14 CFR Part 91: General Aviation
Accident occurred Friday, September 24, 2010 in Chatsworth, GA
Probable Cause Approval Date: 05/16/2011
Aircraft: CESSNA 172, registration: N84249
Injuries: 2 Fatal,1 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.
Prior to departure, the pilot filed an instrument flight rules (IFR) flight plan to his destination airport and calculated a fuel burn rate of 9 gallons of fuel per hour. Approximately 2 hours and 30 minutes after departure, the pilot canceled his IFR flight plan with the air traffic controller without giving a reason and changed his destination airport. One minute later, the pilot declared an emergency with air traffic control, reporting his engine had failed. Witnesses in the vicinity of the crash site observed the airplane flying at tree top level, and reported they could not hear the engine running. The airplane made a steep right turn, struck the top of a tree, and collided with the ground.
Examination of the airframe and engine revealed no anomalies. The right main fuel tank was not ruptured and contained 1 quart of fuel. The left main fuel tank was not ruptured and contained 2 1/2 gallons of fuel, 2 of which were considered unusable fuel. Review of the airplane logbooks revealed the engine horsepower had been increased to 160 horsepower, and the airplane's fuel burn rate was increased due to a modification by a Supplemental Type Certificate (STC) 8 years prior to the accident. A copy of the STC was not located in the airplane wreckage. The registered owner reported the pilot had received instruction on the STC; however, no documentation was provided substantiating this instruction. He further stated the STC only increased the fuel burn rate for the first 5 minutes of flight at takeoff power. Review of the engine Operator's Manual revealed the maximum fuel usage at full power, is about 13.6 gallons per hour. At 82 percent power the fuel burn rate is about 11.25 gallons per hour.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate flight planning and in-flight fuel management resulting in a total loss of engine power due to fuel exhaustion. Contributing to the accident was the operator's failure to ensure aircraft records pertaining to engine modifications and fuel burn rates were available to flight crewmembers.
HISTORY OF FLIGHT
On September 24, 2010, at 2249 eastern daylight time, a Cessna 172K, N84249, registered to Flight Training Express (FTE) LLC, operating as a 14 Code of Federal Regulations Part 91 personal flight, collided with a tree and the ground during a forced landing in the vicinity of Chatsworth, Georgia. Visual meteorological conditions (VFR) prevailed. The certificated commercial pilot, located in the right front seat, and the private pilot rated passenger, located in the left front seat, were killed. The rear seat passenger received serious injuries. The airplane sustained substantial damage. The flight originated from Massey Ranch Airpark (X50) New Smyrna Beach, Florida. The pilot obtained an instrument flight rules clearance from Daytona Approach Control at 1908, en-route to Lovell Field Airport (CHA), Chattanooga, Tennessee.
According to Chattanooga Approach Control, the pilot canceled the IFR flight plan at 2242:23 and proceeded VFR. The controller acknowledged the cancellation and informed the pilot to maintain his present transponder squawk and to report Chattanooga in sight. At 2244: 23, the pilot informed the controller that he was going to land at Dalton, Georgia, and the controller informed the pilot to report the airfield in sight. At 2245:52, the pilot stated, "and Chattanooga approach mayday, mayday, mayday, we have an engine failure". The controller replied, do you have Dalton in sight? The pilot responded we are at 2,000 feet and have the airfield in sight. The controller asked the pilot at 2246 if he was able to make the airport and he stated, "We are not sure". The pilot asked the controller at 2246:17 if he was familiar with the terrain and the controller replied negative. There was no further communication between the pilot and the controller. At 2248:09, Atlanta Air Route Traffic Control Center contacted Chattanooga approach and stated, "This is north, I don't know if you noticed but southeast of Dalton I saw the seventy seven hundred code squawking". He further stated the airplane was about 3.1 miles southeast of Dalton, Georgia. Emergency 911 operators in vicinity of Chatsworth, Georgia, received calls stating an airplane had crashed and emergency first responders arrived on scene at 2256.
The rear seat passenger stated he was asleep for most of the flight. When he woke up the pilot informed him, "I think we need to land". The passenger looked at one of the fuel tank gauges and it was very low. The engine then started running rough. The pilot started switching the fuel tanks and the engine quit. The pilot declared an emergency and made a right turn. The airplane clipped a tree and the passenger later woke up in the hospital.
Two witnesses located in the vicinity of the crash site observed the airplane flying towards their home north bound at tree top level. The white landing light was on and a red and green light was also visible. They could not hear the engine running as it went directly over them. The engine was whistling like a fan. The airplane made a steep right turn over the race track located near the house and came directly over their son’s house trailer. The airplane struck the top of a tree and descended nose down over a logging truck and collided with a ditch/culvert. The airplane bounced, went through a barbed wire fence, spun around, and came to rest facing back toward the trailer and was adjacent to the road.
PERSONNEL INFORMATION
The pilot located in the right front seat, age 24, held a commercial pilot certificate issued on August 24, 2010, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. In addition, the pilot held a CFI certificate with ratings for airplane single-engine land and instrument airplane issued on April 12, 2010. The pilot’s last instrument proficiency check and last flight review was conducted on September 1, 2010. The pilot’s log book was not located and his total time was not determined. The pilot held a Federal Aviation administration (FAA) first class medical certificate, issued on August 14, 2007, with the restriction, “must wear corrective lenses.”
The private pilot rated passenger, located in the left front seat, age 21, held a private pilot certificate issued on June 1, 2010, with a rating for airplane single-engine land. No medical certificate was located at the crash site. Review of the FAA data base revealed the passenger held a third class medical dated April 8, 2010 with no restrictions. Review of the pilot’s log book revealed she had logged 54 total flight hours in airplane single-engine land. No flight time had been logged in the Cessna 172K. The pilot had 10.5 total hours as pilot in command. The last flight entry in her log book prior to the accident was May 30, 2010. The last flight review was conducted on June 1, 2010.
AIRCRAFT INFORMATION
The Cessna 172K was a four-place airplane with a fixed tricycle landing gear, serial number 17258394, manufactured in 1969. A Lycoming, 160-horsepower, horizontally-opposed four-cylinder engine powered the airplane. Review of the airplane logbooks revealed the last annual inspection was conducted on January 3, 2010, at a recorded tachometer time of 3684.6 hours. The last 100-hour inspection was conducted on September 7, 2010, at a recorded tachometer time of 4,183.1 hours. The tachometer meter at the accident site indicated 4,226.3 hours. The airplane flew 43.2 hours since the last 100-hour inspection. The engine was overhauled on May 15, 2002, by Coastal Aviation Services and has 1,695.2 hours since major over haul. The total airframe hours at the time of the accident was 5,708. The HOBBS meter was destroyed.
The airplane was last refueled at Massey Ranch Air Park (X50), on September 24, 2010, with 13 gallons of 100 low lead fuel. The aircraft airworthiness certificate and aircraft registration were not located at the crash site. The airplane was modified in accordance with RAM Supplemental Type Certificate (STC) Number SE3692SW, which modified the Lycoming model O-320-E2D engine, serial number L-43485-27A, to increase 5 minute takeoff maximum power rating to 160 horsepower, in accordance with RAM Aircraft Limited Partnership. The Owner’s Manual and the FAA Form 337 including Flight Manual Supplements as required by the STC were not found in the airplane. The registered owner stated the missing items were located in a black vinyl zippered bag issued to the pilot and kept in the airplane during the flight. The black zippered bag was not located at the crash site or in the accident airplane. The registered owner stated the pilot was aware of the increase engine horsepower and fuel burn rate. In addition, he had received instruction on this, however no documentation to support this was received from FTE.
An email received from the deceased left front seat passenger's family stated they had received documents from the funeral director with their daughters personal effects. The email stated a blue folder was sent with her belongings containing several documents from FTE containing aircraft information pertinent to N84249.
METEOROLOGICAL INFORMATION
The 2219 Dalton Municipal Airport (DNN), Dalton, Georgia, surface weather observation was: wind calm, visibility 10 miles, scattered clouds 8,500 feet, temperature 22 degrees Celsius, dew point temperature 17 degrees Celsius, and altimeter 30.10 inches of mercury.
WRECKAGE INFORMATION
Examination of the crash site revealed the airplane grazed the top of a 75-foot tall tree in a descending attitude. The airplane collided with a culvert 127 feet down the crash debris field measured with a traffic wheel and global positioning system. The airplane rotated around its horizontal axis and came to rest on a heading of 020 degrees magnetic. The crash debris line extended 189 feet.
Examination of the wreckage revealed the upper and lower engine cowling remained attached to the airframe and was fragmented. The propeller remained attached to the propeller crankshaft flange. The engine assembly was displaced upward and to the right. All engine mounts and accessories except for the carburetor remained attached to the engine. The firewall was bent inward and upward. The nose landing gear and strut separated and were located underneath the fuselage.
Examination of the forward cabin area revealed the windshield was fragmented and located at the end of the crash debris line. The instrument panel was fractured in multiple pieces. The throttle was in the full increase position, the mixture was full rich position, and the carburetor heat was off. The fuel selector valve was in the both position. Continuity of the flight controls was confirmed from the control yokes aft to all flight control surfaces. The left and right main landing gear remained attached to the fuselage.
Examination of the right wing revealed it was accelerated forward. The leading edge of the wing was crushed inward 6 feet 8 inches outboard of the wing root, extending outboard to the wingtip. The wingtip was damaged. The wing strut remained attached to the wing and the fuselage and was not damaged. The aileron remained attached to all attachment points and was not damaged. The flap was damaged and remained attached to all attachment points. The flap jack screw was examined and indicated the flaps were in the retracted position. The upper spar cap of the right wing rear spar was separated one foot outboard of the wing root. The right fuel cap was intact with a tight seal and the right main fuel tank was not ruptured. No browning of vegetation was present. One quart of fuel was recovered from the fuel tank by recovery personnel.
The tail cone separated aft of the baggage compartment. Diagonal bending was present aft of the baggage compartment where the empennage separated from the fuselage. The vertical fin and left and right horizontal stabilizers remained attached to the empennage and were not damaged. The rudder remained attached to the vertical fin and the bottom ten inches of the rudder was bent upward. The left elevator was not damaged and remained attached to the horizontal stabilizer. The right elevator was damaged and remained attached to the horizontal stabilizer. The trim tab was in the neutral position and remained attached to the right elevator.
Examination of the left wing revealed the leading edge was crushed inward 6 feet 8 inches outboard of the wing root, extending outboard to the wingtip. The wingtip was damaged. The wing strut remained attached to the wing and the fuselage and was not damaged. The aileron remained attached to all attachment points and was not damaged. The flap was damaged and remained attached to all attachment points. Both wing attachment points were intact. The left fuel cap was intact with a tight seal and the left main fuel tank was not ruptured. No browning of vegetation was present. Two and one half gallons of fuel was drained from the left main fuel tank by recovery personnel.
Examination of the engine assembly revealed the left and right engine exhaust pipes were buckled and the muffler was crushed. The No.1 induction tube was displaced aft at the manifold. The oil sump was intact. The oil cooler remained attached to the firewall and was crushed. The alternator and drive pulley remained attached to the engine assembly and was damaged. The alternator cooling fan was crushed against the alternator. The starter remained attached to the engine and the bendix pinion was extended and gouge marks were present on the front of the bendix housing from contact with the engine starter ring gear. The right magneto developed spark at all ignition towers when rotated by hand. The left magneto plastic point's assembly was damaged and the ignition towers would not produce spark. The vacuum pump remained attached to the engine and was fractured at the mounting pad, and the spline drive was damaged. The rotor and vanes were intact. The fuel strainer remained attached to the fire wall and fuel was present in the filter screen below the fuel strainer pick up pipe. The No.1 cylinder exhaust push rod tube and No.3 cylinder intake push rods were damaged. The carburetor lower bowl was separated from the top throttle body. The main nozzle was broken. The carburetor float was crushed. The carburetor needle valve was not located and the seat was not damaged. The mixture lever was not located. No fuel was present in the fuel lines or carburetor.
The engine was partially disassembled. The starter ring gear was fractured. The crankshaft flange was bent. The top and bottom ignition harness were damaged. The top and bottom were removed and exhibited light white combustion deposits. The four bottom spark plugs exhibited lead fouling. Electrode wear was advanced on all. The gap settings measured .025 inch with a filler gage. The engine was rotated by hand at the propeller flange. Compression and suction was obtained at all cylinders. The rocker arms and valves moved when the crankshaft was rotated. The oil filter was removed, opened, and was free of contaminants. The oil suction screen was removed and was free of contaminants.
MEDICAL AND PATHOLOGICAL INFORMATION
The Georgia Bureau of Investigation, Chief Medical Examiner, Decatur, Georgia, conducted an autopsy on the pilot on September 25, 2010. The cause of death was blunt force injuries. The Bioaeronautical Research Science Laboratory, FAA, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the CFI. The specimens were negative for ethanol, carbon monoxide, cyanide, basic, acidic, and neutral drugs.
The Georgia Bureau of Investigation Chief Medical Examiner, Decatur, Georgia, conducted an autopsy on the private pilot rated passenger on September 25, 2010. The cause of death was blunt force injuries. The Bioaeronautical Research Science Laboratory, FAA, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the private pilot. The specimens were negative for ethanol, carbon monoxide, cyanide, basic, acidic, and neutral drugs.
ADDITIONAL INFORMATION
United States Government Flight Information Airport Facility Directory for the Southeast United States found in the airplane expired on June 3, 2010. The U. S. Terminal Procedures for Southeast found in the airplane expired on September 23, 2010.
The aircraft is equipped with one 21 gallon metal tank in each wing. The Owner’s Manual states on page 3-3, that 2 gallons of unusable fuel are in each tank. Review of the pilot's flight plan revealed he had planned on a fuel burn rate of 9 gallons of fuel per hour.
The airplane departed X50 at 1908 and climbed to 5,000 feet. The last radar contact with the aircraft occurred at 2249. The total flight time was 3 hours and 41 minutes. The distance between X50 and the accident site is approximately 412 nautical miles.
According to Figure 5-3 in the Aircraft Owner’s Manual, a climb to 5,000 feet from sea level at the aircraft’s maximum gross weight would use 2.6 gallons of fuel on a standard day. The time to climb would be 11.5 minutes. Figure 5-4 indicates the aircraft uses 9.0 gallons of fuel per hour at an altitude of 5,000 feet when the engine is run at 82 percent brake horse power (BHP), (assuming proper leaning procedures as listed in the Aircraft Owner’s Manual) on a standard day. At a BHP of 49 percent the aircraft uses 6.0 gallons per hour. The remaining flight time would have used 31.5 gallons of fuel at a power setting of 82 percent BHP on a standard day.
A review of the aircraft logbooks revealed that Ram Aircraft Limited Partnership STC Number SE3692SW was installed on 05-15-02. The STC increased the maximum horse power of the engine to 160 horsepower. The 13380 Lycoming engine fuel burn curve depicts fuel usage for an O-320 series 160 horsepower engine, maximum fuel usage at full power, to about 13.6 gallons per hour. At 82 percent power the fuel burn rate is about 11.25 gallons per hour. At this fuel burn rate, 39.375 gallons of fuel would be required during the cruise portion of the accident flight.
Review of the airplanes flight track revealed the planned distance from X50 to CHA is 427 nautical miles (NM). The actual distance from X50 to the end of the radar track is 412 NM. Review of the flight plan found in the airplane wreckage revealed the planned flight time was 3 hours and 44 minutes at a planned average speed of 114 knots. The actual time in flight was 3 hours and 41 minutes with an average speed of 111 knots. The planned fuel burn for the flight was 33.5 gallons based on a 9 gallon per hour fuel burn rate, but it did not take into account the fuel used by the STC'd engine of 11 gallons per hour.
(From L-R) Abraham George, 24, with Jaskinder Samra, 21, and Shaun Thacker, 21, from Caerwent
A 21-year-old trainee pilot died in a plane crash when another pilot refused to accept the empty fuel gauge reading, saying his own calculations were more accurate.
Jaskinder Kaur Samra, from Wednesfield, near Wolverhampton, was a passenger in the rented 1969 Cessna aircraft piloted by American friend Abraham George, 24, who also died in the tragedy.
A second passenger, Shaun Thacker, from Monmouthshire in Wales, miraculously survived the crash after wrapping himself in a duvet to protect his body.
He told an inquest that moments before the plane came down, he told Mr George that the fuel gauge was low, to which Mr George replied: 'I've done a maths calculation about the distance and I trust my maths more than a 1969 fuel gauge.'
Shortly after those fateful words on the 427-mile flight, from New Smyrna Beach, Florida to Chattanooga, Tennessee, the engine lost power and the plane crashed.
Thacker's survival meant he was able to tell Black Country coroner Robin Balmain the tale of the crash on September 24, 2010.
Mr Thacker, who holds a commercial pilot's license, said he had been at flight school with Miss Samra in the US for around nine months before the crash.
He said of Mr George: 'He was my commercial instructor. He had a lot of experience in that type of aircraft.'
He said he had just been in the rear seats sleeping but woke up: 'I glanced over to look at the instruments and noticed the fuel gauge had a low indication. I brought it to the knowledge of Abraham.
After Mr George told him he'd done the maths, Mr Thacker settled back in the duvet only to hear the engine start to run rough as it became starved of fuel.
'That was when the pilot realized there was big trouble.'
Attempts to use both of the plane's fuel tanks at the same time failed, and Mr George issued a Mayday call, telling air traffic controllers he had to make an emergency landing at Dalton Municipal Airport in Georgia.
Mr Thacker said: 'All I can remember is we could see the runway for Dalton - we were actually lined up with the runway. The only thing after that I remember is I noticed we were very low. From my opinion we were never going to make it.
'There was a race track lit up. I said 'just aim for that and we should be able to get down''.
But the plane collided with trees and crashed nose-down into a ditch, spun around and ended up next to a road in Chatsworth, three miles south-east of Dalton, killing Miss Samra, a former pupil of Queen Mary's Grammar School in Walsall, and Mr George.
Mr Balmain ruled Miss Samra, died as the result of an accident.
Miss Samra's mother Mindie said afterwards: 'Abraham is not here to answer for himself so we are never going to know how he put his planning together. But we want Jaskinder's legacy to live on. We've got to keep those happy memories with us all the time to keep us going.'
A 21-year-old man who survived a horrific plane crash that killed a
fellow trainee pilot relived the moments that led up to the fatal crash
in a Coroner's Court.
Shaun Thacker, of Monmouthshire, gave evidence at an inquest, which
found that the crash claimed two lives when it ran out of fuel.
Mr Thacker had been at flight school with Jaskinder Kaur Samra, 21,
who lost her life in the crash. The pilot of the aircraft, Abraham
George, 24, also lost his life in the crash, on September 24, 2010.
The coroners court sitting at Smethwick Council House in the West
Midlands heard how Mr George had refused to accept that the empty fuel
gauge was correct, saying his own calculations were more accurate.
Mr Thacker, a rear-seat passenger who holds a commercial pilot’s
licence, said he had been at flight school with Miss Samra in the US for
around nine months before the crash. He miraculously survived the
incident.
He was not sure if the planned 427-mile flight, from New Smyrna
Beach in Florida to Chattanooga in Tennessee, had been intended as a
pleasure trip for her or if it was to give her more in-flight
experience.
He said of Mr George: “He was my commercial instructor – he taught
me for my commercial licence. He had a lot of experience in that type of
aircraft.”
Mr Thacker said he survived because he was wrapped in a duvet which smothered the impact.
He said he had just been sleeping, and woke up: “I glanced over to
look at the instruments and just noticed the fuel gauge had a low
indication. I brought it to the knowledge of Abraham.
He said ‘I’ve done a maths calculation about the distance and I trust my maths more than a 1969 fuel gauge’.”
Mr Thacker settled back in the duvet only to hear the engine start to run rough as it became starved of fuel.
“That was when the pilot realised there was big trouble.”
Attempts to use both of the plane’s fuel tanks at the same time
failed, and Mr George issued a May Day call, telling air traffic
controllers he had to make an emergency landing at Dalton Municipal
Airport in Georgia.
Mr Thacker said: “All I can remember is we could see the runway for
Dalton – we were actually lined up with the runway. The only thing after
that I remember is I noticed we were very low.
From my opinion we were never going to make it.
“There was a race track lit up. I said ‘just aim for that and we should be able to get down on that’.”
But the plane collided with trees and crashed nose-down into a
ditch, spun around and ended up next to a road at Chatsworth, three
miles south-east of Dalton, killing Miss Samra, a former pupil of Queen
Mary’s Grammar School in Walsall, and Mr George.
Mr Balmain ruled Miss Samra, who was single, died as the result of an accident.
He said: “This is a particular tragedy because this is a death of a
young lady at the beginning of her life who was doing something that she
loved to do.”
He added there was “fairly concrete evidence that there was a
miscalculation of the amount of fuel that was going to be used on this
flight”.
Miss Samra’s mother Mindie said afterwards: “Abraham is not here
today to answer for himself so we are never going to know the reason
behind how he put his planning together.
But we want Jaskinder’s legacy to live on. We’ve got to keep those happy memories with us all the time to keep us going.”
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