NTSB Factual Report

On November 28, 2013, about 0251 eastern standard time, a Cessna 210L, N777BK, was substantially damaged during a forced landing on a road near Montrose, Pennsylvania. The commercial pilot, the sole occupant, sustained minor injury and the airplane was substantially damaged. The airplane was registered to Flight Express, Inc., and operated by Airnet Systems, Inc., flight USC146, under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a non-scheduled, cargo flight. Marginal visual meteorological conditions prevailed in the area of the forced landing and the flight was operated under the provision of VFR flight following an instrument flight rules (IFR) flight plan was filed but not activated. The flight originated from Teterboro Airport, Teterboro, New Jersey, about 0136, and was destined for Buffalo Niagara International Airport, Buffalo, New York.

The pilot stated that the fuel tanks were filled before departure but he did not check the fuel tanks for contaminants after fueling. He was asked if he was rushed or was in a hurry and he reported he was not rushed, but the cargo arrived at the same time they finished fueling. He later reported that he had not previously encountered any issue with the fuel provided by the same facility.

The pilot further stated that before departure he performed an engine run-up which included checking the magnetos; no discrepancies were reported. The flight departed with the fuel selector positioned to the right tank, and proceeded towards the destination. The flight climbed to 8,500 feet mean sea level where the pilot established cruise flight with the engine rpm at 2,450, and the mixture 100 degrees rich of peak. About 15 minutes after established in cruise flight he switched to the left tank, and about 15 to 20 minutes later, he heard a sound and noticed the cylinder head temperature and exhaust gas temperatures had dropped to their lowest point on the scale and the fuel flow increased between 140 pounds-per-hour and the maximum the needle could go. He adjusted the fuel to air mixture with no affect, though the oil pressure was in the green arc the whole time. He also attempted to restore engine power by switching to the right tank, enrichening the mixture, and placing the fuel pump to the low and high positions for about 5 seconds each, all of which were unsuccessful. Unable to maintain altitude he set a course using the on-board GPS receiver for an airport 25 to 30 miles north of his position but realized he would be unable to land there. He maneuvered the airplane for a forced landing on a road but again realized that he would be unable to reach that road. He descended through clouds between 6,000 and 4,500 feet, and after descending below the clouds, he first spotted a field then a road with a truck. He maneuvered the airplane for a landing on the road, and with 30 degrees of flaps and the landing gear extended, the airplane collided with an unmarked power line that crossed the road diagonally. The airplane banked to the right about 40 degrees, and while attempting to correct the bank the airplane contacted the ground coming to rest upright with two landing gears partially off the road.

According to contract maintenance personnel who recovered the airplane, while attempting to drain the left fuel tank from the sump drain, blockage of the opening by ice was noted. Because the flow of fuel was impeded, a screwdriver was positioned in the opening to keep the fuel flowing. They also reported that while draining the left fuel tank, an icicle about ¼ inch in diameter and ice pellets 3/16 inch in diameter were noted. While draining the right fuel tank, it contained some ice estimated to be about 20 percent of the amount found in the left tank. The total amount of fuel drained from both fuel tanks was approximately 53 gallons, which was equally divided. The contamination drained from the fuel tanks was not retained.

A Federal Aviation Administration (FAA) airworthiness inspector examined the airplane and during inspection of the fuel strainer noted it contained a mixture of 50 percent water and 50 percent 100 low lead fuel. With FAA oversight, an employee of the operator checked the left header tank and found it contained some water. The seals of both fuel filler caps were found to be satisfactory, as were both fuel tank sump drains which were the correct part number. Cursory examination of the engine revealed it could be safely run. Removal of one spark plug from each cylinder revealed the spark plugs from the Nos. 5 and 6 cylinders were black in color consistent with a rich mixture. The engine was removed from the airplane and transported to the operator's facility in Ohio for an engine test with FAA oversight.

A test club propeller was installed and the engine was placed in a test cell for an attempted engine run. Prior to running the engine, the fuel injector nozzles were removed from each cylinder, and while still connected to the fuel injector lines, the auxiliary fuel pump was turned on. The flow of fuel from each nozzle was equal and no water was noted. The fuel injector nozzles were re-installed in each cylinder, and the engine was started and operated for about 30 minutes using only the engine-driven fuel pump. The engine was able to achieve 2,845 rpm (full takeoff rpm is specified to be 2,850). Magneto checks were performed at 1,700 and 2,100 rpm; no discrepancies were reported. A copy of the engine run report is contained in the NTSB public docket.

At the request of the NTSB, FAA personnel inspected the facility that fueled the airplane last. The inspection revealed the truck utilized was clean and in good repair. There were no reports of issues of other airplanes fueled from the same source. Copy of the fueling records and statement from FAA is contained in the NTSB public docket.

Postaccident surveillance by AirNet's FAA principal maintenance inspector (PMI) was performed which revealed 4 instances where other company pilot's did not check the fuel tanks for contaminants after fueling. The airplane's were of a different make and model; however, the failure of the pilot's to check the tanks after fueling is contrary to the operator's Operational Manual. The PMI reported that 2 of the pilots departed without checking the tanks, and the remaining 2 pilot's checked the tanks after prompting from him. Additionally, the PMI alerted other Flight Standard District Offices throughout the U.S. advising them of the issue related to not checking the fuel tanks after fueling. The PMI reported he has not received any negative reports from the other FSDO's.

According to the Director of Operations, postaccident, he attempted to correct the issue by: 1) disseminating that information in a company newsletter, and 2) developed 2 Flight Operations Bulletins advising flight crews of the increased FAA surveillance, reminding flight crews of the requirement to check the fuel tanks after fueling, and also of the location where to check the fuel tanks after fueling.

NTSB Probable Cause

The pilot’s failure to check the fuel tanks for contaminants after fueling, which resulted in a total loss of engine power due to water contamination.