WPR19LA016
2018-10-27 · FiIlmore, California, United States · Minor · 1 aircraft · Status: Completed
Airport SZP
Aircraft involved
Probable cause & findings
A total loss of engine power as a result of the pilot’s failure to remove a towel from the engine’s air induction following maintenance.
Factual narrative
On October 27, 2018, about 1045 Pacific daylight time, a Cessna T210G, N6834R, was substantially damaged when it was involved in an accident near Fillmore, California. The private pilot and pilot-rated passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the airplane idled on the ground for about 15 minutes before departure while he performed a run-up and waited for traffic to vacate the runway. After making a normal departure, he continued east and climbed to about 4,000 ft mean sea level (msl). While in cruise flight with the airspeed about 105 kts, the engine suddenly lost total power. Despite his attempts to troubleshoot the failure, he could not restart the engine and performed a forced landing in a dry riverbed. After touchdown, the airplane rolled several hundred feet in the dry sand. The nose landing gear impacted a rock and collapsed, and the airplane nosed over and came to rest inverted. An external examination of the engine revealed that the crankcase was intact with no evidence of pre-mishap catastrophic mechanical malfunction or fire. The crankshaft was rotated by turning the propeller blades that remained affixed to the crankshaft flange. Thumb compression was established in all cylinders. Valve train continuity was observed, with equal lift action at each rocker assembly; oil was found in the rocker box areas on all cylinders. Upon rotation of the engine, the magnetos and their respective ignition harnesses produced spark in the proper firing order; the magneto impulse couplings were heard to release. The upper sparkplugs were removed and examined. All sparkplugs were dark in color, but the engine manufacturer’s representative stated that they were consistent with normal wear. A lighted borescope was used to perform an internal examination of each cylinders’ combustion chamber, all of which displayed light combustion deposits. Disassembly of the fuel manifold revealed a liquid that was brown in color and had an odor and appearance similar with a mixture of engine oil and aviation fuel. The engine-driven fuel pump dry-bay outlet pipe was removed, and a trace amount of oily film was present. Removal of the fuel injectors revealed that they were saturated with a brown liquid consistent in smell and appearance to engine oil. The turbocharger compressor outlet pipe/hoses (discharge duct) were disassembled, and oil was present in the conduit. The rubber connector nearest the turbo compressor inlet was removed and a lighted electronic borescope was used to inspect the inlet tube. A yellow terry cloth towel (rag) was discovered blocking the turbo inlet tube and the towel had become entangled with the turbo charger compressor wheel. (see Figure 1.) Figure 1: Turbocharger System (showing towel blocking inlet) The compressor wheel was damaged, and several blades were distorted. After the towel was removed, the compressor wheel was free to rotate. When the turbocharger was unable to rotate normally, the ring seals which are used to seal the turbocharger shaft (between the compressor and turbine wheel) will allow oil to escape the shaft bearing area and enter the compressor section. If the airplane is inverted, the oil could migrate through the discharge duct to the upper deck pressure plumbing to the fuel injectors. From injectors the oil could build in the cylinders and, when inverted, drain into the fuel manifold. Additionally, with the induction tube blocked, no ram air would enter the cylinders. (see Figure 2.) Figure 2: Turbocharger System (showing towel blocking inlet) The oil filter displayed a date of June 8, 2018. The pilot stated that the airplane had accrued about 34 hours since the oil change. He stated that to access the oil filter, he removed the airbox and placed a towel in the scat tubing (not disconnected) in an effort to protect the turbocharger from foreign object damage. The pilot stated that, after a normal departure, he climbed the airplane to a cruise altitude about 4,000 ft mean sea level (msl) and configured it for cruise flight. Thereafter, the engine experienced a sudden total loss of power. Despite his attempts to troubleshoot the failure, he could not restart the engine and performed a forced landing in a dry riverbed. After touchdown, the nose landing gear impacted a rock and collapsed, and the airplane nosed over and came to rest inverted. Examination revealed a cloth towel blocking the turbocharger inlet tube that had become entangled with the turbocharger compressor wheel. The towel likely blocked the inlet air from reaching the cylinders, which resulted in a loss of engine power. The pilot stated that during the last oil change, about 34 flight hours before the accident, he removed the airbox and placed a towel in the inlet scat tubing (not disconnected) in an effort to protect the turbocharger from foreign object damage. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- — Aircraft-Aircraft power plant-Turbocharging (recip only)-Turbocharger-Damaged/degraded
- — Aircraft-Aircraft power plant-Engine (reciprocating)-(general)-Incorrect service/maintenance
- — Personnel issues-Task performance-Maintenance-(general)-Pilot
Verbatim from NTSB's published report. Source file
NTSB_2018_WPR19LA016.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- 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…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- 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.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- 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.
- 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…