NTSB Factual Report

HISTORY OF FLIGHT

On March 9, 2002, at 1358 eastern standard time, a Cessna T210N, N2BS, was destroyed when it impacted terrain at Teterboro Airport (TEB), Teterboro, New Jersey. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed for the personal flight destined for Montauk Airport (MTP), Montauk, New York. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

According to transcripts from the Federal Aviation Administration (FAA) air traffic control communications with the pilot:

At 1344:23, the pilot radioed the flight data/clearance delivery controller and advised, "november two bravo sierra, a cessna two ten at millionaire v f r to the northeast with sierra." The flight data/clearance delivery controller instructed the pilot to set his transponder to code 0332, and to contact the local controller when ready to taxi. The pilot acknowledged the transmission.

At 1350:01, the pilot contacted the local controller and advised, "tower, two bravo sierra at millionaire, taxi take off." The local controller instructed the pilot to taxi to runway 6 at intersection GOLF. The pilot responded, "six golf great."

At 1351:48, the pilot advised the local controller that he was ready for departure. The local controller instructed the pilot to hold short of the runway. The pilot acknowledged the transmission.

At 1355:09, the local controller cleared a Grumman Gulfstream IV for takeoff on runway 24.

At 1356:12, the local controller instructed the pilot to "taxi into position and hold" on runway 6 at intersection GOLF. The pilot advised "holding."

At 1357:10, the local controller cleared the pilot for takeoff from runway 6 at intersection GOLF. The pilot advised he was "rolling". No further communications were received from the pilot.

At 1357:40, the local controller cleared N65776, a Cessna 172, for takeoff on runway 6. The pilot acknowledged the instructions.

At 1358:09, a transmission of unknown origin stated, "I got an airplane down here at the end of the runway."

The pilot of the Cessna 172 advised the tower that he was aborting takeoff and stated, "an airplane just went down." Tower personnel immediately notified airport operations.

Several witnesses observed the airplane climbing on departure, and then noticed a reduction in engine noise. Most of the witnesses reported that the airplane turned to the left and descended. However, some witnesses reported the airplane pitched up prior to descending.

A pilot-rated witness reported:

"...I was distracted by the sound of a departing aircraft on runway 6. Looking through my windshield, I saw a single engine Cessna (the sound clearly indicated to me it was a Cessna 210) the aircraft was climbing, and [the] landing gear was retracted. The aircraft had just cleared the runway and had climbed to about 400 feet when the engine appeared to stop. The aircraft pitched up, followed with several steep rolls to the right and left. The aircraft banked to the left and descended nose down, at about 30 feet the aircraft came out of the steep dive and impacted the ground...Smoke was coming from the engine compartment, followed by a small fire [after the airplane came to rest] . After about 10 seconds the fire overwhelmed the aircraft...."

Another witness saw the airplane climbing in a nose high attitude, with the wings level, and it appeared slow. The nose remained up as the airplane initiated an "abrupt" left turn. The wings wobbled in the turn. He said, "I thought the airplane was in a stall. It was turning, but not under control." In the turn, the airplane banked left and descended. When he last saw the airplane, it had completed about 3/4 of its turn from runway heading to its heading at ground impact. He did not see the ground impact. He said the winds were strong, and the flags stood straight out.

A third witness, reported that he saw the airplane climbing, traveling from south to north. It appeared to be climbing normally when it suddenly pitched up about 30 degrees, and the left wing dropped about 70 or 80 degrees. The airplane turned 90 degrees and descended quickly. It hit the ground hard, flat, and slid to a stop. About 50 seconds after the airplane came to a stop, the witness saw flames. The flames were small at first, near the rear of the airplane, but then spread to the rest of the airplane.

The fire was extinguished by the airport emergency personnel.

The accident occurred during the hours of daylight, at 40 degrees, 51 minutes, 35 seconds north latitude, 74 degrees, 03 minutes, and 20 seconds west longitude.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with airplane single engine land, single engine sea, and instrument airplane ratings. On June 27, 2000, when the pilot last applied for an FAA airman medical certificate, he reported that his total flight experience was 3,885 hours. The pilot's logbook was recovered; however, the bottom of the pages, which contained total hours, was burned. In addition, the logbook had been exposed to water, and the column with dates was faded and not readable. Based upon airplane logbook records, and incomplete pilot logbook records, the pilot was estimated to have a total flight experience of about 4,065 hours, about 3,950 hours as pilot-in-command, about 500 hours in make and model, and about 30 hours in the preceding 90 days. The date of the pilot's last flight review was not determined.

AIRCRAFT INFORMATION

The airplane was a 1979 Cessna T210N. The last inspection and maintenance listed in the airplane logbook was an annual inspection, which was completed on December 21, 2001. The airplane was estimated to have been flown about 30 hours since the annual inspection.

According to records from the FAA, the airplane had received several modifications which included, but were not limited to: a Brackett air filter; an auxiliary fuel tank in the aft fuselage; extended wing tips which held fuel, the installation of upper wing surface speed brakes, stall fences on the top side of the wings, and leading edge wing cuffs.

AIRPORT INFORMATION

Teterboro airport had two runways: 6/24, and 1/19. The runways crossed near the north end of the airport. Runway 6 was 6,013 feet long and 150 feet wide. From the intersection of taxiway GOLF, on runway 6, there was about 4,500 feet of runway remaining.

METEOROLOGICAL INFORMATION

Information SIERRA reported winds from 150 degrees at 7 knots. However, at 1351, the winds were recorded as being from 170 degrees at 16 knots with gusts to 20 knots. A witness who was watching airplanes at the airport reported that the winds started to increase about 10 minutes prior to the accident.

RADAR DATA

Radar data was received from the New York TRACON (Newark Antenna), and reviewed. No targets were found that matched the pilot's assigned beacon code of 0332.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in a grassy area on airport property, adjacent to the north airport boundary fence. A debris trail progressed along a magnetic heading of 340 degrees, and extended 245 feet from the first observed ground contact, to the cockpit of the airplane. The airplane came to rest on a heading of 260 degrees magnetic. Items associated with inside the cabin and engine compartment were found along the debris trail. No burn area was visible along the debris trail leading to the airplane.

Fire damage was observed on the right wing, and fuselage cabin. The fire extended forward to the aft portion of the engine compartment, and aft beyond the aft baggage compartment. The right wing was destroyed by fire. The right wing tip, which was found along the debris trail, had no fire damage.

Flight control continuity was verified to the ailerons, elevators, and rudder. The wing flap jackscrew was extended 3.5 inches, which corresponded to a wing flap extension of about 4.3 degrees. The elevator trim tab was extended 1.4 inches, which corresponded to 7 degrees trailing edge tab down. The throttle, propeller control, and mixture control were found in the full forward position; however, the upper engine mounts were broken and the engine had been pulled forward.

The fuel selector was positioned to the left tank. Fuel was found leaking from both wing fuel tanks. A small amount of fuel was found in the fuel line leading to the fuel control unit. The engine driven fuel pump contained fuel, and pumped fuel when rotated. The fuel pump shear shaft was intact.

The crankshaft was rotated and thumb compression was attained in all cylinders. Accessory drive gear rotation was observed. Spark was observed from both magnetos, to the spark plug leads for the upper cylinders.

The three propeller blades were bent opposite the direction of rotation. The next blade was bent about 30 degrees near the hub. The third blade in rotation was bent about 20 degrees at mid-span. The blades were loose in the hub, and could be rotated on their axis.

The air intake for the engine was located on the right side of the engine cowling, on the front of the engine. The air duct led to the engine air filter assembly, and then onto the compressor side of the turbocharger.

The engine air filter was mounted on the aft side of the engine, on the right side. The assembly consisted of a rectangular frame, which held the air filter element and a screen. The screen was mounted on the forward side (air intake side) of the frame, and air filter element was not within the frame. In addition, the air filter frame was partially covered with soot and discolored. On each of the long sides of the air filter frame, there was a rectangular area with defined edges that measured about 5 inches by 1.5 inches, which was different in color from the remainder of the area. Inside these defined area, there was unidentified burned residue.

The air ducting on the exit side of the air filter was melted. The lower part of the ducting, adjacent to the turbocharger, was intact. The air intake of the turbocharger compressor was blocked with the air filter element. The air filter element extended back into the ducting that led to the turbocharger air intake. Small pieces of the air filter element were lodged among the turbocharger compressor blades. Two of the turbocharger compressor blades were bent opposite the direction of rotation. The leading edge surfaces of all compressor blades were smooth to the touch.

A set of socket wrenches and other hand tools were found in the burned fuselage. Their pre-impact location was not determined.

MEDICAL AND PATHOLOGICAL INFORMATION

The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for the pilot.

On March 10, 2002, an autopsy was conducted on the pilot by the medical examiner for Bergen County, State of New Jersey.

ADDITIONAL INFORMATION

According to Section 3 of the Cessna T210N Information Manual, ENGINE FAILURE IMMEDIATELY AFTER TAKEOFF, the first item listed was for the pilot to maintain an airspeed of 85 knots.

According to Section 4 of the Cessna T210N Information Manual, Stalls:

"The stall characteristics are conventional and aural warning is provided by a stall warning horn which sounds between 5 and 10 knots above the stall in all configurations. Altitude loss during a stall recovery may be as much as 300 feet from a wings-level stall and even greater from a turning stall."

The cumulative affect of the various aerodynamic modifications to the airplane stall speed, and altitude loss during stall was not determined.

According to records from the FAA, on March 26, 1982, a Brackett air filter, part number BA 2410, was installed under the authority of supplemental type certificate (STC) SA71GL. According to the installation instruction sheet dated November 29, 1979, and in use at the time of the installation:

"Step 1. CAUTION Be sure to install filter with the backfire screen facing the downstream side (engine side)."

In addition, there was a diagram on the installation sheet that showed airflow, the air filter, and the screen. The BA2410 air filter assembly would have been delivered with one screen. The air filter frame had one decal, which measured 6 inches by 1.5 inches, and covered the installation with a single screen.

In 1993, Brackett Aero Filters adopted the use of two screens on all air filters, and issued revised instructions dated December 8, 1993, for the two screen installation. In addition, the installation decal was replaced by the service decal which measured 5 inches by 1.5 inches and was placed on both side of the air filter frame.

According to the party representative from Brackett Aero Filters, the measurements of the discolored areas on the air filter frame matched an air filter frame delivered after the change to two filter screens. The manufacturing date stamp was not visible and the actual date of manufacturing, and installation date for the air filter frame was not confirmed.

Replacement air filter elements for the BA 2410 air filter assembly were identified as BA 2405. The BA 2405 could be used with either a single screen or double screen installation. The air filter elements were packaged in a plastic bag, imprinted with Brackett Air Filter document I-194, dated March 16, 1994, which contained information for continued airworthiness of the air filter. No instructions for single screen installations were included.

The replacement air filter element was listed as a BA 2305 in the engine logbook, and as a BA 2405 in the last annual inspection paperwork found in the airplane.

According to documents from Brackett Aero Filters, the recommended replacement interval for the filter element was every 200 hours, or each 12 months, or when 50 percent of the surface was covered by foreign material.

The mechanic who performed the annual inspection was interviewed by telephone. He acknowledged that he had performed the inspection, but did not specifically remember changing the air filter. However, he said he was familiar with air filters that had both single and double screens, and was aware that with single screen filters, the screen must be on the engine side of the air filter element.

The airplane was released to a representative of the insurance company on March 11, 2002.

NTSB Probable Cause

Improper maintenance by other maintenance personnel, which resulted in the air filter element being sucked into and blocking the turbocharger inlet, and a subsequent power loss. Factors in the accident were the pilot's failure to maintain airspeed and the tail wind.