073454), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md)
- [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Cessna P210N, 11 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2073454), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna P210N, 16 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073454), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna P210N, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073454), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md)

## Analysis

The pilot reported that the accident flight was the first flight in the airplane since its annual inspection, which occurred about 6 weeks before the accident. He conducted a thorough preflight inspection and run-up. Before takeoff, he added full power with the brakes applied, and, after noting no abnormal engine or instrument indications, he took off. When the airplane reached about 150 to 200 ft above the ground, the engine started to run roughly. The airplane was unable to maintain altitude, so the pilot executed a forced landing to a nearby field. During the landing, the airplane sunk into the mud and nosed over. Postaccident examination of the engine revealed that the fuel lines connected to the input and output of the fuel flow indicator were loose and leaking. After these lines were tightened about 1.5 turns and pressure was applied, a third leak was found in the vicinity of a metal label on the fuel line between the fuel manifold and the fuel pressure gauge. The aircraft manufacturer's service manual states that the engine compartment rubber hoses must be replaced every 5 years or at engine overhaul, whichever occurs first. According to the airplane's maintenance logbook, the most recent engine overhaul occurred about 18 years before the accident. The mechanic who conducted the annual inspection reported that, during the inspection, he removed the fuel lines to and from the engine-mounted fuel flow transducer to troubleshoot a lack of indicated fuel pressure at the cockpit-mounted instrument. It is likely that the mechanic failed to adequately tighten the fuel lines when he reinstalled them.

## Factual narrative

On February 23, 2014, about 1405 mountain standard time, a Cessna P210N, N18DP, experienced a loss of engine power shortly after takeoff from Skypark Airport (BTF), Bountiful Utah. The pilot, the sole occupant, was not injured, and the airplane sustained substantial damage to the left wing and empennage. The airplane was registered to, and operated by, private parties under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The airplane was destined for Heber City Municipal Airport – Russ McDonald Field (36U), Heber Utah. The pilot reported that this was the first flight after the airplane's annual inspection. He conducted a thorough preflight inspection and run-up. Before takeoff, the pilot added full power with the brakes applied. The pilot listened to the engine and watched the instrument gauges; with everything operating normally, he took off. When the airplane reached about 150-200 feet above the ground the engine started to run rough. Unable to maintain altitude, the pilot executed a forced landing onto a nearby field. During the landing, the airplane sunk into the mud and nosed over. During a postaccident examination by a Federal Aviation Administration inspector and a representative from Continental Motors, fuel pressure was applied to the fuel lines from the left wing fuel tank to the engine. It was noted that the fuel lines connecting to the input and output from the JPI fuel flow Indicator were loose and leaking. The lines were tightened at least 1.5 turns and pressure was reapplied to the fuel system. The leaks stopped, however, a third leak was found in the vicinity of a metal label on the fuel line in between the fuel manifold and the fuel pressure gauge. The label indicated that it was installed by Cessna during the fourth quarter of 1977. The Cessna Model P210 Service Manual states "Replace engine compartment rubber hoses every 5 years or at engine overhaul, whichever occurs first." The airplane's engine was last overhauled June 20, 1996. The airplane's maintenance logbook indicated that during the annual inspection that occurred on January 12, 2014, at a tachometer time of 547.07 hours, "Wiring repaired on intercooler temperature probes, and FS-450 fuel scan miniature D connector (JPI fuel flow indicator)." Through email conversation, the mechanic reported that during the annual inspection he removed the fuel lines to and from the engine mounted fuel flow transducer to troubleshoot a lack of indicated fuel pressure at the cockpit mounted instrument.

## Aircraft

- Registration: [N18DP](https://openairdocs.org/deregistered/N18DP-2015-04-02), registration cancelled 2015-04-02, S/N P21000086, built 1978 (OpenAirDocs)
- Reported make and model: CESSNA P210N
- Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs)
- Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: P21000086
- Year built: 1978
- Airframe hours: 4500
- Engines: CONT MOTOR TSIO520P (1B) 285 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Holt Jacky Jr
- Registered owner: Holt Jacky Jr
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, January 12, 2014, 0 hours before
- Departed: BTF, Bountiful, UT
- Destination: 36U, Heber, UT
- Airport: BTF, Skypark Airport, runway 34, 4,700 × 70 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review February 24, 2012; seat: left; restraint: 3-point; flight hours: 1,810 total, 100 in this make and model, 1,457 as pilot in command, 2 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: variable at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 59 °F, dew point 19 °F
- Altimeter: 30.03 inHg
- Observed at: SLC, 6 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 (OpenAirDocs).

- [Accident 20140223001619A](https://openairdocs.org/incident/20140223001619A), Feb 23, 2014: Cessna P210N, Bountiful, UT, Substantial damage. Pilot experienced a loss of engine power after takeoff from runway 36, Bountiful, Utah. The pilot performed a forced landing in a field. During the forced…

## Docket (9 files)

The files NTSB released with the investigation on April 8, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88830. 2.4 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424949&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Record of Conversation – FAA Inspector (5 Embedded Images) (item 2, .PDF, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424950&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20FAA%20Inspector%20(5%20Embedded%20Images)%20%20-Master.PDF
- Record of Conversations – Mechanic (item 3, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424951&FileExtension=.PDF&FileName=Record%20of%20Conversations%20%E2%80%93%20Mechanic-Master.PDF
- Maintenance Logs – Annual Inspection (item 4, .PDF, 910 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424952&FileExtension=.PDF&FileName=Maintenance%20Logs%20%E2%80%93%20Annual%20Inspection%20-Redacted.PDF
- Cessna Service Manual P210 - Excerpts (item 5, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424953&FileExtension=.PDF&FileName=Cessna%20Service%20Manual%20P210%20-%20Excerpts%20-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424954&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424955&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- VIDEO 1: Fuel leak JPI (Courtesy of FAA) (item 8, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424956&FileExtension=.PDF&FileName=VIDEO%201%3A%20Fuel%20leak%20JPI%20(Courtesy%20of%20FAA)-Master.PDF
- VIDEO 2: Fuel leak by Metal tab (Courtesy of FAA) (item 9, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40424963&FileExtension=.PDF&FileName=VIDEO%202%3A%20Fuel%20leak%20by%20Metal%20tab%20(Courtesy%20of%20FAA)-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.