# NTSB WPR15IA263: Cessna T206H, N7269T, Idaho Falls, ID, September 21, 2015 - Type: NTSB incident investigation - Classification: Incident · Minor injuries · Incident investigation · Final report - Date: September 21, 2015, 06:45 local (12:45 UTC) - Place: Idaho Falls, ID - Coordinates: 43.51361, -112.070831 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.5136&lon=-112.0708&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report January 21, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 92007 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15IA263 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92007/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92007 - Page: https://openairdocs.org/ntsb/WPR15IA263 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Cessna T206H, 2 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=2073303), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Cessna T206H, 2 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=2073303), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Owner/builder (probable cause); cases with it: [Cessna T206H, 3 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=2073303), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Owner/builder (probable cause); cases with it: [Cessna T206H, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073303), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Cessna T206H, 2 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=2073303), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/aircraft/N7269T), registered now, S/N T20608050, built 1999 (OpenAirDocs) - Reported make and model: CESSNA T206H - Registry model: [Cessna T206H](https://openairdocs.org/model/cessna-t206h) (registry code 2073303) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: T20608050 - Year built: 1999 - Airframe hours: 5787.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 24; injuries: minor; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20150921015359I](https://openairdocs.org/incident/20150921015359I), Sep 21, 2015: Cessna T206H, Idaho Falls, ID, Minor damage. Cessna 206 (N7269T) departed Idaho Falls, Idaho (ida) airport and upon reaching 300 ft AGL the pilot and passenger smelled smoke. As they turned on the… ## Docket (4 files) The files NTSB released with the investigation on December 2, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92007. 4.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434384&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Maintenance Records (item 2, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434386&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Cessna Service Bulletin SB99-71-06 (item 3, .PDF, 686 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434387&FileExtension=.PDF&FileName=Cessna%20Service%20Bulletin%20SB99-71-06-Master.PDF - Photos (item 4, .PDF, 4 photos, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434385&FileExtension=.PDF&FileName=Photos-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.