Pilot Debrief

CESSNA T210G near Provo, UT — 2009-10-21

Final reportWPR10FA027
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Date
2009-10-21
Location
Provo, UT, USA
Airport
PVU
Aircraft
CESSNA T210G
Registration
N6869R
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Climb

Probable cause

A total loss of engine power due to fuel starvation as a result of the pilot’s inadequate preflight inspection.

NTSB narrative

The accident pilot had taken the airplane to a maintenance facility about two weeks earlier for an annual inspection. On the morning of the accident, the owner and an acquaintance drove to the facility to pick up the airplane with the intention of flying it back to its home airport. After landing at the home airport, they planned to pick up another pilot, who would then fly them back to the facility to pick up a car before returning the airplane to the home airport. The owner stated that he did not visually confirm the fuel quantity in the tanks, noting that the gauges had always been accurate and that he trusted the readings. The fuel quantity gauge for the left tank showed that it was about three-quarters full and the gauge for the right tank showed that it was nearly full. After departure, the owner found several discrepancies with the way the seats had been installed, and, after picking up the other pilot, they flew back to the maintenance facility. The owner and his passenger then left in their car while the other pilot waited for the seats to be fixed. The owner stated that, except for the seat issue, he detected no mechanical problems with the airplane. The manager of the maintenance facility said that after the annual inspection he started the airplane's engine and noted that it started without difficulty. The fuel selector was positioned to the left tank. He looked at the fuel gauges and recalled that the left wing tank's gauge was reading about one needle-width over the one-quarter full level and that the right tank's gauge was reading at or a little bit above one-half full. After the seat issue was resolved, the pilot left in the airplane. The manager did not know if the pilot performed a preflight inspection, but he is certain that the pilot did not use the ladder in the hangar to visually inspect the fuel tanks. Shortly after takeoff, the pilot radioed the tower controller and reported a total loss of engine power and that he was returning to the airport. The airplane impacted an embankment short of the runway. Within 5 minutes of the accident, pilots in a helicopter landed near the wreckage to offer assistance. The pilot who approached the wreckage said that there was no fuel smell present and that he observed no evidence of leaking fuel. The first emergency personnel to arrive at the accident site said that they observed no fuel leaking for the entire time they were on scene. They found the fuel selector valve positioned to the right fuel tank. Examination of the airplane revealed an estimated 10 gallons of fuel in the left wing's integral fuel tank and no fuel was present in the right tank. Drops of fuel were found in the engine's gascolator and in the fuel manifold valve. Several ounces of fuel were found in some fuel lines in the engine compartment, while other lines were dry. The findings of the fuel system examination were consistent with cavitation of the engine-driven fuel pump caused by air contamination in the pump’s fuel supply line. The airplane was equipped with a panel-mounted instrument that records engine parameters. The data showed that, about 40 seconds prior to the engine’s rpm decreasing, the fuel flow began to drop from 30 gallons per hour to zero. Coincident with the fuel flow decrease, the exhaust gas temperatures began a 250-degree rise before they also fell off. The recorded data were consistent with fuel starvation to the engine. Postaccident examination of the airframe and engine revealed no mechanical failure or malfunction that would have precluded normal operation. The fuel tank quantity sending units in both tanks were examined, with no discrepancies noted.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot did not visually confirm fuel quantity before takeoff.

NTSB coding

Evidence available

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

Docket documents26

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