Aviation Accident Summaries

Aviation Accident Summary SEA99LA044

PORT ANGELES, WA, USA

Aircraft #1

N93377

Cessna T210L

Analysis

During the annual inspection, leaking fuel tank caps and a water-contaminated fuel system were discovered. After completion of the annual, to include replacement of the caps and extensive actions to purge the system of any contamination, the pilot was asked to take the airplane on a post-maintenance test flight. During this flight, the pilot, who had been made aware that there had been significant water contamination of the fuel system, was supposed to make sure the aircraft ran properly and that there was nothing wrong with it. The pilot operated the engine prior to takeoff with the left fuel system selected, but did not select the right tank to see if he could detect any residual water contamination in that side of the system. He also did not test the right system while at altitude or when at a location where he could easily reach an airport if the engine lost power. After descending toward his en route destination, the pilot switched to the right fuel system and soon thereafter the engine experienced a complete loss of power. Unable to extend the glide to the airport, the pilot was able to land on a municipal baseball field. Although the touchdown was successful, the pilot was unable to get the airplane stopped prior to impacting the backstop.

Factual Information

On March 26, 1999, approximately 1210 Pacific standard time, a Cessna T210L, N93377, impacted a baseball diamond backstop during a forced landing about one-quarter mile east of William R. Fairchild International Airport, Port Angeles, Washington. The certified flight instructor (CFI) and his passenger, who was also a CFI, received minor injuries. The aircraft, which was owned by a private individual, and was being flown on a post-maintenance test flight by an employee of Wings Aloft, of Seattle, Washington, sustained substantial damage. The 14 CFR Part 91 flight, which was being operated in visual meteorological conditions, departed Boeing Field/King County International Airport about one hour prior to the accident. The ELT, which was activated by the impact, was turned off at the scene. A post-accident engine inspection found water in the fuel injector fuel flow divider (spider), but no other anomalies or discrepancies in any other engine system or component. Further investigation revealed that the aircraft had just come out of annual inspection, and that one issue addressed during the inspection was water contamination of the fuel system. Wings Aloft maintenance personnel had determined that water was being introduced into the fuel system due to leaking fuel tank caps, and therefor had replaced the old caps with new supplemental type certificate (STC) caps. In addition, they drained fuel from both the left and right wing fuel bays, both fuselage reservoir tanks, and the fuel strainer in the nose gear well. This process was repeated with jacks in place that allowed the aircraft to be tilted in a manner that would cause any liquid in the system to flow to its associated drain. The draining process was repeated until several samples of non-contaminated fuel were taken from each of the drains. All the water was then poured into one container where its quantity was determined to be two and one-half cups. The fuel tanks were then emptied of fuel, dried out, inspected, and vacuumed. In addition, the fuel strainer in the nose well was emptied, disassembled and cleaned. At the completion of this process, both wings were filled with fuel and samples were once again taken from all drain sumps. After finding no further contamination, the engine was test run to full power with the fuel selector on the left tank. At the completion of the annual inspection, maintenance personnel asked the CFI to take the aircraft on a 20 to 30 minute post-maintenance test flight as requested by the aircraft's owner. The pilot said he was asked to "... verify it runs and that there was nothing wrong..." with the aircraft. According to the Director of Maintenance, there were no other "limiting conditions" given to the pilot prior to the flight. The pilot said that, although maintenance personnel did not ask him to look for anything specific during the flight, they had previously made him aware that a significant quantity of water had been retrieved from the fuel system during the annual. Prior to departure, the pilot confirmed smooth and proper engine and propeller performance with the fuel selector on the left tank, but he did not switch to the right tank to test for residual water contamination from that side of the fuel system. After takeoff, the pilot climbed to the west and leveled off at 12,500 feet. Upon arriving in the area of Diamond Point, approximately 25 miles east of Fairchild International, the pilot entered a left spiraling descent, which he maintained until he reached 4,000 feet. He did not check to make sure the engine would operate properly with the right tank selected while the aircraft was still at altitude. After reaching 4,000 feet, he continued toward Port Angeles while maintaining a descent rate between 500 and 1,000 feet per minute, and then established the aircraft on a straight-in approach. About three miles from the airport, the pilot completed the before-landing checklist and as part of that process, switched from the left fuel tank to the right tank. He then set the flaps to ten degrees and, when the aircraft was about one-half mile from the threshold, he set the flaps to twenty degrees. About two minutes after switching tanks, as the pilot was reducing the power below 15 inches of manifold pressure, the engine experienced a total loss of power. The pilot then switched back to the left tank, turned on the fuel boost pump, and initiated restart procedures, but the engine did not restart. At that point, according to the pilot, it became clear that he would not be able to glide to the runway, but he thought he could make it to the open area around the municipal baseball fields if he reset the flaps to ten degrees. He therefore reset the flaps to ten degrees and headed for the municipal baseball fields where he attempted an emergency landing. Although his touchdown was successful, he was not able to stop the aircraft before impacting the backstop. A review of the Cessna 210L owners manual revealed that on a "typical flight" it does not call for running the engine on both fuel tanks prior to departure, nor does it call for an in-flight check of both sides of the fuel system prior to executing the before-landing checklist. The manual also does not give specific instructions or checklists for conducting a post-maintenance test flight, but instead leaves the decision as to what actions to take to the discretion of the pilot.

Probable Cause and Findings

The pilot's improper in-flight decision which resulted in a loss of power due to a contaminated fuel system. Factors include unsuitable terrain and the fence.

 

Source: NTSB Aviation Accident Database

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