What happened
On May 17, 2019, a Cessna T210N, registration N6973N, was conducting a visual flight rules (VFR) recreational flight near the Verona Boscomantico airport in Italy. The aircraft, carrying two pilots, was performing circuit patterns when the engine suddenly failed during a left turn at approximately 700 to 1,100 feet altitude.
Following the engine failure, the pilot on the right took control of the aircraft. Realizing that the remaining altitude and distance were insufficient to reach the runway without risking a collision with nearby trees or vineyard structures, the crew decided to execute an emergency ditching. The aircraft impacted the Adige River with the landing gear retracted and flaps extended. While the pilot in the left seat escaped with minor injuries, the pilot in the following right seat sustained serious injuries. The aircraft sustained substantial damage, including a separated tail section and engine cowling deformation.
The investigation
The ANSV investigation focused on the cause of the engine shutdown and the crew's emergency response. Technical examinations of the Continental TSIO-520-R engine revealed no mechanical malfunctions or failures in the fuel system components. Investigators examined the fuel selector valve, which was found in an intermediate position between "left" and "off," suggesting movement occurred during the impact.
Fuel levels were a primary focus. While the pilot on the right believed there was sufficient fuel, evidence suggested the right wing tank was nearly empty. The investigation noted that the pilot on the left had relied on mechanics for the pre-flight fuel check rather than performing a personal visual inspection. Furthermore, the investigation analyzed the crew's coordination and the workload experienced during the sudden transition from monitoring to emergency management.
Findings
- Fuel starvation is the suspected cause of the engine failure, as the right fuel tank was likely depleted.
- There was inadequate flight planning by the pilot in command regarding fuel quantity verification.
- A lack of effective coordination between the two pilots regarding the actual fuel remaining on board.
- The pilot on the right failed to sufficiently monitor fuel levels, despite having the experience to do so.
- A high workload and cognitive gap during the emergency prevented the pilot on the right from correctly applying the engine failure checklist, specifically the instruction to select the fullest fuel tank.