NTSB Factual Report

HISTORY OF FLIGHT

On October 21, 2009, at 1609 mountain daylight time, a Cessna T210G, N6869R, experienced a total loss of engine power during a southbound climb following a 1601 takeoff from the Provo Municipal Airport, Provo, Utah (PVU). The pilot reversed course and attempted to return to the airport. The airplane impacted upsloping terrain adjacent to an airport perimeter road while on short final approach to runway 36. The airplane was substantially damaged, and the commercial certificated pilot, who was the sole airplane occupant, was killed. The airplane was owned and operated by Six Nine Romeo, LLC, Provo. Visual meteorological conditions prevailed at the time of the business flight, and no flight plan was filed. The flight was performed under the provisions of 14 Code of Federal Regulations Part 91.

The airplane's owner reported to the National Transportation Safety Board investigator that the accident pilot had taken the airplane to Central Utah Aviation in Provo about two weeks before the accident for an annual inspection. On the morning of the accident the owner and an acquaintance drove to Provo to pick up the airplane with the intention of flying it back to Spanish Fork, getting the accident pilot to fly them back to Provo to pick up the car and then the pilot returning the airplane to Spanish Fork. The owner stated that he did not visually confirm the fuel quantity in the tanks, noting that the gauges had always been accurate and he trusted the readings. The fuel quantity gauge for the left tank showed approximately three quarters full and the gauge for the right tank showed it was nearly full.

They departed Provo en route back to Spanish Fork and the owner found that the seat back would not stay upright in the locked position and the seat would occasionally slip backward on the tracks a few inches. During the landing at Spanish Fork the pilot’s seat slipped all the way back on the track, which caused him to bounce the landing. He taxied to where the accident pilot was waiting and did not shut down the engine as the pilot opened the right hand door and got in. The pilot told the owner that he saw that the seats had been switched and were installed in the wrong positions. They departed and flew around the area before heading back to Provo to have the seat issue corrected. The owner said they landed about 1520, taxied to the Central Utah Aviation facility and were met by the facility manager. They pointed out the seat problem and the manager arranged to have the seats switched back to their correct positions. The owner and his passenger then left to drive back to Spanish Fork while the accident pilot waited for the seats to be fixed.

The owner stated that except for the seat issue, he detected no mechanical problems with the airplane.

The manager of Central Utah Aviation reported that on September 25, 2009, the accident pilot brought the airplane into the company for the purpose of having an annual inspection performed. The work order was opened on October 12th and the inspection was completed on October 19th. Following completion of the work he moved the airplane from the hangar to the outside ramp. He said he started the airplane's engine, and noted that it started without difficulty. The fuel selector was positioned to the left tank. He looked at the fuel gauges and recalled that the left wing tank's gauge was reading about one needle width over the one-quarter full level and the right tank's gauge was reading at or a little bit above one-half full. The right tank's gauge was definitely indicating less than three-quarters full.

The manager said that on October 21, about 1420, the airplane's owner picked up the airplane and took off. The owner, his female passenger, and the accident pilot returned to the company later during the afternoon. The owner reported that he believed there was a problem with the installation of the two front seats. The manager confirmed that the seats had been installed backwards and he had them removed and installed in their correct positions. The owner and his female passenger left the area in a car while the accident pilot got into the airplane and took off. The manager did not know if the pilot performed a preflight inspection, but he is certain that the pilot did not use the ladder in the hangar for the purpose of visually inspecting the quantity of fuel in the fuel tanks.

An on-duty Provo airport air traffic controller reported to the National Transportation Safety Board investigator that, at 1608, the airplane was a few miles south of the airport, and the pilot stated that he had lost all engine power. The controller immediately cleared the pilot to land on any runway. The controller stated that he watched the airplane's approach to the airport, and nothing unusual was noted regarding the airplane's descent. No unusual maneuvering was observed, and no evidence of smoke was seen trailing from the airplane.

A student and an instructor were flying nearby in a helicopter and heard the emergency declaration over the radio; they were over the crash site within 5 minutes. They landed and the student went to render assistance to the occupant. He reported that there was no fuel smell present and he observed no evidence of leaking fuel.

Two Provo Fire Department firefighters were among the first responders to arrive at the accident site. They reported that they immediately did a complete walk around of the wreckage to ascertain if any hazardous conditions or materials presented a threat to first responders, including fuel leakage. They observed no fuel leaking for the entire time they were on scene.

PERSONNEL INFORMATION

The pilot, age 30, held a commercial pilot certificate with ratings for airplane single engine land and instruments, the most recent issuance of which was dated May 14, 2007. In addition, he held a certified flight instructor certificate with ratings for airplane single engine and instruments, which was last issued on July 29, 2009. A first class medical certificate was issued to the pilot on June 11, 2008, and contained the limitation that correcting lenses must be worn while exercising the privileges of his airman certificates.

A review of the pilot’s personal flight records disclosed a logged total time of 2,015 hours, with several hundred hours accrued in the accident airplane. The pilot was an active flight instructor in the aviation program of a local college and he is estimated to have flown in excess of 160 hours in the past 90 days.

AIRCRAFT INFORMATION

The aircraft is a Cessna T210G, serial number T210-0269, and was manufactured in 1967. According to the maintenance records, the airframe had accumulated a total time in service of 3,739 hours. An annual inspection was endorsed as completed on October 4, 2009.

A Continental TSIO-520-H-C-C engine, serial number 506830 was installed in the airframe. The records show that the engine had accrued a total time in service of 2,809 hours, with 1,166 since major overhaul.

The airplane is equipped with two 45-gallon fuel tanks, one in each wing. The fuel selector valve has 3 positions, LEFT, OFF, and RIGHT.

The aircraft was equipped with a J. P. Instruments EDM-700/800, which is a panel mounted gauge that the operator can monitor and record up to 24 parameters related to engine operations. See the Tests and Research section of this report for complete details of the data extracted from the unit during post accident examinations. The unit recorded an engine run time of 78 minutes from the time the owner first picked up the airplane from Central Utah Aviation on the afternoon of the accident until the accident.

AIRPORT INFORMATION

The Provo Municipal airport is a tower controlled public airport with two intersecting runways and it is located on the edge of a large lake. Runway 36/18 is 6,614 feet long by 150 feet wide and is paved with asphalt. Runway 31/13 is 8,599 feet long by 150 feet wide and is also paved with asphalt. The field elevation is 4,493 feet mean sea level.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot sustained fatal injuries in the accident and an autopsy was conducted by the Utah State Medical Examiner’s Office. The cause of death was attributed to blunt force traumatic injury. The results of toxicological tests on samples retained during the autopsy were negative for alcohol. Levels of Acetaminophen, Brompheniramine, Dextromethorphan, and Diphenhydroamine were detected in the pilot's blood and urine specimens.

WRECKAGE AND IMPACT

The Safety Board investigator's on-scene examination of the accident site and airplane wreckage revealed that the airplane's belly initially impacted concrete slabs that were located on the south embankment of the Dike (perimeter) Road. Thereafter, the airplane came to rest on the road, about 30 feet north of the point of initial impact. The accident site is located less than 50 feet east of runway 36's extended centerline, and about 760 feet south of the landing threshold.

First emergency personnel responders reported that they found the fuel selector valve positioned to the right fuel tank. They moved the valve to the OFF position.

The initial examination of the airplane revealed an estimated 10 gallons of fuel was located in the left wing's integral fuel tank. During the subsequent examination of the airframe and engine, drops of fuel were found in the engine's gascolator and in the fuel manifold valve. Several ounces of fuel were found in a couple of fuel lines in the engine compartment, while other lines were dry.

No fuel was observed in the right wing's fuel tank. The right wing's forward fuel supply line to the right side header tank was found broken open at its header tank connection. The connection area was impact damaged. No evidence of fuel was found in the ground beneath this breached line. Additionally, none of the first responders to the accident site, including civilian, police, and fire department personnel, reported any evidence of fuel beneath the right side of the airplane, including the right wing and right header tank.

The fuel tank quantity sending units in both tanks were examined, with no discrepancies noted.

TESTS AND RESEARCH

Engine Examination

The engine was a Continental TSIO-520-H-C-C, serial number 506830. According to Continental factory records, the engine as new was assembled on July 12, 1976, and shipped to the customer September 10, 1976.

The engine cowling was damaged and remained attached to the airframe. The propeller assembly was damaged and remained attached to the crankshaft propeller flange. An oil puddle approximately 1 foot by 3 feet in length was visible near the forward right side of the engine. The upper engine cowling was removed from the aircraft. The fuel supply line from the boost pump to the fuel pump was removed and no fuel was present. The supply line from the fuel control to the manifold valve separated at the fuel control fitting. The supply line to the fuel control was removed and approximately 1 ounce of fuel obtained. The oil return line from the oil cooler separated at the oil pump attachment. The upper spark plugs were removed and the electrode areas were clear of deposits and had (worn-out to normal) wear conditions when compared to a Champion AV-27 chart. Carbon deposits were visible near the outer edges of the electrode end of the spark plug. The cylinders were boroscoped and the combustion chambers and piston heads had light grey deposits. The valve heads were undamaged and exhibited normal thermal discoloration. During the on-site inspection the crankshaft rotated freely by hand approximately 10 degrees. Engine control continuity was obtained to the throttle, mixture and propeller cables.

Following recovery of the airplane, the engine forward and lower cowlings were removed from the engine. The left side exhaust stacks and muffler, cross-over tube and the tail pipe had impact damage. A wastegate hydraulic line had impact damage near its connection and continued to leak engine oil during the inspection. Mechanical damage was found on the airframe structure adjacent to the damaged wastegate hydraulic line. The wastegate valve and actuator assembly was undamaged and moved normally with the use of a hand tool. The turbocharger turbine shaft was intact and rotated freely by hand. The compressor and turbine blades were undamaged. The induction tube to the turbocharger, the induction balance tube, and the number 6 cylinder induction elbow had impact damage. The oil sump was crushed up and the oil quick drain plug was safety wired incorrectly. The controller was removed from the firewall and was undamaged. The alternator and left induction elbow were removed to facilitate the removal of the fuel pump. The fuel pump was removed from the engine and the drive coupler was intact. The fuel pump was disassembled and fuel was present in the pump. The fuel control unit was removed from the engine and had impact damage to the pressure fitting to the fuel manifold valve line. The fuel manifold valve was disassembled and fuel was present. The screen was removed and had a light amount of debris and the diaphragm was undamaged. The ignition leads were removed from the right side lower plugs. The left side lower ignition leads were cut from the spark plug attachments due to impact damage to the exhaust assembly. The cylinder rocker covers were removed and the cylinder overhead components were lubricated and undamaged. The crankshaft was rotated and compression and valve continuity was obtained. The magneto impulse coupling engaged and spark was obtained from the ignition lead ends. Gear continuity was obtained from the propeller assembly to the accessory gears and fuel pump drive gear. The fuel lines were removed from the fuel manifold valve to the fuel nozzles. The fuel lines were free of debris. The fuel nozzles were removed and were free of debris. The propeller assembly had impact damage. The spinner was crushed at the tip and sections of the cylinder could be seen through lacerations of the spinner. During the follow-up inspection propeller hub oil dripped from the hub.

EDM-700/800 Instrument Data

The aircraft was equipped with a J. P. Instruments EDM-700/800, which is a panel mounted gauge that the operator can monitor and record up to 24 parameters related to engine operations. Depending on the installation engine parameters monitored can include:

- Exhaust Gas Temperature (EGT)

- Cylinder Head Temperature (CHT)

- Oil Pressure and Temperature

- Manifold Pressure

- Outside Air Temperature

- Turbine inlet Temperature

- Engine Revolutions per Minute

- Compressor Discharge Temperature

- Fuel Flow

- Carburetor Temperature

- Battery Voltage

The unit can also calculate, in real-time, horsepower, fuel used, shock cooling rate and EGT differentials between the highest and lowest cylinder temperatures. The calculations are also based on the aircraft installation. The unit contains non-volatile memory for data storage of the parameters recorded and calculated. The rate at which the data is stored is selectable by the operator from 2 to 500 seconds per sample. The memory can store up to 20 hours of data at a 6 second sample rate. The data can then be downloaded by the operator using the J.P. Instruments software.

The unit was harvested from the wreckage and sent to the NTSB's recorder laboratory for data extraction. The EDM recording contained approximately 11 hours of data over 11 power cycles. The accident flight was the last flight of the recording and its duration was approximately 13 minutes. Two plots containing EDM data recorded during the October 21, 2009 accident flight and the previous flight are included in the Engine Data Monitor Specialists Factual Report, which is contained in the Public Docket for this case. Plot one contains the downloaded data for the entire accident flight, all times referenced are MDT.

At approximately 16:01:30 the Eng1 RPM starts to increase to approximately 2,500 rpm. A slight reduction in Eng1 RPM to approximately 2,460 rpm can be seen at 16:05:18. At 16:06:12 the Eng1 RPM starts a reduction to approximately 1,570 rpm. At 16:08:12 the En

NTSB Probable Cause

A total loss of engine power due to fuel starvation as a result of the pilot’s inadequate preflight inspection.