NTSB CAROL · Event
Event ERA18LA103
Aircraft involved
Probable cause & findings
The improper adjustment of the fuel pump by maintenance personnel, which resulted in an overly rich fuel/air mixture and a total loss of engine power.
Factual narrative
On March 13, 2018, about 1330 eastern daylight time, a Cessna T210N, N5382A, was substantially damaged when it was involved in an accident near Orlando, Florida. The commercial pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and a coworker were conducting routine test flights with new camera equipment that had just been installed on the airplane. On the morning of the accident, the pilot performed a two-hour test flight with no issues. After starting the engine and waiting about 5 minutes to allow the camera system to boot up, the pilot taxied to the runway and was cleared for takeoff. As the airplane climbed, he felt there was something wrong with the engine, although it continued to produce power. He checked all the instruments and gauges and did not see any abnormalities. When the airplane reached cruise altitude, the pilot reduced power and the engine "quit." The pilot notified air traffic control of the engine failure and performed a forced landing on a road. Examination of the airplane by a Federal Aviation Administration inspector revealed that the empennage was separated from the fuselage. Both wings were buckled, and both wing assemblies were leaking fuel. The engine was removed and sent to the manufacturer for further examination and testing. After an examination, the engine was prepared and placed in an engine test cell. The engine ran normally up to about 2,100 rpm, then emitted black smoke from the exhaust and began to lose power when the throttle was increased, consistent with an overly rich fuel/air mixture. The fuel pump was leaned, and further test runs were completed with no anomalies. The unmetered pressure was at or slightly above the maximum pressure for full throttle. Upon completion of the standard run, the fuel pump was set back to the as-received setting and exhibited the same loss of power demonstrated during the first test. The throttle body and fuel pump were bench tested and both units failed to meet production standards. A review of the maintenance logbook entries revealed that on July 25, 2016, a fuel system adjustment was performed at a tachometer time of 9,854.4 hours. As of the last annual inspection on February 25, 2018, the engine had accumulated a total of 455.6 hours. On the morning of the accident, the pilot performed a 2-hour test flight with newly-installed camera equipment, during which the airplane performed normally. While taking off on the second flight of the day, the pilot felt that there was something wrong with the engine. There were no abnormal indications and the engine continued to produce power until the pilot leveled the airplane at cruise altitude; the engine then lost total power and the pilot subsequently conducted a forced landing onto a road, resulting in substantial damage to the wings. A test run of the engine revealed that the fuel pump was adjusted to an excessively rich fuel flow setting, which resulted in a loss of power when the throttle was increased past about 2,100 rpm. The fuel pump was readjusted and the engine performed nominally. When the fuel pump was reset to the as-received setting, the engine exhibited the same loss of power as during the first run. Bench testing of the throttle body and fuel pump revealed that both units failed to meet production standards. Review of the airplane's maintenance records indicated that a fuel system adjustment was performed almost 2 years before the accident. It is likely that the improper fuel pump setting resulted in an overly rich fuel/air mixture and the subsequent loss of engine power; however, the reason for the loss of engine power during the accident flight, and not during previous flights since the fuel pump was adjusted, could not be determined. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- C Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel - C
- F Personnel issues-Action/decision-Action-Incorrect action selection-Maintenance personnel - F
- — Aircraft-Fluids/misc hardware-Fluids-Fuel-Incorrect service/maintenance
Verbatim from NTSB's published report. Source file
NTSB_2018_ERA18LA103.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, engine failure, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
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