Pilot Debrief

CESSNA TU206G near Saint Ignatius, MT — 2015-08-03

Final reportWPR15LA229
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Date
2015-08-03
Location
Saint Ignatius, MT, USA
Aircraft
CESSNA TU206G
Registration
N235HM
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

Maintenance personnel’s failure to tighten a fuel line, which resulted in a loss of fuel pressure and a subsequent loss of engine power during cruise flight and an off-airport landing and collision with obstacles.

NTSB narrative

The pilot was conducting the airplane's first flight since the engine had undergone maintenance several months earlier. He reported that, after about 45 minutes of flight, he noticed that the exhaust gas temperature (EGT) had increased but that he was able to reduce the temperature by increasing the fuel flow. Shortly after, the EGT again increased, and the pilot began to troubleshoot the issue. The pilot stated that, after he turned the electric fuel boost pump on a second time, the engine ran normally for about 2 minutes and then lost power. He determined that the airplane would be unable to reach the airport, so he initiated a forced landing to a road. During the landing roll, the airplane struck vegetation and a fence. During a postaccident examination of the airplane, blue fuel stains were observed on the top of the engine. The fuel line attached to the fuel flow transducer was found finger tight and leaking. A review of the airplane's maintenance records indicated that, during the maintenance conducted several months before the accident, three cylinders, including the No. 6 cylinder, had been removed and reinstalled. The fuel line attached to the fuel flow transducer was just above the No. 6 cylinder and, therefore, it would been removed to access the cylinder during the maintenance. It is likely that maintenance personnel did not adequately tighten the fuel line during its reinstallation, which led to the loss of fuel pressure and the subsequent loss of engine power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have landed at nearest airport sooner instead of troubleshooting engine issues.

NTSB coding

Evidence available

  • 2 docket documents
View NTSB final reportView NTSB docket

Docket documents2

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