Clearwater, FL, USA
N761HW
CESSNA T210M
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.
HISTORY OF FLIGHTOn January 28, 2012, about 1408 eastern standard time, a Cessna T210M, N761HW, registered to and operated by Pinnacle Sales LLC, sustained substantial damage during a forced landing shortly after takeoff from St. Petersburg-Clearwater International Airport (PIE), Clearwater, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal local flight from PIE. The private pilot, the sole occupant, sustained minor injuries. The flight originated from PIE about 1403. The pilot stated that during his preflight inspection of the airplane he did not visually check the fuel tanks nor did he use the available dipstick to determine the quantity of fuel in the wing fuel tanks. With battery power applied, the left fuel quantity gauge indicated about 25 gallons, and the right fuel quantity gauge indicated slightly more than 1/3 capacity or approximately 15 gallons. After engine start he taxied to the approach end of runway 36R where he performed an engine run-up, checking the magnetos and propeller; no discrepancies were noted. The pilot further stated that during the takeoff roll with the fuel selector positioned to the right tank position, he noted the fuel flow reading was satisfactory. After takeoff he retracted the landing gear, turned left to a heading of about 270 degrees and applied rudder trim to center the ball of the turn coordinator reporting that the flight had been uncoordinated for about 10 seconds. While continuing to climb on a westerly heading he reduced the fuel flow from 41 gallons-per-hour (gph) to 36 gph, and at about 1,600 feet mean sea level, the engine quit. He turned both auxiliary fuel pump switches on for 2 seconds in an attempt to restore engine power but that was not successful. He did not perform any other actions to restore engine power and reported he did not move the fuel selector. He then declared an emergency with air traffic control, trimmed for best glide airspeed between 80 and 85 knots, and turned right to return to the departure airport. While maneuvering with the flaps and landing gear retracted, he cleared one set of power lines then banked right to avoid another set. The left wing then collided with a tree followed by the right wingtip contacting the ground. He rolled to a wings level attitude and the airplane impacted the ground sliding about 110 yards before coming to rest upright. He remained in the airplane for 3 to 4 minutes then evacuated it and after fire rescue arrived was asked to shut off the fuel selector because of fuel leakage at the right side of the airplane forward of the co-pilot’s seat area. He did so, but the fuel leakage continued. A witness reported seeing the airplane flying in a westerly heading about 2,000 to 2,500 feet, followed by hearing the engine rev, sputter, and then quit. He observed the airplane in a sharp bank as if flying to return to the departure airport, then heard the engine operating but reported it sounded as if it was “feathering.” PERSONNEL INFORMATIONThe pilot held a private pilot certificate with ratings for airplane single engine land and sea, airplane multi-engine land, and instrument airplane. He was issued a third class medical certificate on June 1, 2010, with a restriction to have available glasses for near vision. He listed on the NTSB Pilot/Operator Aircraft Accident/Incident report having a total time of 1,756 hours, of which 1,376 were in the accident make and model airplane. AIRCRAFT INFORMATIONThe airplane was manufactured in 1977 by Cessna Aircraft Company as model T210M, and was designated serial number (S/N) 21062279. It was certificated under Part 3 of the Civil Air Regulations and originally powered by a Continental Motors, Inc. (CMI) formerly Teledyne Continental Motors TSIO-520-R engine and equipped with a McCauley constant speed propeller. At manufacture, the gravity fed fuel supply system consisted of a 45 gallon total capacity fuel tank installed in each wing. Each wing tank is plumbed by 3/8 inch fuel lines installed in the front and rear door posts to separate approximately 1 gallon reservoir tanks installed in the cockpit beneath the floor forward of the pilot and co-pilot seats. The fuel is then plumbed from each reservoir tank to the fuel selector valve, forward to the auxiliary fuel pump, to the fuel strainer, engine-driven fuel pump, fuel metering unit, fuel manifold, and finally to the fuel injector nozzles. Excess fuel and vapor are returned from the fuel vapor ejector on the engine-driven fuel pump, through a check valve to the appropriate reservoir tank on the side selected by the fuel selector valve. The fuel selector valve is a three-position valve labeled “Left On”, “Right On”, and “Off.” The airplane was also equipped with a combination analog manifold pressure and fuel flow (pressure) gauge. Since manufacture, the airplane was modified in accordance with (IAW) numerous Supplemental Type Certificates (STC’s). Specifically, an 18-gallon aft baggage compartment fuel tank was installed in November 1998 in accordance with (IAW) STC SA515NE. The aft baggage compartment fuel tank supplied fuel to the right fuel tank via hoses and an electric pump controlled by the pilot. The control switch and quantity gage were installed directly aft of the fuel selector handle. In April 2010, a J.P. Instruments EDM 800 indicator was removed and a JPI EDM 830 was installed IAW STC SA2586NM. The FAA 337 form indicates the installation was a change of the display only. On November 29, 2011, the airplane was modified IAW STC SA02918CH, by installation of a Continental Motors, Inc., IO-550-P6B engine rated for 310 maximum continuous horsepower at 2,700 rpm, and a Hartzell constant speed propeller HC-J3YF-1RF with F7693DF+2 propeller blades. The original exhaust and turbocharger components were retained by the STC, although dual intercoolers were installed. The fuel injection system is from the Continental TSIO-550-C engine which utilizes larger fuel injection nozzles and lower fuel pump pressures than the originally installed engine, and the modified induction system is similar to the TSIO-550-C, G, and K engines. The STC also modified the operational characteristics of the split rocker-type auxiliary fuel pump switch, resulting in the yellow or right side of the switch operating the auxiliary fuel pump at only low speed. The red, or left side of the switch operates the auxiliary fuel pump only at high speed. The STC also replaced the -8 size hose from the fuel strainer to the fuel pump inlet fitting but the line size remained the same. The engine installation results in a manifold pressure limit of 31 inches, with allowance for momentary excursions to 33 inches for cold oil. The fuel flow/pressure normal operating green arc range is 5 to 18 GPH, the caution range is 18 to 30 GPH, and the maximum fuel flow limit is 37 GPH which equates to a maximum metered fuel pressure limit of (13.6 psi). The flight manual supplement associated with the STC engine installation supplied to the pilot incorrectly listed the maximum fuel pressure limit in the limitations section and also in the powerplant markings table. The STC holder reported that as part of the STC installation process for the accident airplane, the combination analog manifold pressure and fuel flow (pressure) gauge was removed and sent to a facility to be remarked so as to coincide with the fuel flow/pressure limitations of the STC. However, the facility did not mark it as instructed. The fuel flow/pressure portion of the gauge was required to have red line radials at 3.0 and 13.6 psi, a green arc normal operating range of 5 to 18 gallons-per-hour (GPH), a yellow arc caution range of 18 to 30 GPH, and a white arc normal climb range of 34 to 37 GPH. The pilot/owner was reportedly instructed about the instrument issue but later reported to NTSB that he had always used the JPI for fuel flow and found it to be very accurate. Additionally as part of the STC installation, an incorrect magnetic pickup for the JPI was provided to the STC holder and installed, resulting in erratic rpm reading at high rpm; however, the pilot reported that he uses an electronic tachometer installed IAW a STC for engine rpm. Following the engine installation in December 2011, a maintenance facility inspected the airplane due to a complaint about poor idling. Maintenance personnel inspected the airplane and noted maintenance discrepancies (chafing, etc.) attributed to the engine installation. As a result of the poor idling, the maintenance facility adjusted the low unmetered fuel pressure, reset the idle mixture, and also twice adjusted the high side fuel flow. The first adjustment of the high side fuel flow was due to a pilot report of fuel flow exceedance, and the second adjustment 2 days later by the same facility was to correct for a low fuel flow condition. The write-up for the second adjustment also indicated that the manifold pressure was adjusted, and those adjustments were performed with the oil temperature between 170 and 180 degrees. At the time of the accident the airplane had been operated for approximately 42 hours since the STC engine was installed. METEOROLOGICAL INFORMATIONA surface observation weather report taken at PIE at 1353, or approximately 15 minutes before the accident, indicates the wind was from 310 degrees at 9 knots, the visibility was 10 statute miles, and clear skies existed. The temperature and dew point were 20 and 09 degrees Celsius, respectively, and the altimeter setting was 30.14 inches of Mercury. AIRPORT INFORMATIONThe airplane was manufactured in 1977 by Cessna Aircraft Company as model T210M, and was designated serial number (S/N) 21062279. It was certificated under Part 3 of the Civil Air Regulations and originally powered by a Continental Motors, Inc. (CMI) formerly Teledyne Continental Motors TSIO-520-R engine and equipped with a McCauley constant speed propeller. At manufacture, the gravity fed fuel supply system consisted of a 45 gallon total capacity fuel tank installed in each wing. Each wing tank is plumbed by 3/8 inch fuel lines installed in the front and rear door posts to separate approximately 1 gallon reservoir tanks installed in the cockpit beneath the floor forward of the pilot and co-pilot seats. The fuel is then plumbed from each reservoir tank to the fuel selector valve, forward to the auxiliary fuel pump, to the fuel strainer, engine-driven fuel pump, fuel metering unit, fuel manifold, and finally to the fuel injector nozzles. Excess fuel and vapor are returned from the fuel vapor ejector on the engine-driven fuel pump, through a check valve to the appropriate reservoir tank on the side selected by the fuel selector valve. The fuel selector valve is a three-position valve labeled “Left On”, “Right On”, and “Off.” The airplane was also equipped with a combination analog manifold pressure and fuel flow (pressure) gauge. Since manufacture, the airplane was modified in accordance with (IAW) numerous Supplemental Type Certificates (STC’s). Specifically, an 18-gallon aft baggage compartment fuel tank was installed in November 1998 in accordance with (IAW) STC SA515NE. The aft baggage compartment fuel tank supplied fuel to the right fuel tank via hoses and an electric pump controlled by the pilot. The control switch and quantity gage were installed directly aft of the fuel selector handle. In April 2010, a J.P. Instruments EDM 800 indicator was removed and a JPI EDM 830 was installed IAW STC SA2586NM. The FAA 337 form indicates the installation was a change of the display only. On November 29, 2011, the airplane was modified IAW STC SA02918CH, by installation of a Continental Motors, Inc., IO-550-P6B engine rated for 310 maximum continuous horsepower at 2,700 rpm, and a Hartzell constant speed propeller HC-J3YF-1RF with F7693DF+2 propeller blades. The original exhaust and turbocharger components were retained by the STC, although dual intercoolers were installed. The fuel injection system is from the Continental TSIO-550-C engine which utilizes larger fuel injection nozzles and lower fuel pump pressures than the originally installed engine, and the modified induction system is similar to the TSIO-550-C, G, and K engines. The STC also modified the operational characteristics of the split rocker-type auxiliary fuel pump switch, resulting in the yellow or right side of the switch operating the auxiliary fuel pump at only low speed. The red, or left side of the switch operates the auxiliary fuel pump only at high speed. The STC also replaced the -8 size hose from the fuel strainer to the fuel pump inlet fitting but the line size remained the same. The engine installation results in a manifold pressure limit of 31 inches, with allowance for momentary excursions to 33 inches for cold oil. The fuel flow/pressure normal operating green arc range is 5 to 18 GPH, the caution range is 18 to 30 GPH, and the maximum fuel flow limit is 37 GPH which equates to a maximum metered fuel pressure limit of (13.6 psi). The flight manual supplement associated with the STC engine installation supplied to the pilot incorrectly listed the maximum fuel pressure limit in the limitations section and also in the powerplant markings table. The STC holder reported that as part of the STC installation process for the accident airplane, the combination analog manifold pressure and fuel flow (pressure) gauge was removed and sent to a facility to be remarked so as to coincide with the fuel flow/pressure limitations of the STC. However, the facility did not mark it as instructed. The fuel flow/pressure portion of the gauge was required to have red line radials at 3.0 and 13.6 psi, a green arc normal operating range of 5 to 18 gallons-per-hour (GPH), a yellow arc caution range of 18 to 30 GPH, and a white arc normal climb range of 34 to 37 GPH. The pilot/owner was reportedly instructed about the instrument issue but later reported to NTSB that he had always used the JPI for fuel flow and found it to be very accurate. Additionally as part of the STC installation, an incorrect magnetic pickup for the JPI was provided to the STC holder and installed, resulting in erratic rpm reading at high rpm; however, the pilot reported that he uses an electronic tachometer installed IAW a STC for engine rpm. Following the engine installation in December 2011, a maintenance facility inspected the airplane due to a complaint about poor idling. Maintenance personnel inspected the airplane and noted maintenance discrepancies (chafing, etc.) attributed to the engine installation. As a result of the poor idling, the maintenance facility adjusted the low unmetered fuel pressure, reset the idle mixture, and also twice adjusted the high side fuel flow. The first adjustment of the high side fuel flow was due to a pilot report of fuel flow exceedance, and the second adjustment 2 days later by the same facility was to correct for a low fuel flow condition. The write-up for the second adjustment also indicated that the manifold pressure was adjusted, and those adjustments were performed with the oil temperature between 170 and 180 degrees. At the time of the accident the airplane had been operated for approximately 42 hours since the STC engine was installed. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted in a grassy open field; the accident site was located at 27 degrees 54 minutes 31.42 seconds North latitude and 082 degrees 43 minutes 10.45 seconds West longitude, or 1.7 nautical miles and 266 degrees from the center of PIE Airport. A PIE Airport Operations Supervisor who was on duty at PIE on the date and time of the accident reported he responded to the accident site after being notified of the accident. After arrival he reported observing fuel leaking on the right side of the airplane which was being treated by local fire rescue; however, the individual did not identify the location of the leak nor could he confirm how much fuel leaked out. The pilot was asked to shut off all fuel related valves that could stop the spill and he complied with the request. Examination of the airplane at the accident site was performed by a FAA airworthiness inspector who reported that vis
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.
Source: NTSB Aviation Accident Database
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