Pilot Debrief

CESSNA T210M near Clearwater, FL — 2012-01-28

Final reportERA12LA164
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Date
2012-01-28
Location
Clearwater, FL, USA
Airport
PIE
Aircraft
CESSNA T210M
Registration
N761HW
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

Probable cause

The total loss of engine power due to fuel starvation for reasons that could not be determined because postaccident testing of the engine did not reveal any malfunctions or failures that would preclude normal operation. Contributing to the accident was the pilot’s improper in-flight fuel management following the loss of engine power.

Contributing factors

Contributing to the accident was the pilot’s improper in-flight fuel management following the loss of engine power.

NTSB narrative

The pilot stated that, during the preflight inspection, he did not visually inspect the fuel tanks or use an available dipstick to determine the fuel quantity. Rather, he relied on the fuel quantity gauges, which indicated the left wing tank had slightly more than 1/2 capacity or about 25 gallons, and the right wing tank had slightly more than 1/3 capacity or about 15 gallons. During the takeoff roll, with the fuel selector positioned to the right tank, the pilot noted the fuel flow reading was satisfactory. After takeoff, the pilot turned left to a west-southwesterly heading and applied rudder trim to center the ball of the turn coordinator, reporting that the flight was uncoordinated for about 10 seconds during the left turn. According to the airplane’s GPS and engine data monitor, while continuing in the west-southwesterly direction and climbing, the pilot reduced the fuel flow from about 41 gallons-per-hour (GPH) to 36 GPH. About 1 minute 18 seconds after takeoff, the fuel flow decreased to 16 GPH and was the same value at the next recorded data point 6 seconds later. The fuel flow then decreased to 0 GPH, increased to 31 GPH, and again decreased to 0 GPH. When the airplane was about 1,600 feet mean sea level, the engine lost power. The pilot turned both auxiliary fuel pump switches on for 2 seconds in an attempt to restore engine power but was not successful. He stated that he did not move the fuel selector. The pilot did not report performing any other actions to restore engine power. He declared an emergency and initiated a right descending turn toward the departure airport while the recorded fuel flow was about 1 GPH. After completion of the right descending turn while flying in a southeasterly direction, the fuel flow increased though engine power was not restored. The pilot turned to the right to maneuver the airplane for a forced landing and during that time the fuel flow again decreased, consistent with fuel starvation. While maneuvering, the left wing collided with a tree followed by the right wingtip contacting the ground. The pilot rolled the airplane to a wings-level attitude and it impacted the ground, resulting in damage to the right 1-gallon reservoir tank. The airplane slid about 110 yards before coming to rest upright. Witnesses and fire department personnel noted fuel leaking due to a cracked fuel line from the right reservoir tank. Any fuel remaining in the right main tank would leak due to this breach in the airplane’s gravity-fed fuel supply system. The amount of fuel leakage could not be determined. Twenty-nine gallons of fuel were drained from the left tank. According to Federal Aviation Administration documentation, the airplane’s engine was installed about 2 months before the accident, in accordance with the applicable supplemental type certificate (STC). During postaccident testing, the engine operated normally when configured to simulate the configuration of the airplane. Although the 41 GPH fuel flow recorded by the engine data monitor before the engine lost power is about 4 GPH greater than the maximum specified in the flight manual supplement pertaining to the STC, flight and ground-based testing of different airplanes equipped with the same engine model with the same engine limitations indicated that excessive fuel flow did not result in the loss of engine power. Therefore, it is unlikely that the excessive fuel flow recorded on the accident flight contributed to the loss of engine power. Review of maintenance records for the accident airplane indicated that it did not have a service kit that was announced via an airplane manufacturer service information letter, nor was it required to. The service kit made available the installation of fuel lines from each reservoir tank to each respective wing tank for excess fuel/vapor return. Because rapid fluctuating fuel flow did not occur during the accident flight, vapor lock is not considered to be a factor in the accident. Based on the available fuel flow data, the engine lost power most likely due to fuel starvation. The reason for the fuel starvation could not be determined because postaccident testing of the engine did not reveal any malfunctions or failures that would preclude normal operation. The pilot operating handbook (POH) cautions that fuel starvation can result if uncoordinated flight occurs for more than 1 minute with a fuel tank that is 1/4 full or less. Although the reported conditions of the accident flight (uncoordinated turn for about 10 seconds with a fuel tank about 1/3 full) do not correspond exactly to the POH guidance, the exact amount of fuel in the right tank could not be determined and it is possible that it was less than 1/3 full. The pilot’s initiation of the flight with the fuel selector positioned to a tank with a lesser quantity of fuel, as indicated by the fuel quantity gauge, and his failure to change the fuel selector following the loss of engine power contradicted procedures in the POH and Federal Aviation Administration-approved airplane flight manual. If the pilot had repositioned the fuel selector to the left tank following the power loss, he would likely have been able to restore engine power.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not visually check fuel tanks before flight.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 35 docket documents
View NTSB final reportView NTSB docket

Docket documents35

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