CEN18FA236

A total loss of engine power due to fuel exhaustion. Also causal was the pilot's failure to divert earlier in the flight to another airport to ensure that the airplane had an adequate fuel reserve, and the malfunction of the landing gear extension system for reasons that could not be determined with the available information.

As the pilot approached his destination after a cross-country flight, the airplane's landing gear did not fully extend. Over the next 7 minutes, the pilot attempted to troubleshoot the landing gear in the airport traffic pattern before he reported to the tower controller, "Well, I just burnt outta fuel, we're totally out bud." The tower controller immediately cleared the pilot to land; however, there were no additional communications from the pilot and the final radar return was recorded about 180 ft above ground level and about a mile northwest of the runway. The airplane impacted trees and an electricity service line in an urban residential area. A postcrash fire destroyed most of the forward fuselage and cockpit. The landing gear motor/pump assembly and the hydraulic fluid lines were damaged during impact and the fire, which precluded comprehensive testing of the landing gear extension/retraction system. The landing gear selector handle and the emergency extension handle were destroyed during the fire. The nose and right main landing gear were found fully extended and secured by their respective downlocks. The left main landing gear was found fully retracted in the wheel well and secured by its uplock. There were small tree branches and leaves observed in the wheel well between the left landing gear leg and the fuselage, indicating that the left landing gear was partially extended and was pushed up into the wheel well during the accident. Both main landing gear moved freely by hand between the retracted and extended positions without any anomalies, and their respective up- and down lock assemblies secured both landing gear as designed. All three landing gear actuators functioned normally when hydraulic pressure was applied using a hand-actuated pump. The extensive impact and fire damage to the landing gear extension/retraction components precluded determination of why the landing gear did not fully extend during the flight. A postaccident engine examination did not reveal any evidence of mechanical malfunction that would have precluded normal operation during the flight. Although the pilot had departed on the flight with enough fuel to reach his intended destination, he did not have enough fuel remaining to adequately address the landing gear malfunction before the airplane had a total loss of engine power due to fuel exhaustion. Federal regulations stipulate that daytime flights under visual flight rules depart with enough fuel to reach the intended destination plus at least 30 minutes of flight at a normal cruising speed. Based on the recorded transmissions between the pilot and the tower controller, the airplane only had about 7 minutes of fuel remaining when the pilot first reported the landing gear malfunction to the tower controller. The pilot should have diverted earlier in the flight to another airport to ensure that the airplane had an adequate fuel reserve.

According to Federal Aviation Administration (FAA) records, the 54-year-old pilot held a private pilot certificate with an airplane single-engine land rating. The pilot's most recent FAA third-class medical certificate was issued on October 18, 2017, with a limitation for corrective lenses. On the application for his current medical certificate, the pilot reported having accumulated 650 total hours of flight experience and 0 hours within the previous 6 months. A review of previous medical certificate applications revealed that the pilot did not report any flight time during the 20-year period before his current medical application in 2017. A pilot logbook was not located during the investigation, and his recent flight experience could not be determined. The Wayne County Medical Examiner's Office, Detroit, Michigan, performed an autopsy on the pilot that attributed the cause of death to multiple blunt-force injuries. Toxicology testing by the FAA Forensic Sciences Laboratory was not possible because the as-received condition of the samples precluded analysis. However, toxicological testing was completed on additional samples sent to a contract laboratory used by the Wayne County Medical Examiner's Office in conjunction with their autopsy. The results indicated the presence of caffeine in peripheral blood, but did not indicate any positive findings of toxicological significance for alcohol, carbon monoxide, or illicit drugs. The airplane, a 1978 Cessna P210N (Centurion), serial number P21000071, was of conventional aluminum construction with a retractable tricycle landing gear and wing flaps. The airplane had a pressurized cabin configured to seat six people and a total fuel capacity of 90 gallons (89 gallons usable) distributed between two wing fuel tanks. On April 22, 2014, the airplane was modified in accordance with Vitatoe Aviation Supplemental Type Certificate SA02918CH with a turbo-normalized system on a stock Teledyne Continental IO-550P engine. The engine provided thrust through a constant-speed, three-blade, Hartzell HC-J3YF-1RF/F8068-2 propeller. The pilot purchased the airplane on April 18, 2018, at 2,487.8 total airframe hours. The airplane's hour meter was destroyed by the postimpact fire, which precluded a determination of the airplane's total service time at the time of the accident. According to available maintenance documentation, the last annual inspection of the airplane was completed on January 29, 2018, at 2,486.3 total airframe hours. As of the last annual inspection, the engine had accumulated 65 hours since new. The maintenance logbook entry for the last annual inspection indicated that the landing gear was successfully cycled four times using the normal extension/retraction system and extended once using the emergency procedure with no anomalies. On February 21, 2018, the landing gear was cycled at least 20 times without any issues after a diode was replaced in the landing gear hydraulic power pack. On April 27, 2018, the left main landing gear leg was removed to replace the hydraulic fluid transfer fitting to the left brake. The left main landing gear leg was reinstalled with new seals. The pilot reported to his insurance company that the oil gauge rod fractured on May 6, 2018, during a flight from Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma, to Pearland Regional Airport (LVJ), Houston, Texas. The pilot consulted an aviation mechanic at LVJ who found the fractured oil gauge rod after the pilot reportedly had an issue getting the oil filler cap to seat properly. The mechanic stated that when he removed the oil filler cap there was only about 2 inches of the oil gauge rod still attached, and that he was able to extract another 3 inches of the oil gauge rod from the tube. The mechanic stated that a borescope inspection revealed tick marks on the inside surface of the crankcase. The oil filter was removed and cut open to check for metal contamination. The mechanic reported that the oil filter contained significant metal debris, and that he told the pilot that the engine needed to be overhauled. The pilot told the mechanic that he had just purchased the airplane and that he could not afford to overhaul the engine. The mechanic then placed a red "Do Not Fly" placard on the pilot-side yoke. The mechanic stated that a couple of weeks later the pilot returned with another oil filter for inspection. The pilot told the mechanic that he had researched online on how to remove metal from an engine by flushing it with diesel fuel. The mechanic stated that there was no metal present when he cut open the oil filter for inspection. The mechanic again told the pilot that he should not fly the airplane until the engine had been overhauled. According to Vitatoe Aviation, the turbo-normalized engine produced 262 brake horsepower at 2,500 rpm with a manifold pressure of 30 inches of mercury (inHg) or less and had a fuel flow of 17.6 gallons per hour (gph). The lean-of-peak cruise setting of 17.6 gph produced a true airspeed of 185-190 knots at 10,000 ft on a standard day. The same lean-of-peak cruise setting produced a true airspeed of about 215 knots at 22,000 ft on a standard day. The maximum operating altitude was 23,000 ft. According to Vitatoe Aviation, to establish cruise power at the desired cruise altitude, the pilot should allow the airplane to stabilize in straight and level flight and reduce engine speed to 2,500 rpm. After the engine speed has stabilized, the pilot should reduce the throttle setting to no more than 30 inHg and reduce fuel flow to 17.6 gph. The pilot should then monitor cylinder head temperature (CHT) readings and close the cowl flaps. If any CHT approaches 380°F or higher, the pilot should gradually reduce fuel flow about 0.3-0.4 gph to maintain CHT below 380°F. On very hot days, it may be necessary to open the cowl flaps slightly to maintain CHT readings below 380°F. Data recovered from the airplane's J.P. Instruments EDM-730 engine monitor and an Appareo Stratus 2S device indicated that, the pilot flew 6 confirmed cross-country flights since he purchased the airplane on April 18, 2018. Further review of the data revealed that that the pilot's leaning method during cruise flight differed from the lean-of-peak method recommended by Vitatoe Aviation. According to the recorded engine data, during cruise flight, the pilot would lean rich-of-peak, with an average fuel flow of about 21 gph. During the previous flight leg from HPY to AWM, the average fuel flow was about 21 gph during cruise flight at 2,530 rpm, 27 inHg manifold pressure, and a hottest CHT of 390°F. During the accident flight, the average fuel flow was about 21 gph during cruise flight at 2,500 rpm, 25 inHg manifold pressure, and a hottest CHT of 380°F. At 1956:36 during the accident flight, the engine had used 71.6 gallons of fuel when the recorded fuel flow suddenly dropped to zero, along with a corresponding drop in rpm, CHT, and exhaust gas temperatures. On June 24, 2018, about 1957 eastern daylight time, a Cessna P210N airplane, N3896P, was substantially damaged when it was involved in an accident in Detroit, Michigan. The pilot and one passenger were fatally injured, and one passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The cross-country flight originally departed from Baytown Airport (HPY), Baytown, Texas, and the pilot refueled at West Memphis Municipal Airport (AWM), West Memphis, Arkansas, before proceeding toward Coleman A. Young Municipal Airport (DET), Detroit, Michigan. According to the fixed-base operator (FBO) employee who fueled the airplane at AWM, the pilot requested that 30 gallons of 100 low-lead aviation fuel be added to each wing tank (60 gallons total). The FBO employee stated that after he had refueled the airplane to the pilot's specifications, the fuel level was about 1/4 inch below the top of the right