# NTSB WPR17LA136: Cessna 310R, N87297, Santa Ana, CA, June 30, 2017

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Class 3 · Limited · Final report
- Date: June 30, 2017, 09:35 local (16:35 UTC)
- Place: Santa Ana, CA
- Coordinates: 33.685001, -117.86277
- Nearby events: https://openairdocs.org/map.md?lat=33.6850&lon=-117.8628&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Western Pacific Region
- Parties: FAA-FSDO, Textron Aviation, Continental Motors Group
- NTSB case key (mKey): 95468
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17LA136
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95468/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95468
- Page: https://openairdocs.org/ntsb/WPR17LA136

## 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

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

- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Cessna 310R, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2074245), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Cessna 310R, 2 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2074245), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 310R, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2074245), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 310R, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2074245), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Fuel system: fuel pressure](https://openairdocs.org/ntsb-findings/01022844): Aircraft › Aircraft systems · Failure; cases with it: [Cessna 310R, 1 case](https://openairdocs.org/ntsb-findings/01022844/cases.md?model=2074245), [All aircraft, 16 cases](https://openairdocs.org/ntsb-findings/01022844/cases.md)
- [Aircraft](https://openairdocs.org/ntsb-findings/01050000): Aircraft › Aircraft power plant · Inoperative; cases with it: [Cessna 310R, 2 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md?model=2074245), [All aircraft, 151 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 310R, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2074245), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Approach-VFR pattern final: Loss of lift](https://openairdocs.org/ntsb-events/500); cases with it: [Cessna 310R, 1 case](https://openairdocs.org/ntsb-events/500/sequence.md?model=2074245), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md)

## 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](https://openairdocs.org/deregistered/N87297-2020-10-03), registration cancelled 2020-10-03, S/N 310R0506, built 1975 (OpenAirDocs)
- Reported make and model: CESSNA 310R (R)
- Registry model: [Cessna 310R](https://openairdocs.org/model/cessna-310r) (registry code 2074245) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 310R0506
- Year built: 1975
- Airframe hours: 8873
- Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating; CONT 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 62; injuries: serious; 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

## 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 20170630008769A](https://openairdocs.org/incident/20170630008769A), Jun 30, 2017: Cessna 310R, Santa Ana, CA, Destroyed. N87297 departed sna at 9:33AM. Shortly after departure, at approximately 400 feet AGL, flying runway heading, and crossing the end of the runway, the pilot…

## Other investigations on N87297 (1)

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.

- [NTSB BFO88LA083](https://openairdocs.org/ntsb/BFO88LA083), Sep 15, 1988: Cessna 310R (N87297), Washington, DC, substantial damage

## Docket (24 files)

The files NTSB released with the investigation on March 24, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95468. 152 MB in all.

- Ntsb-engine data monitor factual report (item 1, PDF, 2 pages, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006828&FileExtension=pdf&FileName=WPR17LA136_Engine%20Monitor_FINAL-Rel.pdf
- Ntsb-engine data monitor factual report - attachment 1 - download data spreadsheet (item 2, CSV, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12007079&FileExtension=csv&FileName=WPR17LA136%20-%20Attachment%201-Rel.csv
- Ntsb-engine data monitor factual report - attachment 2 - plotted engine data (item 3, PDF, 4 pages, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006896&FileExtension=pdf&FileName=Plotted%20Engine%20Data-Rel.pdf
- Radar and ATC comm (item 4, MP4, 10.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006818&FileExtension=mp4&FileName=N87297-Rel.mp4
- Record of conversation-pilot (item 5, PDF, 1 page, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11655798&FileExtension=pdf&FileName=Record%20of%20Conversation-Pisano_Redacted-Rel.pdf
- FAA onsite notes (item 6, PDF, 2 pages, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657176&FileExtension=pdf&FileName=N87297%206-29-17%20Accident,%20FAA%20Notes-OUO_Redacted-Rel.pdf
- Fd-onsite notes and photos (item 7, PDF, 4 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12078813&FileExtension=pdf&FileName=405%20Incident%20FAA%20-Rel.pdf
- NTSB wreckage examination summary (item 8, PDF, 5 pages, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656671&FileExtension=pdf&FileName=WPR17LA136%20Wreckage%20Examination%20Notes-OUO-Rel.pdf
- Textron aviation-tech report (item 9, PDF, 9 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11678827&FileExtension=pdf&FileName=Tech%20Report%20310R0506_Redacted-Rel.pdf
- Cmg-left engine examination report (item 10, PDF, 36 pages, 31.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656116&FileExtension=pdf&FileName=Continental%20Motors%20Engine%20Examination%20Report%20N87297%20LE-Rel.pdf
- Cmg-right engine examination report (item 11, PDF, 36 pages, 32.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11655788&FileExtension=pdf&FileName=Continental%20Motors%20Engine%20Examination%20Report%20N87297%20RE-Rel.pdf
- Maintenance records (item 12, PDF, 6 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656651&FileExtension=pdf&FileName=Maintenance%20Records%20Excerpts-DMS_Redacted-Rel.pdf
- Mccauley examination memo (item 13, PDF, 3 pages, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12079471&FileExtension=pdf&FileName=MPS-18-002ATeardown%20Inspection%20of%20Propeller%20from%20Cessna%20310R%20N87297%20Accident%2017-07_Redacted-Rel-Rel.pdf
- POH engine failure after takeoff-excerpts (item 14, PDF, 5 pages, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656661&FileExtension=pdf&FileName=Pages%20from%20C310R_POH-2%20Engine%20Failure%20After%20Takeoff-Rel.pdf
- X-ray images of the fuel selector valve assemblies (item 15, PDF, 3 pages, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657587&FileExtension=pdf&FileName=310%20Fuel%20Valve%20Assembly-Rel.pdf
- Weight and balance chart (item 16, PDF, 1 page, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657972&FileExtension=pdf&FileName=Weight%20and%20Balance%20310R_-Rel.pdf
- Statement of party representatives to NTSB investigation-cmg (item 17, PDF, 1 page, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657346&FileExtension=pdf&FileName=NTSB%20Party%20Statement%20-%20WPR17LA136%20Charnon_Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation-textron aviation (item 18, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657186&FileExtension=pdf&FileName=NTSB%20Party%20Form-Textron%20Aviation_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 527 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656895&FileExtension=pdf&FileName=Retention-Release-of-Wreckage-Form%202015%20signed_Redacted-Rel.pdf
- Pd onsite photo array (item 20, PDF, 5 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006307&FileExtension=pdf&FileName=Onsite%20Photo%20Array-Rel.pdf
- Faa-photo array (item 21, PDF, 9 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12079384&FileExtension=pdf&FileName=FAA%20Photo%20Array-Rel.pdf
- Video 1 (item 22, AVI, 26.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656592&FileExtension=avi&FileName=C016_PTZ_TRMA__AOA_Gate_8_2017-06-30_2039-Rel.avi
- Video 2 (item 23, AVI, 25.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657256&FileExtension=avi&FileName=C871_PTZ_MainSt_Parking_SW_Bus_2017-06-30_2035-Rel.avi
- Video 3 (item 24, MP4, 9.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11656843&FileExtension=mp4&FileName=Video%20of%20crashing%20airplane-Rel.mp4

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.

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