# NTSB WPR23LA177: Cessna 210M, N777CF, Pasco, WA, May 4, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 3, 2023, 18:35 local (May 4, 2023, 01:35 UTC) - Place: Pasco, WA - Coordinates: 46.277985, -119.10897 - Nearby events: https://openairdocs.org/map.md?lat=46.2780&lon=-119.1090&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 109772 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA177 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/109772/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=109772 - Page: https://openairdocs.org/ntsb/WPR23LA177 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 210M, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2073450), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 210M, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=2073450), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 210M, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073450), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna 210M, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2073450), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 210M, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073450), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N777CF), registered now, S/N 21062059, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 210M - Registry model: [Cessna 210M](https://openairdocs.org/model/cessna-210m) (registry code 2073450) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21062059 - Year built: 1977 - Airframe hours: 2230.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: none; 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 ## 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 20230504006519A](https://openairdocs.org/incident/20230504006519A), May 4, 2023: Cessna 210M, Pasco, WA, Substantial damage. Repositioning flight from rld to psc and on downwind. Radios were intermittent. Just turning base the engine died. Aircraft couldn't make it to the field and… ## Docket (10 files) The files NTSB released with the investigation on November 7, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=109772. 46.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 16 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17525778&FileExtension=pdf&FileName=NTSB%20Form%206120%20WR23LA177_Redacted-Rel.pdf - Photos (item 2, PDF, 4 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17621339&FileExtension=pdf&FileName=Photos%20for%20WPR23LA177-Rel.pdf - Airframe and engine examination final report (item 3, PDF, 14 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17529762&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination%20Report%20WPR23LA177-Rel.pdf - Memo for record engine examination #1 (item 4, PDF, 2 pages, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17528865&FileExtension=pdf&FileName=MFR%20Engine%20exam-Rel.pdf - Airframe and engine examination number 2 (item 5, PDF, 5 pages, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17529772&FileExtension=pdf&FileName=Airframe%20and%20engine%20exam-Rel.pdf - Engine data monitor MVP-50 data (item 6, CSV, 960 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17528736&FileExtension=csv&FileName=accident%20flight%20csv-Rel.csv - Interviews (item 7, PDF, 4 pages, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17528662&FileExtension=pdf&FileName=Interviews%20All-Rel.pdf - Maintenance records (item 8, PDF, 5 pages, 37.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17528381&FileExtension=pdf&FileName=May%208%20Doc%203_Redacted-Rel.pdf - Maintenance manual for removal of alternator (item 9, PDF, 2 pages, 340 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17565536&FileExtension=pdf&FileName=MM%20Alternator%20removal-Rel.pdf - Record of conversation owner (item 10, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17528828&FileExtension=pdf&FileName=ROC%20Mark%20Peterson%20Owner-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.