WPR23LA177

NTSB accident investigation · Cessna 210M · Pasco, WA · May 4, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
May 3, 2023, 18:35 local (May 4, 2023, 01:35 UTC)
Place
Pasco, WA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N777CFCessna 210M
Defining event
Landing: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20230504006519A
Case key
109772

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

Improper maintenance on the fuel outlet line to the fuel servo, which resulted in the line partially separating from the fuel outlet fitting and the subsequent fuel starvation and total loss of engine power.

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 210M: 1 caseAll aircraft: 371 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Incorrect service/maintenanceCessna 210M: 1 caseAll aircraft: 141 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 returning the airplane to its home airport after completion of a 100-hour inspection, an annual inspection, and additional maintenance that was required due to the improper installation of the battery. While on the base leg for landing, the engine lost total power. The pilot initiated an off-airport emergency landing and during the rollout, the airplane contacted road signs, which substantially damaged the left and right wings and the right horizontal stabilizer. Recorded engine data revealed consistent operation of the engine throughout the flight until about 1-minute before the loss of data, when the data indicated a total loss of power. Examination of the engine revealed the fuel outlet line to the fuel servo was loose on the fuel outlet fitting, which resulted in fuel starvation of the engine. When the improper maintenance to the fuel line occurred could not be determined; the recent maintenance performed on the engine did not require removal of the fuel outlet line.

Factual narrative

On May 3, 2023, about 1835 Pacific daylight time, a Cessna 210M, N777CF, was substantially damaged when it was involved in an accident near Pasco, Washington. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal fight. The pilot reported that he departed the Richland Airport (RLD), Richland, Washington, and was destined for the Tri-Cities Airport (PSC), Pasco, Washington--the airplane’s home airport. While on the base leg for runway 21L, at about 85 knots airspeed, the engine lost total power. The pilot initiated an emergency landing to an off-airport site and, during the rollout, the airplane contacted road signs, which substantially damaged the left and right wings and the right horizontal stabilizer. The pilot reported that the airplane had just undergone an annual inspection and that there were about 66 gallons of fuel in the wing tanks for the 10-mile flight. Data recovered from the engine data monitor (EDM) revealed engine performance parameters for the 30-minute accident flight. The data revealed consistent operation for the engine throughout the takeoff, climb, enroute-cruise, and descent phases of flight. During the last minute of the flight, all cylinder head temperatures, all exhaust gas temperatures and the fuel flow and fuel psi reduced in value consistent with a total loss of power. The engine was examined and prepared for a test run. Attempts to test run the engine resulted in the engine running for about 2 to 3 seconds before losing power; fuel was observed puddling under the airplane. Further examination revealed the fuel servo outlet line was loosely attached to the fuel servo fitting as shown in Figure 1. No additional anomalies were noted with the airframe or engine that would have precluded normal operation. Figure 1. Photo showing the fuel line off the fuel fitting of the fuel servo. A review of the maintenance logbooks for the airplane revealed that the airplane had undergone a 100-hour inspection that was signed off by the shop’s airframe and powerplant mechanic. The airplane also underwent an annual inspection that was signed off by a shop employee with inspection authorization. According to the mechanic who performed the 100-hour inspection, while working on the airplane, he mistakenly installed the battery leads on the wrong battery posts. This action resulted in a need for additional maintenance over and above the 100-hour and the annual inspections. This additional maintenance included removing and replacing the alternator, and voltage regulator, in addition to removing and repairing the Garmin GTN750, and the transponder. According to the Director of Maintenance, the maintenance shop used online digital maintenance manuals for all the maintenance performed on the airplane and that he could see no reason the fuel line would have been disturbed when removing or reinstalling the alternator. A review of the Cessna Maintenance Manual instructions for removal ofthe alternator did not direct removal of the fuel servo outlet line. Maintenance records did not show maintenance performed on the fuel servo or fuel outlet line, going back as far as the installation of the rebuilt engine around November 8, 2016.

Aircraft

Registration
N777CF
Reported as
Cessna 210M
Category
Airplane
Serial number
21062059
Built
1977
Airframe hours
2,230.4
Engine
Continental IO-520L-46B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 3, 2023
Departed
RLD · Richland, WA
Destination
Same as departure
Flight plan
VFR
Airport
KPSC · Tri-cities Airport, runway 21L, 4,423 × 75 ft, asphalt
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display

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
66
Injuries
None
Certificates
Private, Recreational
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
April 20, 2023
Seat
Left
Restraint
3-point
Flight hours
2,666 total · 72.75 in this make and model · 15.6 in the last 90 days · 8.4 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 7 knots
Visibility
4 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 57 °F
Altimeter
29.52 inHg
Observed at
KPSC
METAR
KPSC 040153Z 34007KT 4SM HZ CLR 30/14 A2952 RMK AO2 SLP994 T03000144

Docket · 10

The files NTSB released with the investigation on November 7, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 46.0 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.