Pilot Debrief

CESSNA P210N near Bountiful, UT — 2014-02-23

Final reportWPR14LA118
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Date
2014-02-23
Location
Bountiful, UT, USA
Airport
BTF
Aircraft
CESSNA P210N
Registration
N18DP
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

Fuel starvation due to the in-flight loosening of the fuel lines attached to the fuel flow indicator as a result of inadequate maintenance.

NTSB narrative

The pilot reported that the accident flight was the first flight in the airplane since its annual inspection, which occurred about 6 weeks before the accident. He conducted a thorough preflight inspection and run-up. Before takeoff, he added full power with the brakes applied, and, after noting no abnormal engine or instrument indications, he took off. When the airplane reached about 150 to 200 ft above the ground, the engine started to run roughly. The airplane was unable to maintain altitude, so the pilot executed a forced landing to a nearby field. During the landing, the airplane sunk into the mud and nosed over. Postaccident examination of the engine revealed that the fuel lines connected to the input and output of the fuel flow indicator were loose and leaking. After these lines were tightened about 1.5 turns and pressure was applied, a third leak was found in the vicinity of a metal label on the fuel line between the fuel manifold and the fuel pressure gauge. The aircraft manufacturer's service manual states that the engine compartment rubber hoses must be replaced every 5 years or at engine overhaul, whichever occurs first. According to the airplane's maintenance logbook, the most recent engine overhaul occurred about 18 years before the accident. The mechanic who conducted the annual inspection reported that, during the inspection, he removed the fuel lines to and from the engine-mounted fuel flow transducer to troubleshoot a lack of indicated fuel pressure at the cockpit-mounted instrument. It is likely that the mechanic failed to adequately tighten the fuel lines when he reinstalled them.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Tightening fuel lines during annual inspection could have prevented leaks.

NTSB coding

Evidence available

  • Video
  • Photos
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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