WPR16LA030

NTSB accident investigation · Cessna T210N · La Verne, CA · November 19, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
November 19, 2015, 13:35 local (21:35 UTC)
Place
La Verne, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N91HCCessna T210N
Defining event
Approach: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report March 19, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20151119022499A
Case key
92345

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

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The total loss of engine power for reasons that could not be determined based on the available information.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The commercial pilot was performing an aerial survey flight and departed with the fuel tanks filled to maximum capacity. After performing the survey, he began his return to the destination airport with about 40 minutes of fuel on board. While en route, he determined the fuel quantity was lower than he expected and opted to divert to a nearby airport. Before landing, the pilot switched the fuel selector to the fullest fuel tank (left side), which showed about 6-7 gallons; the right side showed about 4-5 gallons. While on final approach, the engine suddenly experienced a total loss of power, and the pilot was unable to restart it. With the propeller windmilling, the pilot aligned the airplane with the closest runway and configured the airplane for best glide. As the airplane neared the ground, the left wing collided with a sign and the airplane impacted the ground. The airplane erupted in flames and was partially consumed by fire. The left wing was separated from the airframe and mostly consumed by fire. The right wing was partially burned and remained loosely attached to the airframe. Wreckage retrieval personnel recovered about 2 1/4 gallons of fuel from the right wing and stated that there was water in the sample; however, foam had been used to extinguish the fire, and the source of the water could not be determined. Due to the severe damage to the fuel system, continuity of the system could not be established. The examination revealed no evidence of mechanical malfunction or failures of the airframe or engine that would have prevented normal operation. Fuel consumption calculations revealed that, if the airplane departed on the flight with full fuel tanks, then there should have been about 21 gallons of fuel on board at the time of the accident. Due to the damage and postimpact fire, which precluded thorough examination of the fuel system and determination of the amount of fuel on board, the reason for the loss of engine power could not be determined.

Factual narrative

The factual narrative1,186 words

The airplane, a Cessna Aircraft T210N, serial number 64441, was equipped with a Continental Motors TSIO-520-R engine, serial number 512148. The operator provided excerpts from the engine logbooks that included the last maintenance performed. The records indicated that the last annual inspection was recorded as being completed in May 2015 at a tachometer time of 6,788.6 hours and a total airframe time of 10,862.5 hours; the tachometer time at the time of the accident was 5,435 hours, or about 35 hours after the maintenance. A fuel consumption calculation prepared by a Cessna Aircraft Company representative (contained in the public docket for this accident) showed that the airplane should have had about 21 gallons of fuel on board at the time of the accident, assuming that the airplane was filled to maximum capacity (89 gallons) prior to departure, as reported by the pilot. According to the pilot, the airplane climbed to about 14,000 ft msl and cruised at about 13,600 msl at an average speed of 165 kts. According to the Cessna Aircraft Pilot's Operating Handbook (POH) for the airplane, to maintain that airspeed, the engine would be operating at 2,400 rpm and 24 inches of manifold pressure. Based on this assumption, with the airplane configured at a gross weight of 3,7000 lbs, the fuel consumption to reach the cruising altitude would be about 44.5 lbs and the consumption during cruise flight would be about 81 lbs per hour. With the engine operating about 4 hours and 20 minutes, this would equate to a total fuel consumption of 68 gallons. The pilot stated that he was averaging about 18 gallons per hour and should have had enough fuel to make it to the runway. He estimated that he was airborne for about 4 hours and 20 minutes and he recalled that in the past, the airplane could fly for 4.7 hours. He thought there might have been a fuel starvation event but didn't know what the reason would be. On November 19, 2015, about 1335 Pacific standard time, a Cessna T210N Centurion, N91HC, experienced a loss of engine power and collided with a sign while the pilot was making an emergency approach to land at Brackett Field, La Verne, California. Aircraft Guaranty Corp was the registered owner and was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot, the sole occupant, was seriously injured; the airplane sustained substantial damage. The aerial surveying personal flight originated from Camarillo Airport, Camarillo, California about 0910 and the pilot had intended to land back at that airport. Visual meteorological conditions prevailed and no flight plan was filed. The pilot stated that he was an airplane mechanic for his profession, but had been down in southern California for the previous two days helping doing an aerial surveying job. Earlier in the morning he had the fuel tanks filled to maximum capacity and flew his intended route down in the San Diego area. As he began to return back to thedestination airport, he recalled having 15 gallons of fuel on board, which the JP Instrument (JPI) gauge indicated equated to about 40 minutes of flight time. About 1325 he began to descend from his en route altitude of about 13,500-14,000 feet mean sea level (msl) and opted to land at Brackett due to the airplane's low fuel quantity. Before landing, the pilot switched to the fullest tank (left side) which showed about 6-7 gallons and the right side had about 4-5 gallons. While on final approach, the engine suddenly lost power and despite his attempts, he was unable to successfully have it restart. With the propeller wind milling he aligned with the closest runway and configured the airplane for the best glide. The left wing suddenly impacted a sign that he did not previously observe and the airplane dove toward the ground. The pilot egressed through the windshield and shortly thereafter, the airplane erupted in flames. The airplane came to rest about 620 feet east of runway 26R. The Federal Aviation Administration (FAA) provided the audio recording of the Brackett Air Traffic Control (ATC) communication with the pilot. The pilot made his initial radio call about 1330 stating that he was inbound to land and had the current ATIS (Automated Terminal Information System) information. The tower instructed him to enter the right base leg of the traffic pattern for runway 26L. After reading back the controller's instructions, the pilot stated that he was "quite low on fuel." The tower cleared the pilot to land on runway 26L at 1335 and he acknowledged. After about one minute and 15 seconds, the pilot transmitted that he was now requesting to land on runway 26R. About 5-10 seconds after the pilot made a radio call reading back his amended clearance, the airplane impacted the sign. A post accident examination was conducted by a Federal Aviation Administration (FAA) inspector and a mechanic. The airplane had been disassembled during the recovery process and the center fuselage section was consumed by fire. A complete examination report with accompanying photographs are in the public docket for this accident. The left wing was separated from the airframe and only a small outboard section remained; the rest was consumed by fire. The right wing was partially burned and remained loosely attached to the airframe at the accident site; the Monarch-style fuel cap was secure. The wreckage retrieval personnel recovered 2 gallons and 1 quart of fuel from the right wing and stated that there was water in the sample. He noted that foam had been used to extinguish the fire and could not determine if the water was present because of the foam. The fuel system had been severely compromised by the fire and investigators were unable to establish continuity from the wing through the fuselage to the engine-driven fuel pump. The fuel selector was found, and removed from the deformed cabin area; post crash fire precluded it from turning. An external examination of the enginerevealed that cylinder fins and outer cooling fins were crushed and bent on the left side of the engine. After the spark plugs had been removed the cylinder heads were bore-scoped with no internal cylinder anomalies identified during that internal inspection. The exhaust system was observed to have sustained ductile bending and crushing aft of the turbo-charger. The turbo-charger exhibited no apparent damage and rotated freely by hand. The ignition harnesses were attached from both magnetos to their respective spark plugs. The magnetos remained securely attached to their respective mounts. Investigators removed the right magneto and tested the internal continuity via hand rotation which produced spark. The top spark plugs were removed; no mechanical damage was noted and the electrodes and posts exhibited no abnormal or remarkable color markings. Continuity of the fuel system could not be established due to the post crash fire. The Hartzell propeller blades were observed attached to their hub assemblies, which were attached to the propeller shaft flange. The propeller blades were torsionally twisted and exhibited an "S" bend. There was no evidence of mechanical malfunction or failure with the airframe or engine.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N91HC
Reported as
Cessna T210N
Category
Airplane
Serial number
64441
Built
1981
Airframe hours
10,863
Engine
Continental Motor TSIO-520-RCM, 285 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial observation · Part 91
Operator
Aircraft Guaranty Corp
Registered owner
Aircraft Guaranty Corp
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 29, 2015
Departed
CMA · Camarillo, CA
Destination
POC · La Verne, CA
Airport
POC · Brackett Field, runway 26R, 3,661 × 75 ft, asphalt
Equipment
Electronic flight bag or handheld 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
46
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
September 28, 2015
Seat
Left
Restraint
3-point
Flight hours
1,500 total · 85 in this make and model · 1,450 as pilot in command · 50 in the last 90 days · 26 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 23 °F
Altimeter
29.95 inHg
Observed at
KPOC, 1 nm away

Docket · 5

The files NTSB released with the investigation on November 6, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.0 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.