WPR19LA016

NTSB accident investigation · Cessna T210 · FiIlmore, CA · October 27, 2018

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
October 27, 2018, 10:45 local (17:45 UTC)
Place
FiIlmore, CA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N6834RCessna T210
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Soderlund, Federal Aviation Administration, Teledyne Continental Motors
FAA report
20181027020939A
Case key
98562

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

A total loss of engine power as a result of the pilot’s failure to remove a towel from the engine’s air induction following maintenance.

Findings · 3

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 · Damaged/degradedCessna T210G: 1 caseAll aircraft: 29 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect service/maintenanceCessna T210G: 1 caseAll aircraft: 497 casesProbable cause
MaintenancePersonnel issues › Task performance · PilotCessna T210G: 1 caseAll aircraft: 143 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

The pilot stated that, after a normal departure, he climbed the airplane to a cruise altitude about 4,000 ft mean sea level (msl) and configured it for cruise flight. Thereafter, the engine experienced a sudden total loss of power. Despite his attempts to troubleshoot the failure, he could not restart the engine and performed a forced landing in a dry riverbed. After touchdown, the nose landing gear impacted a rock and collapsed, and the airplane nosed over and came to rest inverted. Examination revealed a cloth towel blocking the turbocharger inlet tube that had become entangled with the turbocharger compressor wheel. The towel likely blocked the inlet air from reaching the cylinders, which resulted in a loss of engine power. The pilot stated that during the last oil change, about 34 flight hours before the accident, he removed the airbox and placed a towel in the inlet scat tubing (not disconnected) in an effort to protect the turbocharger from foreign object damage.

Factual narrative

On October 27, 2018, about 1045 Pacific daylight time, a Cessna T210G, N6834R, was substantially damaged when it was involved in an accident near Fillmore, California. The private pilot and pilot-rated passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the airplane idled on the ground for about 15 minutes before departure while he performed a run-up and waited for traffic to vacate the runway. After making a normal departure, he continued east and climbed to about 4,000 ft mean sea level (msl). While in cruise flight with the airspeed about 105 kts, the engine suddenly lost total power. Despite his attempts to troubleshoot the failure, he could not restart the engine and performed a forced landing in a dry riverbed. After touchdown, the airplane rolled several hundred feet in the dry sand. The nose landing gear impacted a rock and collapsed, and the airplane nosed over and came to rest inverted. An external examination of the engine revealed that the crankcase was intact with no evidence of pre-mishap catastrophic mechanical malfunction or fire. The crankshaft was rotated by turning the propeller blades that remained affixed to the crankshaft flange. Thumb compression was established in all cylinders. Valve train continuity was observed, with equal lift action at each rocker assembly; oil was found in the rocker box areas on all cylinders. Upon rotation of the engine, the magnetos and their respective ignition harnesses produced spark in the proper firing order; the magneto impulse couplings were heard to release. The upper sparkplugs were removed and examined. All sparkplugs were dark in color, but the engine manufacturer’s representative stated that they were consistent with normal wear. A lighted borescope was used to perform an internal examination of each cylinders’ combustion chamber, all of which displayed light combustion deposits. Disassembly of the fuel manifold revealed a liquid that was brown in color and had an odor and appearance similar with a mixture of engine oil and aviation fuel. The engine-driven fuel pump dry-bay outlet pipe was removed, and a trace amount of oily film was present. Removal of the fuel injectors revealed that they were saturated with a brown liquid consistent in smell and appearance to engine oil. The turbocharger compressor outlet pipe/hoses (discharge duct) were disassembled, and oil was present in the conduit. The rubber connector nearest the turbo compressor inlet was removed and a lighted electronic borescope was used to inspect the inlet tube. A yellow terry cloth towel (rag) was discovered blocking the turbo inlet tube and the towel had become entangled with the turbo charger compressor wheel. (see Figure 1.) Figure 1: Turbocharger System (showing towel blocking inlet) The compressor wheel was damaged, and several blades were distorted. After the towel was removed, the compressor wheel was free to rotate.When the turbocharger was unable to rotate normally, the ring seals which are used to seal the turbocharger shaft (between the compressor and turbine wheel) will allow oil to escape the shaft bearing area and enter the compressor section. If the airplane is inverted, the oil could migrate through the discharge duct to the upper deck pressure plumbing to the fuel injectors. From injectors the oil could build in the cylinders and, when inverted, drain into the fuel manifold. Additionally, with the induction tube blocked, no ram air would enter the cylinders. (see Figure 2.) Figure 2: Turbocharger System (showing towel blocking inlet) The oil filter displayed a date of June 8, 2018. The pilot stated that the airplane had accrued about 34 hours since the oil change. He stated that to access the oil filter, he removed the airbox and placed a towel in the scat tubing (not disconnected) in an effort to protect the turbocharger from foreign object damage.

Aircraft

Registration
N6834R
Reported as
Cessna T210 (G)
Category
Airplane
Serial number
T210-0234
Built
1966
Airframe hours
8,745
Engine
Continental TSIO-520-C(2B), 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 27, 2018 · 84.3 hours before
Departed
SZP · Santa Paula, CA
Destination
L45 · Bakersfield, CA
Airport
SZP · Santa Paula
Equipment
Onboard weather, ADS-B, Auto-pilot, Handheld GPS

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
70
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Last flight review
December 15, 2017
Seat
Left
Restraint
3-point
Flight hours
5,300 total

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 7 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 55 °F
Altimeter
30.01 inHg
Observed at
KSZP, 6 nm away

Docket · 5

The files NTSB released with the investigation on March 9, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 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.

Other investigations on N6834R · 2

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