WPR21LA078

NTSB accident investigation · Cessna P210N · Moab, UT · January 2, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
January 2, 2021, 14:30 local (21:30 UTC)
Place
Moab, UT · Airport
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N833RTCessna P210N
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
Vitatoe Aviation LLC, FAA-FSDO
FAA report
20210102000419A
Case key
102485

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 improper application of full throttle during takeoff, which resulted in loss of engine power due to an excessive fuel flow and overly rich fuel mixture.

Findings · 2

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.

Action: incorrect action selectionPersonnel issues › Action/decision · PilotCessna P210N: 2 casesAll aircraft: 397 casesProbable cause
Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Capability exceededCessna P210N: 1 caseAll aircraft: 59 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 was departing on the first flight of the day in cold weather conditions after the airplane had spent several hours inside a hangar to melt ice from the airframe and warm the engine. About 100-200 ft above ground level (agl) shortly after takeoff, the engine began to run rough and lost partial power. He retracted the landing gear, and the engine subsequently lost additional power. The pilot decided to land on the remaining runway and extended the landing gear. The airplane landed on the left side of the runway before veering right and exiting into the snow-covered runway safety area. The right main landing gear collapsed, and the airplane came to rest on the right wingtip and right horizontal stabilizer. The front passenger reported to the pilot that the fuel flow gauge read about 42 gallons of fuel per hour (gph) during the takeoff. Recovered engine data indicated that fuel flow values exceeded 47 gph before the second loss of engine power. During an engine test run, the engine hesitated when the throttle was advanced, and the manifold pressure indicated 34.2 inHg, fuel flow 44 gph, at 2,720 rpm. After the engine reached a normal operating temperature, the engine ran normally. No component adjustments were made to the engine during the test run. According to the engine operating handbook, during the first flight of the day, the manifold pressure will normally exceed 31 inHg and fuel flows will exceed 37 gph if the throttle is opened fully. The handbook advised that manifold pressure be monitored and that the throttle be set to provide 31 inches of manifold pressure. It is likely that, during takeoff, the pilot fully advanced the throttle, which resulted in a high manifold pressure and high fuel flow, an excessively rich fuel/air mixture, and a subsequent loss of engine power.

Factual narrative

On January 2, 2021, about 1430 mountain standard time, a Cessna P210N airplane, N833RT, was substantially damaged when it was involved in an accident near Moab, Utah. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the airplane was brought into a hangar for a few hours to melt ice that had accumulated on the airframe. When the engine would not start after several attempts, the airplane was brought back into the hangar for a few more hours to warm the engine. After the initial engine startup, the oil pressure and oil temperature indications were confirmed, and the pilot taxied the airplane to the runup area. The engine runup revealed no anomalies. Shortly after takeoff, about 100 to 200 ft above ground level (agl), the engine began to run rough and lost partial power. The pilot retracted the landing gear but soon felt additional loss of engine power followed by a loss of altitude and maneuverability. The pilot extended the landing gear and performed a forced landing onto the remaining runway. The airplane landed on the left side of the runway before veering right and exiting into the snow-covered runway safety area. The right main landing gear collapsed, and the airplane came to rest on the right-wing tip and right horizontal stabilizer. The pilot reported that the landing gear was possibly not in the fully extended position upon landing. The front passenger reported to the pilot that the fuel flow gauge indicated about 42 gallons of fuel per hour (gph) during the takeoff. At 1453, the recorded weather at Canyonlands Field Airport (CNY), Moab, Utah, included wind from 330° at 8 knots, and a temperature of -6 C°. The airplane was installed with a Continental IO-550 engine that was converted from a normally aspirated engine to a turbo-normalized engine on November 9th, 2020. This was also the date of the last annual inspection with an engine total time of 0.0 hours. The engine had about 40 hours of operation at the time of the accident. Vitatoe Aviation owns the Supplemental Type Certificate (STC) SA02918CH that was installed. Recovered engine data revealed a loss of rpm, manifold pressure, and fuel pressure during the takeoff. These values were restored shortly before dropping again. Manifold pressure and fuel flow values reached a maximum of 33.7 inHg and 47.9 gph, respectively. During a postaccident test run, the engine hesitated; however, manifold pressure indicated 34.2 in Hg and the fuel flow was 44 gph, at 2,720 rpm. After the engine was at normal operating temperature, the manifold pressure and fuel flow displayed nominal values when the engine was operated at 2,700 rpm. Following the engine test run, a test flight was performed with no anomalies noted through multiple power settings. No component adjustments were made to the engine during the test run. The Vitatoe Pilot Operating Handbook (POH) Supplement Rev. B issued onJuly 24, 2014, stated: On the first flight of the day, when the throttle is advanced for takeoff, manifold pressure will normally exceed 31.0 inches Hg and fuel flows will exceed 37 GPH if the throttle is opened fully. Momentary manifold pressures up to 33.0 inches Hg are acceptable. If manifold pressure consistently exceeds 31.0 inches of Hg, mechanical adjustment may be necessary. On any takeoff, the manifold pressure should be monitored, and the throttle set to provide 31.0 inches Hg; then, for maximum engine power, a full rich mixture should provide at least 35 GPH (36-37 GPH preferred).

Aircraft

Registration
N833RT
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000809
Built
1982
Airframe hours
3,200
Engine
Continental/Vitatoe TSIO-550-P6B, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Nash LLC
Registered owner
Nash LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 8, 2020 · 40 hours before
Departed
KCNY · Moab, UT
Destination
KSLN · Salina, KS
Flight plan
IFR
Airport
CNY · Canyonlands Fld, runway 03/21, 7,360 × 100 ft, asphalt
Equipment
ADS-B, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Satellite tracking device, Stall warning system

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
49
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 9, 2019
Seat
Left
Restraint
3-point
Flight hours
899.5 total · 528.3 in this make and model · 670.5 as pilot in command · 42.6 in the last 90 days · 15.8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
21 °F, dew point 18 °F
Altimeter
3020.00 inHg
Observed at
KCNY

Docket · 10

The files NTSB released with the investigation on April 5, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.3 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.