Friday, March 16, 2018

Fuel Starvation: Cessna 210M Centurion, N761DV, accident occurred March 16, 2018 in Shelburne, Chittenden County, Vermont

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Portland, Maine

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 


Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf 
 
http://registry.faa.gov/N761DV


Location: Shelburne, VT
Accident Number: ERA18LA111
Date & Time: 03/16/2018, 1445 EDT
Registration: N761DV
Aircraft: CESSNA 210
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Aerial Observation

Analysis 

The commercial pilot stated that he did not visually check either fuel tank before takeoff because he had observed the airplane being fueled the day before; he assumed that the tanks were full (44.5 gallons of usable fuel per tank, 89 gallons total) and that he would have sufficient fuel (6.5 hours) for his estimated 5-hour aerial survey flight. He departed with the fuel selector positioned to the left tank; his normal routine was to switch fuel tanks every hour for the first 4 hours of flight. About 3 hours into the flight, the engine lost total power. The pilot switched the fuel selector to the right tank and attempted to restart the engine to no avail; he made a forced landing to a snow-covered field, which resulted in substantial damage to the fuselage, an engine mount, and the firewall. Postaccident examination revealed that the left- and right-wing fuel tanks were undamaged, that both fuel caps were secure, and that there was no evidence of leaks. The left tank was empty, and 33 gallons of fuel were drained from the right tank. Visual examination of the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot indicated that his typical routine was to switch fuel tanks every hour, given the amount of fuel remaining in the right tank, it is likely that the pilot did not adequately manage the fuel supply during flight, which resulted in the total loss of engine power due to fuel starvation.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation.

Findings

Aircraft
Fuel - Fluid management (Cause)
Fuel selector/shutoff valve - Incorrect use/operation (Cause)

Personnel issues
Use of equip/system - Pilot (Cause)

Factual Information 

On March 16, 2018, about 1445 eastern daylight time, a Cessna 210M, N761DV, sustained substantial damage during a forced landing after a total loss of engine power near Shelburne, Vermont. The commercial pilot was not injured. The airplane was registered to and operated by GV Air, Medford, Oregon, as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated at the Burlington International Airport (BTV), Burlington, Vermont, about 1140.

The pilot stated that he conducted a preflight inspection of the airplane but did not visually check either fuel tank because he had observed the airplane being fueled the day before and he assumed the tanks were full (44.5 gallons usable per tank, 89 gallons total). The pilot said that the airplane burned about 13.5 gallons per hour and had a total fuel endurance of 6.5-hours, which was sufficient for his planned aerial survey flight of 5-hours. The pilot said he departed on the left tank and his normal routine was to switch fuel tanks every hour for the first 4 hours of flight. At 1435, almost 3 hours into the flight, with the fuel selector on the left tank, the engine abruptly stopped producing power. The pilot pushed the mixture control full forward and turned the fuel pump on. He then switched the fuel selector to the right tank and attempted to re-start the engine, but was unsuccessful , and he made a forced landing on a snow-covered field. The airplane came to rest upright and the nose wheel had separated, which resulted in substantial damage to the fuselage, an engine mount, and the firewall. The outboard section of the right wing was also damaged.

Postaccident examination of the airplane revealed the left and right-wing fuel tanks were undamaged and both fuel caps were secure. The left-wing fuel tank was empty, and about 33 gallons of fuel were drained from the right tank. Further examination of the fuel system revealed no evidence of leaks and there was no staining on the airplane or area surrounding the airplane. Visual examination of the engine revealed no mechanical deficiencies.

The pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. He reported a total of 521 hours of flight experience, of which, 65 hours were in the same make and model as the accident airplane. His last Federal Aviation Administration (FAA) second-class medical certificate was issued on November 18, 2017.

Weather reported at BTV at 1454 was wind from 290° at 11 knots, visibility 10 miles, scattered clouds at 3,600 ft, overcast clouds at 7,000 ft, temperature -3° C, dewpoint -12° C, and a barometric pressure setting of 29.69 inches Hg. 

History of Flight

Maneuvering
Fuel starvation (Defining event)
Loss of engine power (total)

Emergency descent
Off-field or emergency landing

Landing
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Commercial
Age: 24, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 11/28/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/18/2017
Flight Time:  521.4 hours (Total, all aircraft), 65 hours (Total, this make and model), 450 hours (Pilot In Command, all aircraft), 131 hours (Last 90 days, all aircraft), 60 hours (Last 30 days, all aircraft), 4.4 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N761DV
Model/Series: 210 M
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 21062182
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 08/01/2017, Annual
Certified Max Gross Wt.: 3803 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 10030.7 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO 520 SERIES
Registered Owner: On file
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: BTV, 337 ft msl
Distance from Accident Site: 9 Nautical Miles
Observation Time: 1454 EDT
Direction from Accident Site: 40°
Lowest Cloud Condition: Scattered / 3600 ft agl
Visibility:  10 Miles
Lowest Ceiling: Overcast / 7000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 290°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.69 inches Hg
Temperature/Dew Point: -3°C / -12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Burlington, VT (BTV)
Type of Flight Plan Filed: None
Destination: Burlington, VT (BTV)
Type of Clearance: VFR Flight Following
Departure Time: 1140 EDT
Type of Airspace: Class C

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 44.380556, -73.227500 (est)

Preventing Similar Accidents  

Flying on Empty 

Prevent the Preventable With Careful Fuel Management

The problem

Within fuel-related accidents, fuel exhaustion and fuel starvation continue to be leading causes. From 2011 to 2015, an average of more than 50 accidents per year occurred due to fuel management issues. Fuel exhaustion accounted for 56% of fuel-related accidents while fuel starvation was responsible for 35% of these accidents.

Fuel exhaustion is running out of fuel whereas fuel starvation is having fuel onboard but it doesn’t reach the engine for reasons such as a blockage, improperly set fuel selector, or water contamination.

More than 66% of fuel management accidents occurred on flights when the intended destination airport was different than the departure airport. About 80% of all fuel management accidents occurred during the day in visual meteorological conditions; only 15% occurred at night.

Almost half of pilots involved in fuel management accidents hold either a commercial or air transport pilot certificate (48%); pilots holding private or sport pilot certificates make up 50%. Only 2% of accidents involved student pilots.

Pilot complacency and overestimation of flying ability can play a role in fuel management accidents.

Running out of fuel or starving an engine of fuel is highly preventable. An overwhelming majority of our investigations of fuel management accidents—95%—cited personnel issues (such as use of equipment, planning, or experience in the type of aircraft being flown) as causal or contributing to fuel exhaustion or starvation accidents. Prudent pilot action can eliminate these issues. Less than 5% of investigations cited a failure or malfunction of the fuel system.

Related accidents

The NTSB has investigated numerous accidents involving fuel exhaustion or starvation, such as the following:

The commercial pilot of a Beech 19A reported that, during the initial climb after takeoff for the flight, which was the first flight after completion of an annual inspection, the engine lost power at an altitude of about 500 ft. He made a left turn to return to the airport but instead touched down hard next to the runway. During the annual inspection, maintenance personnel had placed the fuel selector valve in the OFF position and did not return it to the full-ON position before the flight. The pilot reported that he and the owner usually kept the fuel selector valve in the ON position and that he did not use a checklist or confirm that it was in the full-ON position before takeoff. The probable cause of the accident was the pilot's failure to reposition the fuel selector valve to the ON position prior to takeoff resulting in a loss of engine power due to fuel starvation. Contributing to the accident was the pilot's failure to properly complete the pre-takeoff checklist. (WPR16CA145)

The private pilot of a Piper PA-24-250 reported that, before departure, the airplane’s digital cockpit fuel gauges indicated that the two wing tanks contained about 5 gallons of fuel each for the 10- to 15-minute flight. About 4 miles from the destination airport, the engine began to run roughly, and the pilot switched the fuel tank selector from the left-wing tank to the right-wing tank. The engine continued to run roughly and subsequently lost all power. Postaccident examination found that the fuel quantity gauges indicated no fuel remained, and no fuel was observed in either of the wing fuel tanks. Given the fuel consumption rate in the airplane’s Pilot Operating Handbook (POH), a 15-minute flight would have consumed about 3.5 gallons, not including the fuel required for engine startup, taxi, and takeoff. The pilot used the digital cockpit fuel gauges as his only indication of the fuel level and did not confirm the displayed quantity either visually or with another fuel measurement device before takeoff. The probable cause of the accident was the pilot’s improper preflight inspection, which resulted in fuel exhaustion and a total loss of engine power. (ERA13LA408)

About 10 minutes into the flight, the private pilot of a Cirrus SR22T reported to an air traffic controller that the engine was running rough and that he needed to return to his departure airport. During a second instrument approach, the engine lost power, and the pilot attempted a forced landing to a field, where the airplane came to rest on its right side. The pilot and one passenger sustained serious injuries, and a second passenger sustained fatal injuries. No evidence of fuel or fuel spillage was observed at the accident site. An examination and operational test of the engine found no defects in engine operation, and the engine produced full-rated power. According to the pilot, the airplane’s management company did not fuel the airplane as he had requested. The pilot did not visually verify the fuel level in the tanks during his preflight inspection and departed with his flight displays indicating low fuel alerts. The probable cause of the accident was the pilot's failure to adequately preflight the airplane prior to departure, which resulted in a loss of engine power due to fuel exhaustion. (CEN12FA037)

What can you do?

Know how much fuel you have onboard AT ALL TIMES.

During your preflight inspection, measure and/or visually confirm the fuel quantity in your tanks. Do not rely exclusively on fuel gauges.

Know how much fuel you will need for a given flight.

Make sure you have a fuel reserve for each flight.

Know your engine’s fuel burn rate and actively monitor the fuel burn rate for the entire time the engine is operating.

Know your aircraft’s fuel system and how it works.

Review your aircraft’s POH and use the appropriate checklists.

Don’t stretch your available fuel supply. Stop and get gas!

Interested in more information?

The following links are to recent articles and other resources about fuel management:

The March 2017 issue of NASA’s newsletter CALLBACK contains an article about complacency in aviation that discusses a pilot who was complacent in using checklist procedures and starved the engine of fuel.

The fuel management edition of AOPA’s Safety Advisor provides pilots detailed information and suggestions to improve fuel awareness and reduce fuel-related incidents.

The January 2017 issue of Aviation Safety magazine contains an article titled, “Fuel Systems 101,” which discusses how most fuel management accidents result from pilots’ poor planning or failure to understand how aircraft fuel systems deliver fuel to the engine.

The NTSB’s Aviation Information Resources web page, www.ntsb.gov/air, provides convenient access to NTSB aviation safety products. This safety alert and other can be accessed from the Aviation Safety Alerts link.


The NTSB presents this information to prevent recurrence of similar accidents. Note that this should not be considered guidance from the regulator, nor does this supersede existing FAA Regulations (FARs).




SHELBURNE, Vt. — A small plane crashed Friday in Shelburne.

Police said it happened about 2:40 p.m. on Dorset Street.

Investigators said the plane crashed in a homeowner's yard.

The pilot was the only person on the Cessna and was not injured.

Police said he was doing routine land survey work in the area when the plane's engine stopped at about 2,600 feet.

The plane's nose and wing were damaged but it did not strike the house.

The owners were not home when the plane crashed.

Police said the Florida-based company that owns the plane will have to work with the homeowners to get it removed and fix any damage to their yard.

According to FAA records, the 41-year-old is registered to GV Air in Medford, Oregon.

It's certificate was renewed in May 2017.

Multiple crews responded to the scene.

Original article can be found here ➤ http://www.mynbc5.com






SHELBURNE, Vt. - Shelburne Police say a small single engine Cessna plane went down in a residential area Friday afternoon.

Police say they got the 911 call around 2:40 Friday afternoon that a plane had gone down in the 5200 area of Dorset Street.

Shelburne Police say the pilot, Ryan Carraway, 24, was the sole occupant, and uninjured.

According to police, Carraway works for GV AIR INC out of Florida, and was performing surveying.

Carraway was flying the Cessna 210 when he says he experienced engine failure.

Police say he was able to land in a field to avoid injuring himself or others, but the plane experienced extensive damage.

Original article ➤ http://www.mychamplainvalley.com

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