The flight was the first flight in the Cessna P210N since its annual inspection, which occurred about six weeks before the accident.
The pilot conducted a thorough preflight inspection and run-up. Before takeoff, he added full power with the brakes applied, and, after noting no abnormal engine or instrument indications, he took off.
When the airplane reached about 150 to 200 feet above the ground, the engine started to run roughly. The airplane was unable to maintain altitude, so he executed a forced landing to a field near Bountiful, Utah. During the landing, the airplane sunk into the mud and nosed over.
Post-accident examination of the engine revealed that the fuel lines connected to the input and output of the fuel flow indicator were loose and leaking.
After these lines were tightened about 1.5 turns and pressure was applied, a third leak was found in the vicinity of a metal label on the fuel line between the fuel manifold and the fuel pressure gauge.
The aircraft manufacturer’s service manual states that the engine compartment rubber hoses must be replaced every five years or at engine overhaul, whichever occurs first. According to the airplane’s maintenance logbook, the most recent engine overhaul occurred about 18 years before the accident.
The mechanic who conducted the annual inspection reported that, during the inspection, he removed the fuel lines to and from the engine-mounted fuel flow transducer to troubleshoot a lack of indicated fuel pressure at the cockpit-mounted instrument.
It is likely that the mechanic failed to adequately tighten the fuel lines when he reinstalled them.
The NTSB determined the probable cause as fuel starvation due to the in-flight loosening of the fuel lines attached to the fuel flow indicator as a result of inadequate maintenance.
NTSB Identification: WPR14LA118
This February 2014 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
The mechanic will remember this one. I have found that when conducting a 100hr/annual inspection you must use a checklist. But, add to that a break sheet like we did at Cessna, showing: who, what, when and why it was getting done on a particular area of the ship. It is always good to use another set of eyes to re-inspect the work previously done. Personally, I always liked the next day review, before closing up the ship. Inspect the work done from the day or evening before.
This pilot was lucky. He just joined the 20% Club… About 1/5 of NTSB reportable accidents have a maintenance root cause.