NTSB CAROL · Event
Event WPR13LA047
Aircraft involved
Probable cause & findings
The loss of engine power during initial climb for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation.
Factual narrative
On November 20, 2012, about 1120 Pacific standard time, a Cessna 210D, N3919Y, sustained substantial damage as a result of a forced landing following a loss of engine power during initial climb near San Rafael, California. The certified commercial pilot, the sole occupant of the airplane, sustained minor injuries. Visual meteorological conditions prevailed for the proposed cross-country flight, which was being operated in accordance with 14 Code of Federal Regulations (CFR) Part 91 as a personal flight, and a flight plan was not filed. The flight was originating from the Martin Ranch Airport (CA35), San Rafael, California, at the time of the accident, with an intended destination of Chico, California.In a written statement submitted to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot reported that prior to take off the fuel selector was in the right tank position. Additionally, he confirmed by "sticking" (measuring) the fuel levels, that he had a total of 29 gallons on board; 6 gallons in the left tank and 23 gallons in the right tank. The pilot stated that after taking off and during the initial climb, the engine was delivering full power. About 500 feet above ground level (agl) the pilot reported that the engine experienced a total loss of engine power, at which time he turned on both fuel pumps and switched the fuel selector from the right tank to the left tank; this action did not restore power to the engine. The pilot subsequently switched the fuel selector back and forth several times, but with no success of restoring engine power. The pilot revealed that at this time he set up for a forced landing to a marsh. After landing, the airplane slid about 100 feet before coming to rest upright. The airplane had sustained substantial damage to the lower right forward area of the fuselage, which resulted in the right fuel reservoir tank being ruptured. The pilot opined that after exiting the airplane, he observed fuel draining out of the lower right cowling at about one-half gallon per minute. In a telephone conversation with the NTSB IIC, a first responder reported that while walking toward the accident site and when he was about 75 yards from the wreckage, he detected a very strong odor of fuel. He further reported that when he was about 30 to 40 yards from the airplane he observed a distinct sheen on the surface of the water, which he thought was fuel leaking from the airplane, although he did not visually observe fuel escaping from the airplane. In a telephone conversation with the NTSB IIC, the owner of the salvage company that recovered the airplane reported that only about 1 gallon of fuel was recovered from the left fuel tank, and that the tank had not been breached. Additionally, he reported that while the right fuel tank had not been breached, the associated fuel lines had been compromised, which he said explained the fuel odor and the fuel in the water outside and around the airplane. The salvage owner also reported that the fuel selector was in the RIGHT TANK position at the accident site. Subsequent to the airplane being recovered to a secured storage facility, and at the request of the NTSB IIC, the engine was examined and a test run was performed by a Continental Motors, Inc. (CMI) air safety investigator under the supervision of a Federal Aviation Administration (FAA) aviation safety inspector. Prior to the test run, maintenance records were reviewed. The engine was a Continental IO-520-A (32), serial number 112876-R, with a build date of October 19, 1999. The engine's most recent annual inspection was performed on May 1, 2012, at a tachometer time of 571.3 hours, which corresponded to the time since the last major overhaul. At the time of the examination, the tachometer read 592.2 hours. Maintenance records did not indicate the actual total time of the engine. An external examination of the engine revealed no impact damage. The top sparkplugs were removed and displayed a lean operation with little-to-no deposits or soot. A borescope inspection of all six cylinders revealed no signs of operational distress to any of the cylinders, pistons, or valves. A thumb compression test resulted in suction and compression being obtained on all six cylinders. Additionally, during crankshaft rotation a spark was obtained on all six top ignition leads. In preparation for the test run the three-bladed, variable-pitch McCauley propeller was removed due to the damage sustained by all three blades and was replaced with a two-bladed, fixed-pitch propeller for the test run. Additionally, as the right fuel reservoir tank had been ruptured, the fuel hose between the auxiliary electric boost pump and the engine-driven fuel pump inlet was removed from the boost pump end, and an alternate electric fuel boost pump and alternate fuel tank were attached to the engine-driven fuel pump's inlet line. Electric power was supplied to the alternate electric boost pump and the engine was started using the accident aircraft's ignition/starting system. The engine ran through various power settings with no anomalies noted. The engine revolutions per minute (RPM) was limited to 2,500 during the engine run for safety reasons. The engine's mixture control was adjusted throughout the engine run and the fuel flow and RPM instrument readings represented what was to be expected for a given adjustment. The engine ran for 0.2 hours on the tachometer (592.2 to 592.4); about 15 minutes. The examination and test run of the engine did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower. Following the engine run the fuel supply system was examined. The alternate electric boost pump was removed from the fuel supply system and the fuel line between the auxiliary boost pump and the engine-driven fuel pump remained disconnected. The left fuel return line was plugged at the left wing root and compressed air was provided to the left fuel tank supply tube with the right fuel tank selected [this fuel selector position would block fuel from getting to the fuel strainer and electric boost pump from the left fuel tank]. With the compressed air supplied to the left pickup tube, compressed air could be heard entering and filling the left fuel reservoir; however, compressed air did not exit the fuel selector. The same test was then conducted with the fuel selector positioned to the left fuel tank, which is a position that would permit fuel to flow from the left fuel tank, through the left fuel reservoir, to the fuel strainer and auxiliary/engine-driven fuel pumps. When compressed air was supplied to the left pickup tube, it could be observed exiting the line that would normally supply the engine-driven fuel pump. No blockage or ruptures were noted on the left side fuel supply system. Before departure, the pilot confirmed the fuel level by measuring the quantity of each tank, which totaled 6 gallons in the left tank and 23 gallons in the right tank. The fuel selector was placed in the right tank position for takeoff. After taking off to the northeast and when about 500 feet above ground level during the initial climb, the engine experienced a total loss of power. The pilot switched on both boost pumps, moved the fuel selector back and forth between tanks several times, and attempted to restart the engine; however, the engine did not regain power. The pilot subsequently made a forced landing to a marsh. The airplane sustained substantial damage to the lower right forward area of the fuselage, which resulted in the right fuel reservoir tank being ruptured; neither fuel tank was breached. Recovery personnel reported that they drained 1 gallon of aviation fuel from the left fuel tank and that the fuel selector switch was in the right tank position. Postaccident examination did not reveal any anomalies that would have precluded normal operation. A postaccident test run of the engine was accomplished with no anomalies noted. After the engine run was completed, the airplane's left and left fuel supply systems were examined. The examination revealed that there were no blockages or ruptures to the left fuel supply system and that the right fuel reservoir tank rupture permitted whatever fuel was present in the right fuel tank to drain from the system after the accident. The reason for the reported total loss of engine power 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 Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
- — Aircraft-Aircraft power plant-Power plant-(general)-Malfunction
Verbatim from NTSB's published report. Source file
NTSB_2012_WPR13LA047.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 (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.
- NASA NTRS 2020 · Technical Memorandum (TM)
Evaluation Issues for a Flight Deck Interface; CAST SE-210 Output 2: Report 4 of 6
This report is part of a series of reports that addresses flight deck design and evaluation, written as a response to loss of control accidents.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
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- Semantic Scholar 2025 · Article (Applied Sciences)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
Browse the full corpus — academia portal ↗