The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Oklahoma City, Oklahoma
Continental Motors; Mobile, Alabama
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Oklahoma City, Oklahoma
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas
Investigation Docket - National Transportation Safety Board:
Location: Ada, Oklahoma
Accident Number: CEN20LA053
Date and Time: January 1, 2020, 15:46 Local
Registration: N94227
Aircraft: Cessna T210
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 2 Minor
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot and one passenger were conducting a cross-country flight in the single engine airplane. The pilot thought that the fuel tanks had been topped off on a level surface before departure, but he did not observe the fueling and did not confirm the actual fuel quantity before departure. About 3.5 hours after departure, after having switched from the left fuel tank to the right, the pilot reported that the engine experienced a loss of power and told air traffic control (ATC) that he had a fuel issue and needed to land immediately. The pilot was able to restart the engine briefly but again experienced a loss of engine power. He made a forced landing to a field then continued into a fence and impacted several trees and the airplane sustained substantial damage to both wings, fuselage, empennage, and engine mounts.
Postaccident examination of the wreckage revealed that both fuel tanks were breached at the leading edges. The fuel tank caps were secured in place and there was no sign of blue fuel staining on the wings. The examination did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation.
A postaccident fuel calculation based on fuel receipts for the round-trip cross-country flight revealed that the airplane would have contained about 69 gallons of fuel before departure. Based on the fuel calculation, there should have been about 26 gallons of fuel remaining in the fuel tanks during the loss of engine power. The pilot stated that he did not complete a preflight fuel burn calculation or check the amount of fuel on the fuel receipt after fueling.
It is likely that the pilot did not switch to the right fuel tank when he reported doing so or did not allow enough time for the fuel to reach the engine before attempting an engine restart. Based on postaccident fuel calculations and the lack of evidence of a fuel tank leak, the pilot did not adequately manage the available fuel during the flight, which resulted in fuel starvation and a loss of engine power.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation, and the pilot’s inadequate preflight inspection and preflight fuel planning.
Findings
Personnel issues Preflight inspection - Pilot
Personnel issues Fuel planning - Pilot
Personnel issues Decision making/judgment - Pilot
Aircraft Fuel - Fluid management
Environmental issues Rough terrain - Contributed to outcome
Factual Information
History of Flight
Prior to flight Aircraft inspection event
Enroute-cruise Fuel starvation (Defining event)
Landing-flare/touchdown Off-field or emergency landing
On January 1, 2020, about 1546 central standard time, a Cessna T210L airplane, N94227, was substantially damaged with it was involved in an accident near Ada, Oklahoma. The pilot and one 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 had the fuel tanks topped off at Centennial Airport (APA), Denver, Colorado, and departed with 90 gallons of fuel. He had the right fuel tank selected during takeoff and initial climb and noted a fuel burn of 16.5 gallons per hour during the climb. After climbing to 11,500 ft mean sea level, he noted a fuel burn of 14.5 gallons per hour and switched to the left tank. After using the left tank for 1.75 hours, he switched to the right tank for about 1.25 hours.
According to an ATC summary and automatic dependent surveillance-broadcast data, at 1539, the airplane was in cruise flight about 11,500 ft mean sea level when the pilot reported a fuel issue to ATC and requested to land immediately. About 1 minute later, while receiving directions to Ada Regional Airport (ADH), Ada, Oklahoma, the pilot stated that he restarted the engine and continued to descend toward ADH. According to the pilot, when the engine experienced a loss of power, he selected the left fuel tank and the engine successfully restarted for a short time. The engine again experienced a loss of power, and he was unable to restart it, so he proceeded to ADH. The controller mistakenly reported the ADH airport identifier as ADA several times when queried by the pilot.
At 1543, the pilot stated that he was having issues with his instruments and then received a nogyro vector approach from ATC. At 1545, the pilot stated that he had the airport in sight. According to the pilot, as he descended and approached ADH, he extended the landing gear and flaps. At 1546, radar contact was lost, and the pilot stated, “I’m not sure I can make this runway, I’m trying.” There were no further transmissions from the pilot. The airplane cleared one set of powerlines then the pilot maneuvered under a second set of powerlines and made a forced landing.
Pilot Information
Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With waivers/limitations
Last FAA Medical Exam: July 20, 2018
Occupational Pilot: No
Last Flight Review or Equivalent: October 19, 2019
Flight Time: 1915 hours (Total, all aircraft), 1582 hours (Pilot In Command, all aircraft), 8.3 hours (Last 90 days, all aircraft), 6 hours (Last 30 days, all aircraft)
Passenger Information
Certificate:
Age: Female
Airplane Rating(s):
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: 3-point
Instrument Rating(s):
Second Pilot Present: No
Instructor Rating(s):
Toxicology Performed: No
Medical Certification:
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:
The pilot completed a 1.4-hour flight review in the accident airplane on October 24, 2019, then flew the airplane 1 hour back home. Before these flights, the last time he had flown the airplane was on February 13, 2016.
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N94227
Model/Series: T210 L
Aircraft Category: Airplane
Year of Manufacture: 1974
Amateur Built:
Airworthiness Certificate: Normal
Serial Number: 21060549
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: October 6, 2019 Annual
Certified Max Gross Wt.: 3800 lbs
Time Since Last Inspection: 12 Hrs
Engines: 1 Reciprocating
Airframe Total Time: 5997 Hrs as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: TSIO-520-R
Registered Owner:
Rated Power: 310 Horsepower
Operator: On file
Operating Certificate(s) Held: None
The airplane's pilot operating handbook listed that the airplane holds 90 gallons of fuel, 1 gallon of which is unusable (45 gallons in each tank, 0.5 gallon of which is unusable).
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KADH, 1016 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 21:55 Local
Direction from Accident Site: 15°
Lowest Cloud Condition: Clear
Visibility 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 17 knots / 26 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 200°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.68 inches Hg
Temperature/Dew Point: 11°C / 1°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Denver, CO (APA)
Type of Flight Plan Filed: None
Destination: Shreveport, LA (SHV)
Type of Clearance: VFR flight following
Departure Time: 12:06 Local
Type of Airspace: Class E
Page 6 of 9 CEN20LA053
Airport Information
Airport: Ada Regional Airport ADH
Runway Surface Type:
Airport Elevation: 1015 ft msl
Runway Surface Condition: Unknown
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced landing
Wreckage and Impact Information
Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries:
Aircraft Explosion: None
Total Injuries: 2 Minor
Latitude, Longitude: 34.807333,-96.66704(est)
Pictures of the accident site showed that the airplane had landed in a field, continued through a fence and impacted a line of trees. The airplane came to rest upright with the nose tilted up and the right wing low (figure 1). Postaccident examination revealed that the fuel tanks were both breached at the leading edges. The fuel tank caps were secured in place and there was no sign of blue fuel staining on the wings. The inspector did not observe any fuel in the right fuel tank, although the wing was on a decline. The fuel selector had been turned off after the accident.
Postaccident examination of the airframe and engine examine revealed no preaccident anomalies that would have precluded normal operation.
Additional Information
A review of the historical ADS-B data from FlightAware.com showed that, on December 24, 2019, the pilot had completed a multi-leg cross-country flight from Lakefront Airport (NEW), New Orleans, Louisiana, to Cox Field Airport (PRX), Paris, Texas, for a total of 2.5 hours enroute. He then flew to Liberal Mid-America Regional Airport (LBL), Liberal, Kansas, for 2.0 hours en route, and finally to APA for 1.75 hours en route. Fuel receipts showed that he added 52.8 gallons of fuel at LBL and 46 gallons of fuel at APA. However, the investigation could not determine the amount of fuel added to each tank nor the total amount of fuel in each tank after the fueling.
The pilot stated that the airplane was on level ground when it was fueled at APA. When asked if he observed the fueling process he stated, “I was not on the ladder with [the airport employee who fueled the airplane] … he claimed he topped it off I had no reason to doubt him.” The pilot stated that he did not complete a preflight fuel burn calculation for any of the flights. He did not check the amount of fuel on the fuel receipt or compare it to any fuel calculations because he would have only done so while completing a fuel plan.
The pilot did not open the fuel caps between fueling and the accident flight to confirm the amount of fuel in each tank, but he did confirm that the fuel caps were tight. He did not trust or rely on the fuel gauges in the airplane because they were always “bouncing around” and never showed the right amount. He discussed one time in the recent past when he had topped off the fuel tanks and one of the gauges showed empty.
A postaccident fuel calculation based on the fuel receipts for the round-trip cross-country flight revealed that the airplane would have contained about 69 gallons of fuel before departure from APA. If the airplane departed on the accident flight with 69 gallons, the amount in each tank would have been about 34 gallons. The fuel burn calculation for the accident flight revealed that the airplane likely burned 43 gallons of fuel before the loss of engine power. The fuel calculation revealed that there should have been about 26 gallons of fuel remaining during the loss of engine power.
No comments:
Post a Comment