NTSB Identification: LAX90FA145.
The docket is stored on NTSB microfiche number 43463.
Nonscheduled 14 CFR
Accident occurred Friday, April 13, 1990 in GRAND CANYON, AZ
Probable Cause Approval Date: 04/13/1992
Aircraft: CESSNA T207, registration: N91081
Injuries: 7 Serious.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.ACCORDING TO WITNESSES, THE ACFT WAS ABOUT TO TOUCHDOWN FROM A NORMAL APCH TO RWY 21, WHEN IT ENCOUNTERED VARIALBLE WIND CONDS & BALLOONED TO ABOUT 70' AGL. THE PLT INITIATED A GO-AROUND. SHORTLY THEREAFTER, WITNESSES OBSERVED A PUFF OF SMOKE EMANATE FROM THE ACFT, THEN THE PLT TRANSMITTED THAT THE FLT WAS 'GOING DOWN.' SUBSEQUENTLY, THE ACFT COLLIDED WITH TREES ON WOODED TERRAIN ABOUT 1/2 MI FROM THE DEP END OF THE RWY. AN EXAM REVEALED A LACK OF POWER SIGNATURES ON THE PROP; EVIDENCE OF SOOTING WAS FOUND ON THE SPARK PLUGS (INDICATING A RICH MIXTURE). TESTING OF THE TURBO-CONTROLLER REVEALED EVIDENCE THAT IT HAD BEEN ADJUSTED TO A LOW SETTING; THE TURBO WOULD ONLY PRODUCE A MAXIMUM AIR FLOW EQUAL TO HIGH CRUISE POWER. THE ENG MANUFACTURER RPRTD THAT THIS SITUATION COULD PRODUCE AN OVER-RICH MIXTURE, PARTICULARILY IF THE THROTTLE AND/OR MIXTURE CONTROLS WERE IMPROPPERLY MANIPULATED. THE PILOT LACKED EXPERIENCE IN ACFT WITH TURBO-CHARGED ENGS & HE WAS NOT TRAINED IAW THE COMPANY TRAINING PROGRAM.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
IMPROPER ADJUSTMENT OF THE TURBO-CHARGER ABSOLUTE PRESSURE CONTROLLER, AND IMPROPER MANIPULATION OF THE POWER PLANT CONTROLS BY THE PILOT DURING THE GO-AROUND. FACTORS RELATED TO THE ACCIDENT WERE: FAILURE OF COMPANY MANAGEMENT TO PROPERLY TRAIN THE PILOT IN ACCORDANCE WITH THE APPROVED COMPANY TRAINING PROGRAM, AND THE PILOT'S LACK OF EXPERIENCE IN TURBO-CHARGED ENGINE OPERATIONS. Index for Apr1990 | Index of months