# NTSB WPR19LA016: Cessna T210, N6834R, FiIlmore, CA, October 27, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: October 27, 2018, 10:45 local (17:45 UTC) - Place: FiIlmore, CA - Coordinates: 34.374168, -118.96194 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3742&lon=-118.9619&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Soderlund, Federal Aviation Administration, Teledyne Continental Motors - NTSB case key (mKey): 98562 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98562/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98562 - Page: https://openairdocs.org/ntsb/WPR19LA016 ## 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 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 · Damaged/degraded (probable cause); cases with it: [Cessna T210G, 1 case](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=2073432), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna T210G, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2073432), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna T210G, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=2073432), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/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 (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna T210G, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073432), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## 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](https://openairdocs.org/deregistered/N6834R-2019-10-18), registration cancelled 2019-10-18, S/N T210-0234, built 1966 (OpenAirDocs) - Reported make and model: Cessna T210 (G) - Registry model: [Cessna T210G](https://openairdocs.org/model/cessna-t210g) (registry code 2073432) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: T210-0234 - Year built: 1966 - Airframe hours: 8745 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: minor; 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 ## 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 20181027020939A](https://openairdocs.org/incident/20181027020939A), Oct 27, 2018: Cessna T210G, Santa Paula, CA, Substantial damage. On 10/27/2018 N6834R a Cessna T210G departed Santa Paula airport. During climbout to the east at four thousand feet the engine lost power. A turn was initiated… ## Other investigations on N6834R (2) 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 LAX79FUG25](https://openairdocs.org/ntsb/LAX79FUG25), Mar 24, 1979: Cessna T210G (N6834R), Chino, CA, substantial damage - [NTSB MKC69D0398](https://openairdocs.org/ntsb/MKC69D0398), Apr 3, 1969: Cessna T210G (N6834R), Ravenna, NE, substantial damage ## Docket (5 files) The files NTSB released with the investigation on March 9, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98562. 2.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 305 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11465717&FileExtension=pdf&FileName=Z%20-%20Attachment%2001%20-6120_Redacted-Rel.pdf - Record of conversations (item 2, PDF, 1 page, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11465982&FileExtension=pdf&FileName=Z%20-%20Attachment%2003%20-Records%20of%20Conversation-Rel.pdf - Examination notes (item 3, PDF, 8 pages, 11 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11466651&FileExtension=pdf&FileName=Z%20-%20Attachment%2002%20-Examination%20Notes-Rel.pdf - Jpi data (item 4, CSV, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11616472&FileExtension=csv&FileName=JPI%20Data-Rel.csv - Statement of party representatives to NTSB investigation (item 5, PDF, 1 page, 353 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11466699&FileExtension=pdf&FileName=Z%20-%20Attachment%2004%20-Party%20Form_Redacted-Rel.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.