NTSB Factual Report

HISTORY OF FLIGHT

On October 3, 2010, about 1535 Pacific daylight time, a Cessna 310, N310XX, was substantially damaged when it impacted terrain shortly after takeoff from runway 22 at Catalina Airport (AVX), Avalon, California. The non-instrument rated owner-pilot and one passenger received minor injuries, and one passenger received serious injuries. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Meteorological conditions were changing rapidly, and no flight plan was filed for the flight.

According to the pilot, he and the passengers landed at AVX on Catalina Island the previous day, and the passengers remained on the island while the pilot continued on to John Wayne-Orange County Airport (SNA), Santa Ana, California. On the day of the accident, the pilot departed SNA a few hours late due to weather, and landed at AVX, where he and the passengers then began lunch. While dining, the pilot noticed that the weather was deteriorating, and suggested that they depart before instrument meteorological conditions prevailed. The passengers and pilot boarded the airplane, and the pilot started the engines. Due to the deteriorating weather and the fact that he had just flown in from SNA, the pilot conducted what he termed an "abbreviated" engine run-up during the taxi-out. The pilot planned to conduct what he referred to as a "Vx takeoff," which entailed an initial climb at the airplane's best angle-of-climb speed. According to the pilot, the best angle-of-climb speed (Vx) was approximately the same as the minimum controllable airspeed (VMC), which was about 85 mph.

The pilot stated that the takeoff roll was normal, but about 2 to 3 seconds after liftoff, the airplane veered "sharply to the left," which he interpreted as a failure of the left engine. Because he was concerned about airspeed decay due to the flaps and landing gear being extended, the pilot pushed the nose down to maintain airspeed. He then noticed the "right wing coming up," so he retarded the right throttle. The airplane then entered a cloud/fog bank, and impacted terrain. It came to a stop quickly, with the cabin intact, but very shortly thereafter was engulfed by fire. All three occupants exited the airplane without external assistance.

The wreckage was examined on-site by National Transportation Safety Board (NTSB), Federal Aviation Administration (FAA), and manufacturers’ personnel. It was recovered to a secure facility for detailed examination and testing. Subsequent to that, the engines were removed and sent to Teledyne Continental Motors in Mobile, Alabama, and the left fuel selector valve was sent to Precision Airmotive in Marysville, Washington, for additional testing

PERSONNEL INFORMATION

According to FAA information, the 54-year-old pilot held a private pilot certificate with airplane single- and multi-engine land ratings. His most recent FAA third-class medical certificate was issued in December 2009. According to the pilot, he had approximately 700 hours of total flight experience, of which 650 hours were in the accident airplane. He reported that his personal flight records were on board the airplane at the time of the accident, and were consumed in the fire. An email from his flight instructor stated that the pilot's most recent flight review was completed on July 12, 2010. Despite multiple requests, the pilot did not provide a completed accident reporting form to the NTSB.

AIRCRAFT INFORMATION

General Information

The airplane was manufactured in 1956, and was registered to the pilot in 2004. It was equipped with two Teledyne Continental Motors (TCM) O-470-M engines, each driving a controllable pitch, metal, two-bladed propeller. The airplane was equipped with tricycle-configuration retractable landing gear, and split-style trailing edge flaps.

Fuel System

The airplane was equipped with two 50-gallon tip tanks for fuel. Each tank contained a cockpit-controlled boost pump. The airplane was equipped with two fuel selector valves, one for each engine. A fuel strainer was located downstream of each fuel selector valve. Each engine was equipped with an engine-driven fuel pump and a pressure carburetor.

Two separate rotary-style fuel selector controls, one for each engine, were mounted side-by-side in a recess on the cockpit floor between the two front seats. Each valve control layout was the same, with three possible setting positions; one each at the 9 o'clock (left), 6 o'clock (aft), and 3 o'clock (right) position. Those positions were respectively labeled "LEFT ON TANK," "BOTH OFF," and "RIGHT ON TANK." Setting the left selector control to "LEFT ON TANK" would provide fuel to the left engine from the left tank, while setting it to the "RIGHT ON TANK" would enable a cross-feed setting, where the left engine would feed from the right tank. The right selector valve controls and plumbing were similarly configured.

Each selector valve was mounted on the outboard aft wall of its respective engine nacelle. A series of mechanically linked rods, oriented transversely with respect to the airplane, coupled each selector valve control to its respective valve. Actuation of the left or right cockpit fuel selector control rotated the respective rod assembly about its longitudinal axis, which rotated the internal valve mechanism, enabling selection of the tank to be used to provide fuel to each engine. There was a one-to-one ratio between the rotation of the cockpit control and the rotation of the selector valve; rotating the control 90 degrees rotated the valve 90 degrees. Detents for each of the selected positions, each 90 degrees apart, were located on the valve body.

The manufacturer's recommended engine start and takeoff procedure was to feed each engine from its respective fuel tank. In that configuration, the left fuel selector control would point to the left, and the right selector control would point to the right. Each selector valve control would point aft when "BOTH OFF" was selected.

Maintenance Records Information

According to the maintenance records, the most recent annual inspection was completed in June 2010. The records indicated that at that time, the airplane had accumulated a total time in service (TT) of 5,520 hours. The engine records indicated that as of that annual inspection, both the left and right engines had accumulated a TT since major overhaul (TSMOH) of 1,713 hours. The airplane and engines had accumulated about 500 hours in the 5 years prior to the accident. Examination of the records for the previous 5 years did not reveal any noteworthy relevant mechanical issues.

METEOROLOGICAL INFORMATION

The 1451 automated weather observation at AVX included winds from 280 degrees at 7 knots; visibility 10 miles, clear skies; temperature 19 degrees C; dew point 14 degrees C; and an altimeter setting of 30.00 inches of mercury.

The 1532 observation included winds from 240 degrees at 11 knots; visibility 2 miles in haze, few clouds at 100 feet; temperature 17 degrees C; dew point 14 degrees C; and an altimeter setting of 29.99 inches of mercury.

The 1534 observation included the same values as the observation 2 minutes prior, except for visibility 1 mile in mist, a broken cloud layer of indeterminate height, and a vertical visibility of 200 feet.

AIRPORT INFORMATION

According to FAA Airport/Facilities Directory information, AVX was equipped with a single runway, designated 04/22, which was paved, and measured 3,000 feet by 75 feet. Airport elevation was 1,602 feet above mean sea level (msl). The airport was not equipped with an air traffic control tower.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright, about 880 feet southeast of the runway, at an elevation about 80 feet below the runway elevation. The terrain of the impact area was flat and sloped down in the direction of travel, with some small cactus and scrub vegetation. Ground scars indicated that the airplane first impacted the terrain about 660 feet from the runway, and about 60 feet below the airport elevation. The ground scars were aligned on a magnetic heading of approximately 150 degrees, and the airplane came to rest on a magnetic heading of approximately 072 degrees. The fuselage and cabin exhibited severe fire damage. Most of the cabin shell, and most of the interior components, exclusive of steel items, were consumed by fire.

Exclusive of the fire damage to the fuselage, the airplane was essentially intact, and all major components, with the exception of the tip tanks and landing gear, were attached and in their normal relative positions. The tip tanks were separated from the airplane and substantially damaged, so no fuel quantity information could be obtained. The empennage and wings, including the nacelles and engines, exhibited minor thermal damage. All flight control surfaces were present and attached to their aerodynamic surfaces, and control continuity was established. The setting positions for the cockpit flight and engine controls and switches could not be determined.

Both engine cowlings were impact damaged, but both engines were in good condition, with little or no thermal damage. Engine impact damage was primarily limited to the exhaust piping and some other hardware on the undersides of both engines. The propeller blades remained attached to their respective hubs, and the hubs remained attached to their respective engines. No blades appeared feathered, and all blades were bent aft, with minimal leading edge and rotational signature damage. On scene examination of the engines and propellers did not reveal any pre-accident conditions or failures that would have precluded normal operation.

The fuel selector valve for the right engine was found set to the right fuel tank. The fuel selector valve for the left engine was found displaced approximately 30 degrees from the off position, towards the left tank setting.

The engines were removed and shipped to the Teledyne Continental Motors in Mobile, Alabama, for additional examination and testing. The left fuel selector valve was removed for additional testing.

Refer to the following section and the accident docket for detailed information.

ADDITIONAL INFORMATION

Owner's Manual and Pilot-Produced Checklists

According to the pilot, he utilized personal, customized checklists for his operation of the airplane. He stated that the checklists were derived from the manufacturer's owner's manual (OM) and modified to a "more efficient and comprehensive format." Several companies that do not manufacture aircraft produce and sell such modified checklists for aircraft owners and operators. Some aftermarket or more recent manufacturer's checklists incorporate double checks, in the form of subsequent duplicate entries, for items, such as fuel selector position, that are critical to flight safety.

The pilot's checklist used on the accident flight was consumed in the fire, but he provided a document, which he said was the same as the one he used. He stated that his checklist was contained on two sides of a single sheet of paper. Comparison of the pilot-provided checklist with that in the OM revealed that the OM tended towards phrases or sentences for each item, whereas, the pilot's checklist items were primarily single-word "challenge and response" style entries. The OM checklist utilized bold font for the section/phase of flight headers, and numbered the steps in each section, while the pilot's checklist, including section/phase of flight headers, was unnumbered, virtually all a single font style, and cluttered in appearance. In addition, multiple hand-written entries were interspersed among the printed entries on the pilot's checklist. The OM checklist contained a "Before Starting Engine," a "Starting Engine," a "Warm-Up And Ground Test," and a "Before Take-Off Or During Taxi" section. In contrast, the pilot's checklist appeared to combine those sections into two sections entitled "Start-Up" and "Run-Up."

Step 9 of the OM "Before Starting Engine” checklist appeared as follows:

(9) Check left engine fuel selector valve "ON LEFT TANK," and right engine fuel selector valve “ON RIGHT TANK.”

In contrast, the pilot’s corresponding personal checklist entry was:

“FUEL,L&R ON”

Neither the OM checklist nor the pilot’s personal checklist subsequently re-addressed the fuel selector valve position in any of their respective sections for start, runup, or takeoff.

Shutdown and Pre-Takeoff Procedures

In a post accident interview with the NTSB, the pilot stated that when securing the airplane for every shutdown, he would run the engines "lean" for a few minutes at an rpm of about 1,200. He would then shut down the engines via the mixture control, and after that, he would turn the fuel selector valves to "off." He stated that he followed those procedures after landing at AVX on the day of the accident. The checklists provided by the pilot did not contain any post-landing or engine shutdown procedures. Examination of the OM "After Landing" checklist revealed that it did not contain any steps regarding the fuel selector valves.

During that same interview, as well as in another interview with FAA personnel, the pilot stated that he conducted an "abbreviated" engine run-up prior to the accident departure, since he had conducted a full and satisfactory run-up prior to leaving SNA. He explained that the abbreviated run-up consisted of a magneto check during taxi-out.

In a subsequent email communication to the NTSB, the pilot modified or amplified his account of some of the information he had previously provided. Regarding his previous statement that he turned the fuel selectors off after every flight, the pilot stated that that was "not procedural" to him, and that sometimes he did not shut the fuel off. Regarding his previous description of the accident flight engine run-up, he amended the description by adding "the only item missing on the run-up would have been prop feather." In his original recount of the event, he stated that he advanced to engines to 2,200 rpm prior to brake release. His revised account stated that he ran the engines to 2,200 rpm for 5 to 10 seconds while the airplane was on the concrete apron adjoining the threshold of runway 22 at AVX.

Single Engine Operating Airspeeds

Chapter 12 ("Transition to Multiengine Airplanes") of the FAA Airplane Flying Handbook (AFH, FAA-H-8083) contained the following information:

"The basic difference between operating a multiengine airplane and a single-engine airplane is the potential problem involving an engine failure. The penalties for loss of an engine are twofold: performance and control. The most obvious problem is the loss of 50 percent of power, which [significantly] reduces climb performance…. The other is the control problem caused by the remaining thrust, which is now asymmetrical. Attention to both these factors is crucial to safe one engine inoperative (OEI) flight."

The AFH further noted that:

"Twin-engine airplanes have several additional performance "V" speeds unique to OEI operation. These speeds are differentiated by the notation "SE," for single engine."

Excerpted key AFH definitions or descriptions included:

VXSE - Best angle-of-climb speed with one engine inoperative.

VYSE- Best rate-of-climb speed with one engine inoperative. Marked with a blue radial line on most airspeed indicators. Above the single-engine absolute ceiling, VYSE yields the minimum rate of sink.

VSSE– Safe, intentional one-engine-inoperative speed. Originally known as safe single-engine speed. Now formally defined in Title 14 of the Code of Federal Regulations (14 CFR) Part 23, Airworthiness Standards, and required to be established and published in the AFM/POH. It is the minimum speed to intentionally render the critical engine inoperative.

VMC – Minimum control speed with the critical engine inoperative. Marked with a red radial line on most airspeed indicators. The minimum speed at which directional control can be maintained under a very specific set of circumstances outlined in 14 CFR Part 23, Airworthiness Standards. There is no requirement in this determination that the airplane

NTSB Probable Cause

The pilot's improper setting of the left engine fuel selector valve, which resulted in fuel starvation of the left engine immediately after takeoff. Contributing to the accident was the pilot's decision to try to depart ahead of developing weather, which resulted in his hastened departure procedures and likely led to his failure to recognize the incorrect fuel selector positioning.