This discussion contains extracts from the SACAA’s accident report. It is compiled in the interest of promoting aviation safety and not to establish legal liability.
Accident details
Aircraft registration: ZS-FPJ
Date and time of accident: 19 June 2015 1602Z
Type of aircraft: Cessna C210J
Type of operation: Part 91
PIC license type: Commercial
License valid: Yes
PIC age: 38
PIC total hours: 6400
PIC hours on type: 149
Last point of departure: Piesangshoek
Next intended landing: Nelspruit
Location of accident site: Field near EAQB
Meteorological information: Wind 090/08, viz 10 km. temp +18C
POB: 1+0
People injured: 1
People killed: 0
History of flight
The engine started without difficulty and the pilot waited until all the engine instruments were normal before taxiing in an easterly direction for a westerly departure. He carried out his take-off checks. At 1900 RPM he noted that both magneto drops were 50 RPM.
The pilot selected 10° of flaps and took power. The aircraft accelerated downhill towards the west with a 15 kmh tailwind. The pilot reported that during the climb, at about 100 ft AGL he noticed a gradual loss of power and the aircraft was unable to gain altitude. The RPM surged between 2500 and 2200.
The pilot stated his eyes were outside the cockpit and he did not consider looking inside, to operate the electric fuel booster pump as the aircraft was drifting towards the tree tops. (Jim’s note: but he was able to notice how much the revs were surging.)
During a turn to the right, he lost control. The right wing dropped and the aircraft entered a near vertical descent, colliding with tree stumps on an uphill slope before impacting the ground.
A fierce fire broke out, which ultimately destroyed the aircraft. The pilot unbuckled himself and vacated the burning wreckage through the right-hand door. He sustained minor bruises to his left hand. The farmers in the area drove to the site and assisted with suppressing the fire.
The first witness, a farmer who was at the airstrip, took a video of the aircraft during take-off. The aircraft rotated right at the far end of the runway before climbing and disappearing from his view. The aircraft flight profile on the video clip showed that towards the end of the runway, after rotation, the aircraft had a high nose attitude and the wings were level.
The engine-driven fuel pump was inspected and was found to have a sheared drive pin, P/N 631684, caused by the pump seizure, with a consequent fuel starvation and loss of engine power. When the pump was actuated by hand, there was no movement or continuity to its mechanical linkage that connected into the engine. The primary reason for the fuel pump seizure could not be determined.
Though the engine-driven fuel pump is the primary source of fuel pressure to the engine/injectors, the aircraft also had a back-up auxiliary electric fuel "boost-pump, redundancy system" installed on it. In case the engine-driven pump fails or is unable to maintain adequate fuel flow, the auxiliary fuel pump must be instantly turned on. It is controlled by a switch on the instrument panel.
The pilot admitted than he did not monitor the fuel flow during take-off and at no time did he think of turning on the auxiliary fuel pump.
The POH states that if the engine-driven fuel pump fails during take-off, the pilot should immediately hold the left half of the auxiliary fuel pump switch in the hi position until the aircraft is well clear of obstacles.
The pilot was experienced and familiar with the type of aircraft and well aware of all the emergency procedures. The investigation concluded that the pilot failed to conform to the POH emergency procedure which would have kept the engine running.
Jim’s analysis
I find this incredibly depressing. Just going through my rather feeble recent memory, I can think of this Continental fuel pump issue killing people in two Bonanzas, a Baron, two 210s and a Piper Malibu.
What goes on in people’s heads? Didn’t they read the POH? Didn’t they get a proper conversion? Don’t they understand this very simple system? Can’t they stick to the rules? Are they in such a hurry they don’t think what they are doing? Do they think “it can’t happen to me so I don’t need to worry about it”?
The rule is pretty simple. You do not put the fuel pump on hi for take-off, or in flight, unless there is a problem.
I just don’t get it. Actually that’s a lie – perhaps I do get it. Could it be part of today’s instant gratification culture?
When you get a new toy–an electric fan or a bit of furniture that needs to be assembled–do not read the instructions until you get stuck.
Yep – I’m guilty of this as well. I only pull out the handbook for my motorbike when I can’t figure out how to reset the clock. Same with a Suzuki Swift I bought recently. What a magic little car that is, but I couldn’t figure out how to make the aircon go from fresh air to recirculate air. I kept pushing the button until my son told me to slide it sideways. But read the handbook? No way.
But surely an aeroplane is different. There are a whole lot of apparently simple things, within easy reach, that can kill you if you don’t understand them. The door locking mechanism, the seat adjustment, the control lock, the fuel cock ... even the park brake.
If you try to do aerobatics in a Chipmunk with the brake on you will not be able to recover from a spin. It’s a very simple system, but if you don’t understand it you will die.
Then there are more obscure things. Has the aircraft you normally fly got an alternate static source in the cockpit? Do the fuel caps have breathers? A family of four was recently killed in a Comanche because the pilot didn’t understand the breathing system on the aircraft.
A mate of mine recently wanted me to fly with him in his little CTSW (hell, can’t they give this delightful little aeroplane a proper name?). I insisted on reading the handbook from cover to cover before we even did a pre-flight.
Overkill? I don’t think so. As a founder member of the LCC (the famous Live Cowards’ Club) I don’t want to be in the cockpit of an aeroplane that I don’t understand.
What Can We Learn?
Please RTFFM! (Read The Flight Manual)
With a fuel-injected engine it is critical to keep an eye on fuel flow during take-off. Any slight fluctuation, or decrease in pressure, calls for an immediate abort.
Jim Davis is a natural teacher with a passion for flying training, believes in learning through enjoyment. His book is refreshingly un-textbookish yet thoroughly covers its subject clearly. With over 15,000 hours, including 10,000 in flying instruction for civilian and military pilots, Jim founded South Africa’s largest and most respected flying school, 43 Air School. He is also an author of multiple books on flying training and has contributed numerous articles to flying magazines across two continents. https://www.jimdavis.com.au