WPR15IA263

NTSB incident investigation · Cessna T206H · Idaho Falls, ID · September 21, 2015

Incident · Minor injuriesIncident investigationFinal report
Date
September 21, 2015, 06:45 local (12:45 UTC)
Place
Idaho Falls, ID
Injuries
2 minor
Damage
Minor damage
Phase of flight
Initial climb
Aircraft
N7269TCessna T206H
Defining event
Initial climb: Fire/smoke (non-impact)
Weather
Visual (VMC) · Dawn
Status
Completed · report January 21, 2016
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO
FAA report
20150921015359I
Case key
92007

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

An in-flight fire during initial climb due to the separation of the engine's turbocharger wastegate overboard exhaust tailpipe. Contributing to the accident was the owner's decision to not comply with a service bulletin that addressed the tailpipe separation.

Findings · 4

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.

Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · MalfunctionCessna T206H: 2 casesAll aircraft: 29 casesProbable cause
Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · Not serviced/maintainedCessna T206H: 2 casesAll aircraft: 29 casesProbable cause
MaintenancePersonnel issues › Task performance · Owner/builderCessna T206H: 3 casesAll aircraft: 143 casesProbable cause
Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Owner/builderCessna T206H: 5 casesAll aircraft: 3,098 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

During initial climb and about 200 ft above ground level, the passenger observed smoke, which then rapidly filled the cabin. The pilot immediately turned the airplane toward the runway and subsequently performed a forced landing. Examination revealed that the airplane experienced an in-flight fire due to the separation of the engine's turbocharger wastegate overboard exhaust tailpipe from the turbocharger housing. The hot gases from the exhaust system subsequently burned through the battery's electrical cable insulation, which resulted in arcing, a short circuit, and fire. The airplane manufacturer had issued a service bulletin (SB) 16 years before the incident, which recommended installing a tailpipe lanyard to prevent the separation of the tailpipe. About 6 months before the incident, the airplane experienced a similar separation of the tailpipe. The damage was less severe, and it was limited to the battery and its electrical cables. After that event, the tailpipe clamp and gaskets were replaced, but the owner did not comply with the SB. No lanyard was found on the airplane, and no record was found indicating that the owner had complied with the SB at any time. However, the airplane was operating under the provisions of 14 Code of Federal Regulations Part 91; therefore, compliance with the SB was not mandatory. Although complying with the SB was not mandatory for this airplane's operations, the owner should have complied with the SB to ensure the continued safe operation of the airplane.

Factual narrative

On September 21, 2015, about 0645 mountain daylight time, a Cessna T206H, N7269T, experienced an in-flight fire during initial climb from Idaho Falls Regional Airport, Idaho Falls, Idaho. The airplane was registered to TK Leasing LC, and operated by Aero-Graphics Incorporated, as an aerial survey flight under the provisions of 14 Code of Federal Regulations Part 91. The flight instructor and passenger/camera operator sustained minor injuries related to smoke inhalation. The airplane sustained minor damage. The local flight departed Idaho Falls about 0640; visual meteorological conditions prevailed, and no flight plan had been filed.The pilot reported that he performed a preflight inspection, and the passenger checked the external camera equipment prior to flight. No anomalies were noted, and the engine run-up was normal. During the initial climb, the pilot retracted the flaps, and having reached about 200 ft above ground level the passenger began to see smoke. The pilot initiated a turn to the crosswind leg, and smoke rapidly filled the cabin. The passenger opened the side window, and concerned that it may fan the source of the smoke, the pilot asked him to close it. The pilot then put on his oxygen cannula but it did not provide relief, and by now he was having trouble breathing due to the smoke density. The smoke was now obscuring the instrument panel, but he could partially see the runway and immediately turned the airplane towards it. He opened his side window and put his head outside for a better view, however, the force of the wind made breathing difficult. The pilot then pushed the airplane's nose down, initiating a steep dive to the runway. He could not recall the final stages of the landing, but as soon as the airplane touched the ground, he applied full brake action, locking up the wheels. Once they had come to a stop, the pilot shutoff the fuel mixture control and they rapidly egressed. The airplane sustained thermal damage to the right side of the firewall, the upper and lower engine cowlings, and the forward right section of the fuselage skin, which had burned through to the cabin at the air inlet door. The fire location relative to the air inlet resulted in smoke being forced directly into the airplane's fresh air intake system. Subsequent examination revealed that the wastegate overboard exhaust tailpipe had come away from turbocharger housing. The turbocharger housing outlet was directly in line with the battery mounting tray on the right side of the firewall. The battery had partially melted, and both its positive and negative electrical connecting cables had partially melted. Both cables exhibited globular damage to their copper conductors consistent with arcing and an electrical short circuit. Cessna Service Bulletin SB99-71-06, released December 6, 1999, recommended the installation of a tailpipe lanyard to, "provide a safety link ensuring positive turbocharger exhaust tailpipe retention should the clamp become loose." Nolanyard was found on the airplane, and there was no record in the maintenance logbooks indicating that the service bulletin had been complied with. The service bulletin affected 111 Cessna T206H airplanes, and records provided by Cessna revealed that in the 2-year period following issuance of the service bulletin, 91 of the service bulletin's sub assembly components were sold, with sales then averaging about 3 per year through to 2015. Federal Aviation Administration regulations do not require compliance with service bulletins for aircraft operating under the provisions of 14 Code of Federal Regulations Part 91. The airplane experienced a similar separation of the tailpipe during takeoff on April 28, 2015. On this occasion smoke was again drawn into the cockpit, but damage was limited to the battery and its associated cables. Maintenance records indicated that the tailpipe clamp and gaskets were replaced following the event. The pilot stated that the airplane was equipped with a fire extinguisher, however, his primary focus was with flying the airplane, and the event transpired at such a rapid pace that it wasn't until landing that he and the passenger remembered it was installed.

Aircraft

Registration
N7269T
Reported as
Cessna T206H
Category
Airplane
Serial number
T20608050
Built
1999
Airframe hours
5,787.5
Engine
Lycoming TIO-540 SER, 310 horsepower, reciprocating
Damage
Minor damage
Fire
In-Flight
Flight
Aerial observation · Part 91
Operator
Aero-Graphics Inc.
Registered owner
Tk Leasing Lc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 3, 2015 · 45 hours before
Departed
IDA · Idaho Falls, ID
Destination
IDA · Idaho Falls, ID
Airport
IDA · Idaho Falls Rgnl, runway 2, 9,002 × 150 ft, asphalt
Equipment
Stall warning system, Satellite tracking device, Auto-pilot

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
24
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine sea, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
July 21, 2015
Seat
Left
Restraint
3-point
Flight hours
1,245 total · 165 in this make and model · 1,109 as pilot in command · 165 in the last 90 days · 64 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dawn
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 37 °F
Altimeter
30.05 inHg
Observed at
KIDA

Docket · 4

The files NTSB released with the investigation on December 2, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.2 MB 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.