Saturday, April 10, 2021

Fuel Exhaustion: Cessna 210L Centurion, N210HH; accident occurred April 28, 2020 in New Braunfels, Texas

Aviation Accident Factual Report - National Transportation Safety Board 

The National Transportation Safety Board did not travel to the scene of this accident. 

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; San Antonio, Texas
Textron Aviation; Wichita, Kansas 
Continental Motors; Mobile, Alabama 
RAM Aircraft LP, Waco, Texas

Investigation Docket - National Transportation Safety Board: 

Location: New Braunfels, Texas
Accident Number: CEN20LA162
Date & Time: April 28, 2020, 09:58 Local
Registration: N210HH
Aircraft: Cessna T210
Aircraft Damage: Substantial
Defining Event: Fuel exhaustion
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General aviation - Personal

On April 28, 2020, about 0958 central daylight time, a Cessna T210L airplane, N210HH, was substantially damaged when it was involved in an accident near New Braunfels, Texas. The private pilot sustained no injuries and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot reported that he and a passenger departed on a flight about 0830 from the Midland Airpark (MDD), near Midland, Texas, and were enroute to the New Braunfels Regional Airport, near New Braunfels, Texas, (BAZ). He stated that he had performed the "standard" pre-flight checks that included confirming the airplane had about 70 gallons of fuel based on 3 different factors. He and the airplane owner discussed the amount of fuel in the airplane when it was flown last and the owner thought it was full. During the preflight inspection, the pilot noted that the fuel gauges were showing about 70 gallons available. The pilot, in part, stated, "Additionally, I visually inspected both tanks and saw that they were about even and while not completely full, they were close to full." When further asked if he used a stick to verify the fuel level, he stated, "I did not 'stick' the tanks. They appeared to visually match the gauges." To verify the level of fuel the pilot stated, "I used the step on the airplane that is there to stand on and look into the tanks." He stated that the grade of the ramp surface during the preflight was flat.

The flight cruised about 7,500 ft msl. The pilot started a descent to remain clear of the clouds and checked the weather at BAZ. There were broken clouds below 3,900 ft with a ceiling of about 3,500 ft. When the pilot called the BAZ air traffic control tower, he was advised that weather conditions required him to file an instrument flight rules (IFR) flight plan.

The pilot filed a flight plan and subsequently discussed the approach type with an approach controller. The pilot elected an area navigation (RNAV) approach for runway 17, was cleared to fly to a fix on the RNAV 17 approach, and was cleared to climb to 3,000 ft. The pilot programed the RNAV 17 approach in the GPS and headed to the assigned fix.

During the climb, the pilot noticed that the airspeed was decreasing and the engine was not producing normal power. The pilot performed an emergency checklist, and subsequently initiated a descent to an altitude where he could see the ground.

The pilot continued with emergency checklists, which included selecting the fullest tank, and activating the auxiliary fuel pump. However, he was unable to increase engine power. The engine remained at 2,500 RPM.

Upon exiting the clouds, the pilot reduced the airplane's descent rate and evaluated forced landing options. The pilot advised approach control of his decision to land in a field at the end of Canyon Lake. After he realized the flight would not reach the field, the pilot elected to land on the lake with the landing gear intentionally retracted.

The pilot picked a spot in the lake that was clear of boats and trees. Upon reaching a few feet above the water, the pilot "killed the motor," flared to bleed off speed, and kept the airplane's nose up. 

The passenger, in part, stated, "During the landing, I hit my head on the yoke, fell back into my chair, and then tried [to] make my way out of the plane."

The pilot and passenger exited through the windows and subsequently swam to the shore.

Pilot Information

Certificate: Private 
Age: 43,Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: 3-point
Instrument Rating(s): Airplane 
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without waivers/limitations
Last FAA Medical Exam: October 23, 2018
Occupational Pilot: No
Last Flight Review or Equivalent: November 5, 2019
Flight Time: 2256 hours (Total, all aircraft), 97 hours (Total, this make and model), 2256 hours (Pilot In Command, all aircraft), 11 hours (Last 90 days, all aircraft), 11 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

According to the pilot's logbook, he accumulated 144.1 hours of total flight time between the accident flight and his flight review on November 5, 2019, of which 9.4 hours were in the accident airplane and the remainder of that total time was in a Cirrus SR22T.

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N210HH
Model/Series: T210 L 
Aircraft Category: Airplane
Year of Manufacture: 1976 
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 21061462
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: December 5, 2019 Annual
Certified Max Gross Wt.: 3800 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 4707.3 Hrs as of last inspection
Engine Manufacturer: Continental
Engine Model/Series: IO-520-R
Registered Owner:
Rated Power: 310 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

The full cantilever wings have integral fuel tanks. The integral fuel tanks are formed by the forward spar, two sealing ribs, and an aft fuel tank spar forward of the main spar. The fuel system consists of two vented integral fuel tanks (one in each wing), two fuel reservoir tanks, a fuel selector valve, auxiliary fuel pump, fuel strainer, engine-driven fuel pump, fuel/air control unit, fuel manifold, and fuel injection nozzles. The fuel tanks have a total capacity of 90 gallons of which 89 gallons is usable. Fuel quantity is measured by four electrically operated capacitance type fuel quantity transmitters (two in each tank) and indicated by two electrically operated fuel quantity indicators on the right side of the instrument panel. The indicators are marked in gallons (top scale) and pounds (bottom scale) with a red line indicating an empty tank. When an indicator shows an empty tank, about 0.5 gallon remains in the tank as unusable fuel.

The performance specification in the airplane owner's manual, in part, stated that at 10,000 ft, a power setting of 75%, the expected range of the airplane was 830 nautical miles with a time of 4.8 hours.

The airplane's Pilot Safety And Warning Supplements, in part, indicated, "Poor fuel management is often the cause of aircraft accidents. 

The aircraft should be on level ground during all fueling operations, since filling the tanks when the aircraft is not level may result in a fuel quantity less than the maximum capacity. Rapid filling of a fuel tank, without allowing time for air in the tank to escape, may result in a lower fuel quantity.  Some Cessna single-engine airplanes have long, narrow fuel tanks. If your airplane is so equipped, it may be necessary to partially fill each tank alternately, and repeat the sequence as required to completely fill the tanks to their maximum capacity. This method of fueling helps prevent the airplane from settling to a wing-low attitude because of increased fuel weight in the fullest wing tank.

It is always the responsibility of the pilot-in-command to ensure sufficient fuel is available for the planned flight. A pilot should not begin a flight without determining the fuel required and verifying its presence onboard."

The airplane owner's manual, in part, stated, "Prepare for ditching by securing or jettisoning heavy objects located in the baggage area and collect folded coats or cushions for protection of occupants' face at touchdown."

According to the airplane owner and airport records, the airplane was topped of at Llano Municipal Airport (AQO) Llano, Texas, with 46.8 gallons of 100 low lead fuel on March 8, 2020, about 1743. The fuel farm ramp at AQO exhibited a level surface and the airplane owner stated that the airplane appeared level during the fueling service. He visually verified the fuel level as he filled each fuel tank and by the fuel gauges. The owner then flew the airplane to MDD and review of his logbook showed that flight time was 2 hours. On March 28, 2020, the owner flew the airplane locally at MDD for 1.5 hours of flight time.

No struts or steps on the side of the fuselage were seen during a review of photographs of the recovered airplane.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument (IMC)
Condition of Light: Day
Observation Facility, Elevation: KBAZ,645 ft msl 
Distance from Accident Site: 15 Nautical Miles
Observation Time: 09:51 Local 
Direction from Accident Site: 128°
Lowest Cloud Condition: 
Visibility:  6 miles
Lowest Ceiling: Broken / 800 ft AGL 
Visibility (RVR):
Wind Speed/Gusts: 11 knots / 
Turbulence Type Forecast/Actual:  /
Wind Direction: 190° 
Turbulence Severity Forecast/Actual:  /
Altimeter Setting: 29.94 inches Hg
Temperature/Dew Point: 26°C / 22°C
Precipitation and Obscuration: Moderate - None - Haze
Departure Point: Midland, TX (MDD)
Type of Flight Plan Filed: None
Destination: New Braunfels, TX (BAZ)
Type of Clearance: VFR flight following
Departure Time: 08:27 Local 
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 None 
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 29.867776,-98.275833(est)

A Federal Aviation Administration inspector oversaw the recovery of the airplane from the lake and documented the condition of the airplane. The airplane exhibited wrinkled fuselage skins. There were no wing skin anomalies around the integral fuel tanks. Utilizing five-gallon containers, recovered liquid from one fuel tank filled about 2.5 inches of the bottom of one container and a liquid from the other fuel tank filled about 3.5 inches of the bottom of another container.

The airplane's wings were removed, and the disassembled airplane was taken to a recovery yard. Subsequently the sparkplugs were removed by recovery personnel and the plugs did not exhibit any anomalies that could not be attributed to water submersion. About 1/2 gallon of liquid consistent with water was recovered from each header fuel tank. No debris was observed on the fuel screen when
recovery personnel removed it. The fuel manifold was disassembled, and no liquid was observed under its diaphragm. There was a rivet head lodged in the turbocharger impeller. However, there was no damage to the impeller blades, nor any scoring to the sidewalls. Once removed, the turbocharger impeller rotated freely when recovery personnel rotated it by hand.

The magnetos were dried out and a fuel can was plumbed to the airplane by recovery personnel for a test run of the engine. The engine was started, and it was operational during the test run.

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