# NTSB WPR21LA078: Cessna P210N, N833RT, Moab, UT, January 2, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: January 2, 2021, 14:30 local (21:30 UTC) - Place: Moab, UT · Airport - Coordinates: 38.757499, -109.75354 - Nearby events: https://openairdocs.org/map.md?lat=38.7575&lon=-109.7535&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: No injuries - Injuries: 4 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Vitatoe Aviation LLC, FAA-FSDO - NTSB case key (mKey): 102485 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21LA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102485/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102485 - Page: https://openairdocs.org/ntsb/WPR21LA078 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna P210N, 2 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2073454), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Engine fuel and control: fuel controlling system](https://openairdocs.org/ntsb-findings/01057320): Aircraft › Aircraft power plant · Capability exceeded (probable cause); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/01057320/cases.md?model=2073454), [All aircraft, 59 cases](https://openairdocs.org/ntsb-findings/01057320/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 P210N, 11 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2073454), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Takeoff-rejected takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna P210N, 7 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073454), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## 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](https://openairdocs.org/aircraft/N833RT), registered now, S/N P21000809, built 1982 (OpenAirDocs) - Reported make and model: CESSNA P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P21000809 - Year built: 1982 - Airframe hours: 3200 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; 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 ## 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 20210102000419A](https://openairdocs.org/incident/20210102000419A), Jan 2, 2021: Cessna P210N, Moab, UT, Substantial damage. After takeoff from runway 03, at 100-200FT above the ground, the aircraft experienced a loss of power and the pilot retracted the landing gear to reduce drag.… ## Docket (10 files) The files NTSB released with the investigation on April 5, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102485. 12.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15198577&FileExtension=pdf&FileName=WPR21LA078%20NTSB%20pilot%20report%206120_Redacted-Rel.pdf - Photo array-onsite (courtesy of the airport manager) (item 2, PDF, 5 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15139152&FileExtension=pdf&FileName=Photo%20Array-Accident%20Site%20(Courtesy%20of%20the%20Airport%20Manager)-Rel.pdf - Statement of party representatives to NTSB investigation-vitatoe (item 3, PDF, 1 page, 942 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15080246&FileExtension=pdf&FileName=Party%20Form-Vitatoe_Redacted-Rel.pdf - Engine logbook excerpt (item 4, PDF, 1 page, 845 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15079947&FileExtension=pdf&FileName=N833RT%20annual%202020%20engine%20log_Redacted-Rel.pdf - Vitatoe POH supplement-amplified procedures-excerpt (item 5, PDF, 2 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15080681&FileExtension=pdf&FileName=Vitatoe%20POH%20Supplement-Amplified%20Procedures-Excerpt_Redacted-Rel.pdf - Vitatoe POH supplement-normal procedures-excerpts (item 6, PDF, 2 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15080854&FileExtension=pdf&FileName=Vitatoe%20POH%20Supplement-Normal%20Procedures-Excerpt_Redacted-Rel.pdf - Raw engine data (item 7, PDF, 9 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15138187&FileExtension=pdf&FileName=Raw%20Engine%20Data-Rel.pdf - Engine data and graphs (item 8, PDF, 1 page, 809 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15138850&FileExtension=pdf&FileName=Engine%20Data%20and%20Graphs-Rel.pdf - Beegles test run results (item 9, PDF, 1 page, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15079603&FileExtension=pdf&FileName=Email,%20Beegles%20Engine%20Test%20Run-Results_Redacted-Rel.pdf - Email-vitatoe reply on engine test run results (item 10, PDF, 3 pages, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15139053&FileExtension=pdf&FileName=Email%205-17-2021%20Vitatoe%20reply%20on%20engine%20run%20results_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.