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Attributes | |
ACN | 518051 |
Time | |
Date | 200107 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | general aviation : personal |
Make Model Name | Cessna 210 Centurion / Turbo Centurion 210C, 210D |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 13000 flight time type : 100 |
ASRS Report | 518051 |
Person 2 | |
Affiliation | government : faa |
Function | maintenance : inspector |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : engine indications other flight crewa |
Resolutory Action | flight crew : landed in emergency condition |
Consequence | faa : investigated other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : fault isolation performance deficiency : scheduled maintenance performance deficiency : testing |
Supplementary | |
Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Continental IO470E was assembled using all engine parts that were yellow tagged or white tagged and in accordance with overhaul manual. The engine was installed in a 1960 C210. There were after market engine controls installed which were included on the practice copy of the 337 field approval request but did not get xferred to the final request which had about 8 changes to the instrument panel. In rigging the engine throttle and mixture controls, the cessna parts manual shows push rods on throttle and mixture linkages on different sides than the parts manual and the head of the bolt is shown in different directions. The throttle and mixture controls were not the same travel as the original ones were either. I continued to loosely attach push rods, etc, to see if any parts were missing and in need of being purchased, but the rigging was not completed. I had only made a mental note about something not completed on the rigging. Several months later, I was preparing for an annual inspection and did the final tightening on the push rods thinking this completed the rigging on the engine. The fuel pump (engine driven) was yellow tagged and I understood the fuel pressure was factory preset and no further adjustment was made. My continental manual does not mention a need for adjustment nor does my cessna service manual state adjustment is needed. It does say about 4 lines about an adjust kit available about fuel pressure. But, I understood the fuel pressure to have been adjusted when the pump was sent in for overhaul. On the first flight, during takeoff, I had a partial, then seemingly total loss of engine power. FAA investigators told me I incorrectly set up the engine controls (bolt head direction, throttle and mixture rigging, and incorrect fuel pressure) and that I would get a letter of warning north my file. A couple days later, while at a cessna service center, we discovered a malfunctioning magneto. The magneto on the test bench indicated ok. But was firing way off time and on who knows what cylinder. The magneto check before flight, manifold pressure, fuel flow, and all other indications were good. A witness said black puffs of smoke started coming out of the engine before and during power loss. Regarding throttle/mixture adjustments and controls: 1) multiple modifications were written down in a different order on practice copy of 337 field approval request. When they were xferred to the permanent copy, the engine controls weren't listed. 2) I don't feel the bolt direction on the push rods was a factor but I should have done a complete check according to the book on the rigging. The throttle travel reached its stops and the mixture travel reached its full rich stop but was just short of its ico stop. Original style new cables were installed and after market cables removed. 3) fuel pressure adjustment when engine is installed after overhaul was not mentioned in either continental overhaul manual, or cessna service manual. Fuel pressure has been adjusted at cessna dealer and new magneto ordered.
Original NASA ASRS Text
Title: A C210 ON TKOF CLB AT 300 FT DIVERTED DUE TO LOSS OF ENG PWR CAUSED BY A FAILED MAGNETO.
Narrative: CONTINENTAL IO470E WAS ASSEMBLED USING ALL ENG PARTS THAT WERE YELLOW TAGGED OR WHITE TAGGED AND IN ACCORDANCE WITH OVERHAUL MANUAL. THE ENG WAS INSTALLED IN A 1960 C210. THERE WERE AFTER MARKET ENG CTLS INSTALLED WHICH WERE INCLUDED ON THE PRACTICE COPY OF THE 337 FIELD APPROVAL REQUEST BUT DID NOT GET XFERRED TO THE FINAL REQUEST WHICH HAD ABOUT 8 CHANGES TO THE INST PANEL. IN RIGGING THE ENG THROTTLE AND MIXTURE CTLS, THE CESSNA PARTS MANUAL SHOWS PUSH RODS ON THROTTLE AND MIXTURE LINKAGES ON DIFFERENT SIDES THAN THE PARTS MANUAL AND THE HEAD OF THE BOLT IS SHOWN IN DIFFERENT DIRECTIONS. THE THROTTLE AND MIXTURE CTLS WERE NOT THE SAME TRAVEL AS THE ORIGINAL ONES WERE EITHER. I CONTINUED TO LOOSELY ATTACH PUSH RODS, ETC, TO SEE IF ANY PARTS WERE MISSING AND IN NEED OF BEING PURCHASED, BUT THE RIGGING WAS NOT COMPLETED. I HAD ONLY MADE A MENTAL NOTE ABOUT SOMETHING NOT COMPLETED ON THE RIGGING. SEVERAL MONTHS LATER, I WAS PREPARING FOR AN ANNUAL INSPECTION AND DID THE FINAL TIGHTENING ON THE PUSH RODS THINKING THIS COMPLETED THE RIGGING ON THE ENG. THE FUEL PUMP (ENG DRIVEN) WAS YELLOW TAGGED AND I UNDERSTOOD THE FUEL PRESSURE WAS FACTORY PRESET AND NO FURTHER ADJUSTMENT WAS MADE. MY CONTINENTAL MANUAL DOES NOT MENTION A NEED FOR ADJUSTMENT NOR DOES MY CESSNA SVC MANUAL STATE ADJUSTMENT IS NEEDED. IT DOES SAY ABOUT 4 LINES ABOUT AN ADJUST KIT AVAILABLE ABOUT FUEL PRESSURE. BUT, I UNDERSTOOD THE FUEL PRESSURE TO HAVE BEEN ADJUSTED WHEN THE PUMP WAS SENT IN FOR OVERHAUL. ON THE FIRST FLT, DURING TKOF, I HAD A PARTIAL, THEN SEEMINGLY TOTAL LOSS OF ENG PWR. FAA INVESTIGATORS TOLD ME I INCORRECTLY SET UP THE ENG CTLS (BOLT HEAD DIRECTION, THROTTLE AND MIXTURE RIGGING, AND INCORRECT FUEL PRESSURE) AND THAT I WOULD GET A LETTER OF WARNING N MY FILE. A COUPLE DAYS LATER, WHILE AT A CESSNA SVC CTR, WE DISCOVERED A MALFUNCTIONING MAGNETO. THE MAGNETO ON THE TEST BENCH INDICATED OK. BUT WAS FIRING WAY OFF TIME AND ON WHO KNOWS WHAT CYLINDER. THE MAGNETO CHK BEFORE FLT, MANIFOLD PRESSURE, FUEL FLOW, AND ALL OTHER INDICATIONS WERE GOOD. A WITNESS SAID BLACK PUFFS OF SMOKE STARTED COMING OUT OF THE ENG BEFORE AND DURING PWR LOSS. REGARDING THROTTLE/MIXTURE ADJUSTMENTS AND CTLS: 1) MULTIPLE MODIFICATIONS WERE WRITTEN DOWN IN A DIFFERENT ORDER ON PRACTICE COPY OF 337 FIELD APPROVAL REQUEST. WHEN THEY WERE XFERRED TO THE PERMANENT COPY, THE ENG CTLS WEREN'T LISTED. 2) I DON'T FEEL THE BOLT DIRECTION ON THE PUSH RODS WAS A FACTOR BUT I SHOULD HAVE DONE A COMPLETE CHK ACCORDING TO THE BOOK ON THE RIGGING. THE THROTTLE TRAVEL REACHED ITS STOPS AND THE MIXTURE TRAVEL REACHED ITS FULL RICH STOP BUT WAS JUST SHORT OF ITS ICO STOP. ORIGINAL STYLE NEW CABLES WERE INSTALLED AND AFTER MARKET CABLES REMOVED. 3) FUEL PRESSURE ADJUSTMENT WHEN ENG IS INSTALLED AFTER OVERHAUL WAS NOT MENTIONED IN EITHER CONTINENTAL OVERHAUL MANUAL, OR CESSNA SVC MANUAL. FUEL PRESSURE HAS BEEN ADJUSTED AT CESSNA DEALER AND NEW MAGNETO ORDERED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.