WPR17LA136

NTSB accident investigation · Cessna 310R · Santa Ana, CA · June 30, 2017

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
June 30, 2017, 09:35 local (16:35 UTC)
Place
Santa Ana, CA
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N87297Cessna 310R
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA-FSDO, Textron Aviation, Continental Motors Group
FAA report
20170630008769A
Case key
95468

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 pilot’s inability to maintain adequate airspeed after a loss of power to the right engine while maneuvering in the pattern to return to the airport. Contributing to the accident were the loss of power to the right engine for reasons that could not be determined and the pilot’s improper decision to turn toward the inoperative engine during the return flight to the airport.

Findings · 6

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.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 310R: 2 casesAll aircraft: 1,681 cases
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 310R: 2 casesAll aircraft: 3,958 cases
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 310R: 8 casesAll aircraft: 9,295 casesProbable cause
AircraftAircraft › Aircraft power plant · InoperativeCessna 310R: 2 casesAll aircraft: 151 cases

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

The pilot reported that he checked that both fuel selectors were in the “main” position before starting the engine and during run-up before departure and that they remained in that position throughout the flight. Shortly after departing for the personal, cross-country flight and when the airplane was about 400 ft above ground level (agl) with the flaps in the 15°-down position, the right engine lost power. Subsequently, the pilot transmitted a “mayday” to the air traffic control tower, and a controller then cleared him for landing back at the airport. The pilot reported that he then feathered the right propeller, and the airplane was able to maintain an altitude of between 400 and 500 ft agl as he turned it right onto the downwind leg of the traffic pattern. After turning onto the downwind leg, the controller informed the pilot that the landing gear were retracted. The pilot replied that he knew the landing gear were up and that he would lower them on the final approach leg. During the turn to final, the pilot lowered the landing gear, and the airplane started to descend. Radar track data showed the airplane turning right for the final approach at a ground speed of 93 knots, which decreased to 81 knots. After the pilot realized that the airplane would not reach the runway, he made a left turn and prepared for a forced landing on a freeway. The airplane rapidly descended and subsequently impacted the freeway’s center median. Fuel then sprayed from the fuel tanks, followed by explosions. The pilot’s decision of turning right toward the inoperative engine likely reduced the airplane’s available performance capabilities on one engine and increased the pilot’s workload associated with maintaining aircraft control. It is also likely that, during the right turn to the final approach leg, when the pilot lowered the landing gear, airspeed could not be maintained or he could not compensate for the asymmetric thrust when he turned toward the inoperative engine, which led to the loss of control and airplane descent. The right fuel selector valve was found in the “main” position, and the right wing’s leading edge was crushed from the wing root to the separated wing tip area. The right fuel selector was found pulled past the “off-stop” position. The right-wing fuel selector position and the right-wing root damage were consistent with the fuel valve cable being pulled during the accident sequence, which resulted in the valve being repositioned to the “off-stop” position. All fuel caps were found, and the fuel tank filler necks were installed with restrictor orifices. Postaccident examination of the airframe and both engines revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation.

Factual narrative

Nonvolatile Memory Data A review of engine monitor data revealed that, about the time of departure, both engines’ fuel flow and cylinder exhaust gas temperatures (EGT) increased. As the fuel flow started to level out over the next 30 seconds, the right engine’s fuel flow fluctuated, followed by the left engine fuel flow fluctuating. The right engine’s fuel flow decreased to near 0, and the left engine’s fuel flow returned at a lower rate before fluctuating again near the end of the data. The right engine’s EGT decreased, followed by three cylinders’ EGTs increasing near the end of the data. Maintenance History A review of the maintenance records revealed that, on May 12, 2017, the fuel selector valves were removed and replaced with repaired units. According to onboard flight documents, the airplane had accrued 8.9 flight hours, consisting of three flights, since the fuel selector valves were replaced. Engine Failure Emergency Procedures Pilot’s Operating Handbook (POH) The POH, Engine Failure After Takeoff, checklist stated, in part, the following: Mixtures – AS REQUIRED for flight altitude. Propellers – FULL FORWARD. Throttles – FULL FORWARD. Landing gear – CHECK UP. Inoperative Engine: Throttle – CLOSE. Mixture – IDLE CUT-OFF. Propeller – FEATHER. Establish Bank – 5° toward operative engine. Wing Flaps – UP, if extended, in small increments. Climb to Clear 50-Foot Obstacle – 92 (Knots Indicated Airspeed) KIAS. Climb at Best Single – Engine Rate-of-Climb Speed – 106 KIAS at sea level; 94 KIAS at 10,000 feet. Trim tabs – ADJUST 5° bank toward operative engine with approximately 1/2 ball slip indicated on the turn and bank indicator. Cowl Flap – CLOSE (Inoperative Engine). Inoperative Engine – SECURE as follows: Fuel Selector – OFF (Feel For Detent). Auxiliary Fuel Pump – OFF. Magneto Switches – OFF. Alternator Switch – OFF. As Soon as Practical – LAND. The FAA's Airplane Flying Handbook states the following: The basic difference between operating a multiengine airplane and a single-engine airplane is the potential problem involving an engine failure. The penalties for loss of an engine are twofold: performance and control. The most obvious problem is the loss of 50 percent of power, which reduces climb performance 80 to 90 percent, sometimes even more. The other is the control problem caused by the remaining thrust, which is now asymmetrical. Attention to both these factors is crucial to safe one engine inoperative (OEI) flight. The performance and systems redundancy of a multiengine airplane is a safety advantage only to a trained and proficient pilot. Although it is a natural desire among pilots to save an ailing engine with a precautionary shutdown, the engine should be left running if there is any doubt as to needing it for further safe flight. Catastrophic failure accompanied by heavy vibration, smoke, blistering paint, or large trails of oil, on the other hand, indicate a critical situation. The affected engine should be feathered and theSecuring Failed Engine checklist completed. The pilot should divert to the nearest suitable airport and declare an emergency with ATC for priority handling. There are two different sets of bank angles used in OEI flight. 1. To maintain directional control of a multiengine airplane suffering an engine failure at low speeds (such as climb), momentarily bank at least 5° and a maximum of 10° towards the operative engine as the pitch attitude for VYSE [best rate of climb speed with OEI] is set. 2. To obtain the best climb performance, the airplane must be flown at VYSE and zero sideslip with the failed engine feathered and maximum available power from the operating engine. Zero sideslip is approximately 2° of bank toward the operating engine and a one-third to one-half ball deflection also toward the operating engine. If above the airplane's single-engine ceiling, this attitude and configuration results in the minimum rate of sink. On June 30, 2017, about 0935 Pacific daylight time, a Cessna 310R airplane, N87297, was substantially damaged when it was involved in an accident near Santa Ana, California. The pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he checked that both fuel selectors were in the “main” position before starting the engines and during run-up and that they remained in that position throughout the flight. Shortly after departure from John Wayne-Orange County Airport (SNA), Santa Ana, California, and when the airplane was about 400 ft above ground level (agl) with the flaps in the 15°-down position, the right engine lost power. He subsequently transmitted a “mayday” to the air traffic control tower, and a controller then cleared him for landing back at the airport. The pilot then feathered the right propeller, and the airplane was able to maintain an altitude of between about 400 and 500 ft agl as he turned it right onto the downwind leg of the traffic pattern. According to radar data, the airplane maintained a ground speed of between 95 and 102 knots throughout the downwind leg as it slowly neared the runway. The pilot stated that, after turning onto the downwind leg, the controller informed him that the landing gear were retracted. The pilot replied that he knew the landing gear were up and that he would lower them on the final approach leg. During the turn to final, the pilot lowered the landing gear, and the airplane started to descend. The radar track showed the airplane turning right for the final approach at a ground speed of 93 knots, which decreased to 81 knots. After the pilot realized that the airplane was not going to be able to reach the runway, he prepared for a forced landing on a freeway. The airplane subsequently impacted the freeway’s center median. A video provided by a witness showed the airplane in a right-wing-low, 45 bank in a slightly nose-high attitude and descending rapidly toward a freewayfrom the north with the landing gear down. The wings then leveled as the airplane crossed over the freeway about 20 ft agl. The airplane momentarily exited the camera’s view before reappearing impacting the center median divide and opposing lane, followed by fuel spraying from the airplane and subsequent explosions. A security camera video also showed the airplane rapidly descending with the left wing down and the nose high, followed by the left wing impacting the center median divide. Several eyewitnesses reported that they saw the airplane approaching from the northwest, making a right turn, and then suddenly losing altitude. Two witnesses stated that the airplane banked left just before impacting the ground. The debris field was about 150 ft long and crossed over the north- and south-bound lanes of the freeway. The main wreckage was partially consumed by fire, and both engines and propellers remained attached. The horizontal stabilizer had separated from the wreckage and was found farther down the debris field. The airplane had impacted several moving vehicles, and one truck impacted the main wreckage. Postaccident examination revealed that the left and right fuel selector valve handles were in the “main” and “auxiliary” positions, respectively. The left fuel selector valve was found in the “main” position, and the right fuel selector was found pulled past the “off-stop” position. All fuel caps were found, and the fuel tank filler necks were installed with restrictor orifices. Both wing tip tanks had separated from the wings and were found in several sections. The right wing exhibited impact and thermal damage. About 5 ft of the right-wing tip had separated from the wing. The leading edge was crushed from the wing root to the separated tip area. The left wing exhibited impact and thermal damage. About 1 ft of the left-wing tip structure had separated from the wing. The rudder remained attached, and the top half was bent down and right. The horizontal stabilizer had separated from the empennage. Cable control continuity was established to the tail section and both ailerons. The flaps and flap chain drive were found in the 15°-down position. The landing gear were found in the down position. The propeller assemblies exhibited impact damage consistent with a low-power setting during impact sequence. Postaccident examination of the airframe, engines, and propeller assemblies revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N87297
Reported as
Cessna 310R (R)
Category
Airplane
Serial number
310R0506
Built
1975
Airframe hours
8,873
Engines
Cont Motor IO 520 SERIES, 285 horsepower, reciprocatingCont Motor IO 520 SERIES, 285 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 21, 2016 · 74 hours before
Departed
SNA · Santa Ana, CA
Destination
DVT · Phoenix, AZ
Airport
SNA · John Wayne Airport-Orange Coun, runway 20R, 5,701 × 150 ft, asphalt
Equipment
ADS-B

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
62
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 31, 2017
Seat
Left
Restraint
3-point
Flight hours
750 total

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 3 knots
Visibility
8 statute miles
Lowest ceiling
1,600 ft overcast
Temperature
64 °F, dew point 57 °F
Altimeter
29.94 inHg
Observed at
KSNA

Docket · 24

The files NTSB released with the investigation on March 24, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 152 MB in all.

Ntsb-engine data monitor factual reportItem 1 · PDF · 2 pages · 257 KBNtsb-engine data monitor factual report - attachment 1 - download data spreadsheetItem 2 · CSV · 46 KBNtsb-engine data monitor factual report - attachment 2 - plotted engine dataItem 3 · PDF · 4 pages · 379 KBRadar and ATC commItem 4 · MP4 · 10.2 MBRecord of conversation-pilotItem 5 · PDF · 1 page · 199 KBFAA onsite notesItem 6 · PDF · 2 pages · 83 KBFd-onsite notes and photosItem 7 · PDF · 4 pages · 1.4 MBNTSB wreckage examination summaryItem 8 · PDF · 5 pages · 154 KBTextron aviation-tech reportItem 9 · PDF · 9 pages · 1.0 MBCmg-left engine examination reportItem 10 · PDF · 36 pages · 31.0 MBCmg-right engine examination reportItem 11 · PDF · 36 pages · 32.7 MBMaintenance recordsItem 12 · PDF · 6 pages · 4.7 MBMccauley examination memoItem 13 · PDF · 3 pages · 190 KBPOH engine failure after takeoff-excerptsItem 14 · PDF · 5 pages · 158 KBX-ray images of the fuel selector valve assembliesItem 15 · PDF · 3 pages · 242 KBWeight and balance chartItem 16 · PDF · 1 page · 91 KBStatement of party representatives to NTSB investigation-cmgItem 17 · PDF · 1 page · 229 KBStatement of party representatives to NTSB investigation-textron aviationItem 18 · PDF · 1 page · 1.2 MBRelease of aircraft wreckage, NTSB form 6120.15Item 19 · PDF · 1 page · 527 KBPd onsite photo arrayItem 20 · PDF · 5 pages · 2.2 MBFaa-photo arrayItem 21 · PDF · 9 pages · 3.2 MBVideo 1Item 22 · AVI · 26.8 MBVideo 2Item 23 · AVI · 25.4 MBVideo 3Item 24 · MP4 · 9.9 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N87297 · 1

Matched to the same aircraft by N-number and date.