Pilot Debrief

CESSNA T210 near Orlando, FL — 2018-03-13

Final reportERA18LA103
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Date
2018-03-13
Location
Orlando, FL, USA
Airport
ISM
Aircraft
CESSNA T210
Registration
N5382A
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The improper adjustment of the fuel pump by maintenance personnel, which resulted in an overly rich fuel/air mixture and a total loss of engine power.

NTSB narrative

On the morning of the accident, the pilot performed a 2-hour test flight with newly-installed camera equipment, during which the airplane performed normally. While taking off on the second flight of the day, the pilot felt that there was something wrong with the engine. There were no abnormal indications and the engine continued to produce power until the pilot leveled the airplane at cruise altitude; the engine then lost total power and the pilot subsequently conducted a forced landing onto a road, resulting in substantial damage to the wings. A test run of the engine revealed that the fuel pump was adjusted to an excessively rich fuel flow setting, which resulted in a loss of power when the throttle was increased past about 2,100 rpm. The fuel pump was readjusted and the engine performed nominally. When the fuel pump was reset to the as-received setting, the engine exhibited the same loss of power as during the first run. Bench testing of the throttle body and fuel pump revealed that both units failed to meet production standards. Review of the airplane's maintenance records indicated that a fuel system adjustment was performed almost 2 years before the accident. It is likely that the improper fuel pump setting resulted in an overly rich fuel/air mixture and the subsequent loss of engine power; however, the reason for the loss of engine power during the accident flight, and not during previous flights since the fuel pump was adjusted, could not be determined.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have aborted the takeoff upon feeling engine issues during climb.

NTSB coding

Evidence available

  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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