Aviation Accident Summaries

Aviation Accident Summary LAX92FA092

TEMPLE BAR, AZ, USA

Aircraft #1

N22592

CESSNA T210L

Analysis

THE PLT SAID THAT DRG DSCNT FM 10,500 FT, THE MANIFOLD PRESSURE DROPPED TO 18 INCHES. HE DECIDED TO LND AT A NRBY ARPT. WHILE DIAGNOSING THE PROBLEM, HE TURNED ON THE BOOST PUMP & THE ENG LOST MORE PWR. THE COCKPIT BGN TO FILL WITH SMOKE. THE PLT SECURED THE ENG & TURNED THE ELEC SYS OFF. HE BGN A PWR-OFF DSCNT OVR THE ARPT & MANUALLY EXTENDED THE LNDG GEAR. HE THOUGHT HE WAS TOO HIGH, SO HE TURNED THE BATTERY 'ON' TO LOWER THE FLAPS. WITH ELEC PWR RESTORED, THE LNDG GEAR RETURNED TO THE 'UP' PSN. THE PLT AGAIN LOWERED THE LNDG GEAR. UNABLE TO REACH THE RWY, HE TRIED TO RE-START THE ENG ON FINAL APCH, BUT DID NOT HAVE ENOUGH TIME. SUBSEQUENTLY, THE ACFT IMPACTED AN UP SLOPE ABOUT 300 FT SHORT OF THE RWY & CRASHED. AN EXAM OF THE TURBOCHARGER REVEALED THE TURBINE SHAFT FAILED DUE TO MULTIPLE FATIGUE CRACKS. ABOUT 125 FLT HRS BEFORE THE FAILURE, THE TURBINE SHAFT HAD BEEN REWORKED (GROUND & CHROMIUM PLATED), BUT NOT IN ACCORDANCE WITH THE MANUFACTURER'S SPECIFICATIONS. TURBOCHARGER MALFUNCTION WAS NOT ADDRESSED IN THE POH.

Probable Cause and Findings

FATIGUE FAILURE OF THE TURBOCHARGER'S TURBINE SHAFT DUE TO INADEQUATE MAINTENANCE, AND THE PILOT'S IMPROPER IN-FLIGHT PLANNING/DECISION AFTER EXPERIENCING A TURBOCHARGER FAILURE. A FACTOR RELATED TO THE ACCIDENT WAS: THE LACK OF INFORMATION IN THE PILOT OPERATING HANDBOOK CONCERNING TURBOCHARGER FAILURE OR MALFUNCTION.

 

Source: NTSB Aviation Accident Database

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