Rexburg, ID, USA
N6390U
Cessna T210R
The airplane collided with the ground and obstacles following a loss of engine power during takeoff. Witnesses reported the engine losing power during takeoff and the airplane entered a sharp right bank. The airplane then collided with obstacles and terrain. Post accident examination of the engine showed that debris coated the inlet side of the fuel manifold valve which is separated from the outlet side by a screen. When fuel enters the manifold valve, it comes through the screen, and eventually out to the fuel injector nozzles. Due to the amount of debris on the inlet side of the manifold valve, injector fuel pressure could not be obtained above 213 psi (specifications were for 250 psi). With the fuel pump pressure at 83 psi (specifications were for 32.5 psi), at RPMs above 1,500, the fuel pressure may have been excessive, dependent upon the distribution of the debris within the valve. An aviation maintenance technician and a family member reported that the pilot had been experiencing engine trouble during takeoff, similar to the circumstances surrounding the accident, and to correct the problem he would adjust the mixture setting. This adjustment was most likely due to the excessive fuel pressure at the pump, set as a result of the low fuel pressures due to the contaminated manifold valve. As the system pressure increased, the debris generally limited the fuel flow pressure. However, because the debris could move within the valve, the pilot most likely experienced erratic fuel flow pressures. There was no maintenance entry for the adjustment of the fuel pump, nor was any maintenance of the manifold valve noted. Both of these components were remanufactured during the engine overhaul approximately 6.5 years prior to the accident.
1.1 History of the Flight On February 8, 2007, at 1544 mountain standard time, a Cessna T210R, N6390U, collided with terrain and farm equipment during the takeoff-initial climb from runway 17 at Rexburg-Madison County Airport, Rexburg, Idaho. The pilot, who was also the registered owner of the airplane, was operating it under the provisions of 14 CFR Part 91. The private pilot, the sole occupant, sustained fatal injuries; the airplane was destroyed. Visual meteorological conditions prevailed and an instrument flight plan was filed. The flight was originating at the time and destined for Lincoln Regional Airport/ Karl Harder Field, Lincoln, California. According to a family member of the pilot, the pilot traveled to Rexburg every 2 to 3 weeks to visit family members and oversee his private businesses in the area. He rented a hangar at Rexburg. One witness reported seeing the airplane depart normally, and then he heard a "popping" sound and saw a trail of black smoke. The engine then lost power and the airplane began turning to the right. It appeared to the witness that the pilot was attempting to turn back to the runway. The airplane then dove down to the right, with the right wing impacting the ground. Flames quickly consumed the airplane. Another witness, who was standing outside, stated that the airplane had just departed. He heard a pop noise from the airplane and then saw black smoke. The airplane began to lose airspeed and it turned to the right. The airplane then dove down to the right and the right wing impacted the ground first. A witness was standing outside of his house and noticed the airplane because it appeared lower than normal. As he looked up, he noted smoke emitting from the airplane. The witness then stated that he "…heard the pilot shut off the engine and he was gliding into the wind." A few moments later he heard the airplane impact farm equipment machinery and saw smoke immediately. 1.2 Personnel Information 1.2.1 Pilot Information The pilot held a private pilot certificate and was certified to fly in instrument conditions. His last medical was issued on December 5, 2006, and it was a third class. It held the limitation that the pilot must wear corrective lenses. The pilot reported 1,258 flight hours on his last medical application. The pilot's logbook was obtained from his family. It showed that the last entry was dated February 2, 2007. The pilot had accrued approximately 1,333 hours total flight time with 938 hours in the accident airplane. He logged about 60 hours over the 90 days preceding the accident. 1.3 Aircraft Information 1.3.1 General Aircraft History The Cessna T210R was manufactured in 1986. The airplane had been involved in an accident on June 7, 1988, in Tampa, Florida. During a forced landing following a loss of engine power, the airplane impacted the top of an office trailer and guy wire before coming to rest on a roadway. A FAA Form 337 was filed on November 1, 1990, that showed repairs to the fuselage, wings, horizontal stabilizer, and elevators. According to Federal Aviation Administration aircraft registration records, the airplane was sold to the accident pilot on April 3, 2003. The airplane was powered by a Teledyne Continental Motors TSIO-520-CE engine that was equipped with a McCauley D3A34C 410B three-bladed propeller. The engine was overhauled on July 29, 1999. Following the pilot's purchase of the airplane in 2003, the annual inspections were completed by a local aviation maintenance technician (AMT) with inspection authorization, who lived near the pilot's California residence. The California AMT was interviewed regarding the maintenance that he performed on the airplane. The last annual inspection was completed in April of 2006. The California AMT had completed two other annual inspections on the airplane. Other than the annual inspections, the California AMT did not perform any maintenance on the airplane. On April 30, 2004, the cylinders were replaced with cylinder kit 655470A4 at Lincoln Skyways, Lincoln, California, at a total tachometer time of 2,193.8 hours. According to the engine manufacturer, this was an incorrect installation for the TSIO-520-CE engine. The difference between this cylinder kit and the correct cylinder kit were the intake inserts and the machining on the cylinder heads. The intake inserts were tapered on the ordered kit. According to the engine manufacturer's representative, the tapered cylinders would allow for an increase in horsepower. The last annual inspection was completed on April 18, 2006, at a total airframe time of 2,699.2 hours. During the last annual inspection, the California AMT noted in the engine logbook that cylinders 3, 2, 4, and 6 were at the minimum allowable compression and would be sent in for rework. The California AMT noted that he had heard that the cylinders were replaced later in 2006. In the logbook endorsements, the California AMT noted that the fuel screens were cleaned. The California AMT stated that he pulled the fuel control valve/throttle body screen and the airframe fuel system screen located at the lowest point in the fuel system. Based on his recollection, he said that he did not find any major contamination in the screens. On an aircraft owner's group website forum, the pilot expressed frustration regarding the maintenance that had been performed on the airplane's engine. In October of 2006, he noted that the incorrect cylinders had been installed on the engine (approximately 600 hours prior in April, 2004). On November 12, 2006, at an airframe total time of time of 2,824.5, the cylinders were replaced with the correct cylinders by a maintenance facility in Rexburg. The pilot requested that the Rexburg AMT change the airplane's engine cylinders due to oil consumption and low compression. The pilot left the airplane with the AMT for 5 days while he completed the work. During this time, the Rexburg AMT noted that the linkage for the fuel injection system was badly worn and loose, and that it needed to be repaired and calibrated. The pilot told the Rexburg AMT that he was aware of the problem and would look into it at a later date. According to the Rexburg AMT, the pilot had experienced two other power loss events at Rexburg within the past 18 months. The first event occurred when the pilot departed and was in the initial climb out phase of his departure. During the initial climb, the airplane began trailing smoke and descending like it had lost engine power. At some point, power was restored and the pilot continued to California. When the pilot returned to Rexburg several weeks later, the Rexburg AMT asked him about the power interruption. The pilot told him that if he did not warm up the engine enough, or lean the mixture for takeoff, the engine would lose power because the mixture was too rich. The Rexburg AMT further stated that in September of 2006, the pilot was taking several people, including a family member, for an airplane ride. The temperature was near freezing. During the takeoff roll, near the airplane's rotation point, the engine lost power. The engine then regained power and then it lost power again. At this point, the pilot was more than half way down the runway so he aborted the takeoff. He taxied back to runway 17 and departed normally. The Rexburg AMT completed various routine maintenance items on the airplane. About two weeks prior to the accident, he changed the right vacuum pump and again advised the pilot about the worn fuel injection linkages. The pilot told him that the problem would be addressed at a later time. A family member of the pilot was interviewed by the NTSB investigator. He reported that the engine had lost power on several occasions in the past, just following takeoff. The first time it happened was during takeoff, right after the landing gear lifted from the runway. The fuel pressure became high and the engine lost power. The pilot made an adjustment (the family member thought the adjustment was with the throttle), and power was restored. The first time it happened the family member was alarmed, but the pilot explained to him that it was due to "over-fueling" and it was something he was able to control. Further review of the maintenance records did not show any maintenance on the fuel pump (serial number G18704B) or the fuel manifold valve (serial number G108703C) since the engine overhaul in 1999. During this overhaul, the fuel pump and manifold valve had been remanufactured. 1.3.2 Fueling The airplane was fueled with 58.8 gallons of 100 Low Lead (100 LL) fuel (topped off) just prior to departure from Rexburg. 1.4 Meteorological Information The closest official aviation weather reporting station was Rexburg. The following conditions were reported at 1553: visibility, 10 statute miles; sky condition, few clouds at 4,200 feet; temperature, 42 degrees Fahrenheit; dew point, 34 degrees Fahrenheit; wind from 210 degrees at 9 knots; and altimeter, 30.05 inches of Mercury. 1.5 Wreckage and Impact Information The National Transportation Safety Board investigator, a Federal Aviation Administration inspector, and a representative from Cessna Aircraft Company responded to the accident scene on February 9. The airplane came to rest upright in a farm machinery yard located off the west- southwest end of runway 17 at Rexburg Airport and was extensively damaged from fire and impact. The main wreckage was 600 feet from the end of the runway. The airport was separated from the farm machinery yard by a paved road that generally ran from north to south. The first identified point of contact was a gouge in the soil on the east side (airport side) of the road, containing fiberglass fragments and paint chips. Moving west-southwest approximately 11 feet, investigators identified several scrape marks on the paved surface of the road. From the scrape marks, two curled gouges, located 3 feet apart, one was 22 inches and one was 25 inches in length, were located on the paved surface. Forward of this point, a radome, originally installed on the right wing tip, was identified, as well as green lens fragments. A large piece of farm equipment called a ripper, containing claw-like extensions, was originally parked several feet forward of this location. This ripper was found tangled with the left wing, which remained partially attached to the fuselage, approximately 20 feet from its original position. All control surfaces remained attached to their respective structures. Both fuel tanks were breached. 1.6 Medical and Pathological Information The Bannock County Coroner, Pocatello, Idaho, completed an autopsy. The FAA Bioaeronautical Research Laboratory completed toxicology testing. The results were negative for volatiles and tested drugs. 1.7 Tests and Research On February 10, 2007, the wreckage was examined in a hangar following its recovery from the accident site. The NTSB investigator, an FAA inspector, and representatives from Cessna Aircraft Company and TCM were present. 1.7.1 Engine 1.7.2.1 Engine Initial Examination The Teledyne Continental engine TSIO-520-CE (325 horsepower, 2700 rpm), SN 530065 was examined. The engine was thermally damaged with more thermal damage on the right side than the left. Both magnetos were intact and still attached to the engine. Both had thermal damage to vent lines and leads. The engine was equipped with two wet vacuum pumps, which were undamaged. The linkage assembly between throttle side of the fuel metering unit and the controller had fore and aft and side-to-side movement. The fuel metering unit mixture linkage arm was intact to the mixture cable. The throttle body linkage arm separated from the throttle cable. A section of the linkage arm was still attached to the cable. The following spark plugs were removed 1B, 2T, 3B, 4T, 5T, and 6B. 1B was slightly worn. The spark plug conditions and coloration were consistent with normal operation when compared to a Champion Check-A-Plug chart. The crankshaft was rotated by hand and thumb compression was obtained on all cylinders. The fuel pump was removed and the drive coupling was intact. The fuel pump rotated freely by hand. There was no fuel present during the removal of the pump. The turbocharger could not be rotated by hand. Impact marks were present on the housing and two blades were bent. The wastegate was found in the open position. The linkage assembly was intact and undamaged. The air inlet filter separated from the engine and had thermal and impact damage. The oil cooler separated from its mounts and had thermal damage. The oil sump was crushed but was not breached. The oil filter was dated January 19, 2007, at a total tachometer time of 2,864.5 hours. 1.7.2.2 Engine Test Run at TCM The Teledyne Continental Motors TSIO-520-CE engine was further examined on March 20, 2007, at Teledyne Continental Motors, Mobile, Alabama. The engine was borescoped and no internal damage was noted. After removing and/or replacing various components, the engine was secured in a test cell and test run. The engine started and ran; however, specific fuel flow indication was low. The fuel pump was removed and tested on a bench. The aneroid fuel pressure setting was 83 psi (optimum is 32.5 psi). The pump was recalibrated and reinstalled on the engine. The engine shutdown at engine speeds at 2,700 rpm and above 31 inches of manifold pressure. Manual leaning lessoned the problem; however, optimum power was still not obtained. The fuel manifold valve was removed from the engine along with the fuel injection nozzles. A replacement fuel manifold valve was installed on the engine using the original lines and fuel injector nozzles. The engine was test run with no anomalies noted. The original fuel manifold valve was flowed on a test bench. When fuel enters the manifold valve, it comes through the screen to the outlet side, and eventually out to the fuel injector nozzles. The fuel manifold valve flowed normally until reaching higher pressures. Fuel injector pressure could not be obtained above 213 psi (specifications were for 250 psi). Disassembly of the valve and removal of the screen showed that debris coated its interior on the fuel inlet side. Once the debris was removed, the valve flowed normally. The debris was sent to the Safety Board Materials Laboratory for identification. It was determined through Fourier Transform Infrared (FTIR) Spectroscopy at an outside laboratory that the sample consisted primarily of polyethylene terephthalate, which according to the metallurgist, is commonly used in the manufacture of beverage, food, and other liquid containers. Neither the airframe or engine manufacturer's representatives were aware of any system component or test where this debris would have been introduced. 1.7.3 Propeller The McCauley propeller model D3A34C 410B, serial number 774463, was examined. All blades sustained thermal damage and remnants of the boots remained on the leading edges. Blade 1 was straight and the tip was bent slightly aft. Blade 2 and Blade 3 were loose in the hub. Blade 2, from mid-blade to the tip, the leading edge was gouged. The tip was curled. Blade 3 had melting on the trailing edge and the tip was curled. The hub was fractured in several places. The spinner was crushed and burned away between blades 1 and 3. 1.7.4 Airframe Control continuity was established to all flight controls. The left aileron had separations at the doorframe and outboard where the ripper struck the wing. The cable remained attached to the aileron bellcrank. The elevator trim measured 1.3 inches which, according to Cessna, equated to 0 degrees of trim. The flap actuator measured 2.7 inches. Cessna indicated that 2.35 inches equated to 10 degrees of flaps. The ailerons had ground adjustable trim tabs, with the left tab slightly down. The landing gear was retracted. Fire damage from firewall aft to vertical stabilizer was evident. The entire cabin was destroyed by fire. The fuel selector was positioned in the BOTH position. The fuel shutoff valve was destroyed. From the fuel selector valve,
The loss of engine power due to the contamination of the fuel manifold valve, and the pilot's continued operation of the airplane with known maintenance discrepancies.
Source: NTSB Aviation Accident Database
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