Saturday, June 12, 2021

Fuel Starvation: Cessna 182E Skylane, N3051Y; fatal accident occurred June 12, 2019 in Maitland, Orange County, Florida


Stanley Alfred Rampey, MD

 
Daniel P. Boggs, Investigator In Charge






Aviation Accident Final Report - National Transportation Safety Board 

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Continental Motors; Mobile, Alabama
Textron Aviation; Wichita, Kansas

Investigation Docket - National Transportation Safety Board:

Golden Corner Flying Club


Location: Maitland, Florida 
Accident Number: ERA19FA193
Date & Time: June 12, 2019, 11:02 Local
Registration: N3051Y
Aircraft: Cessna 182 
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

Analysis

The private pilot departed on a visual flight rules cross-country flight; according to his filed flight plan, the airplane had 4 hours of fuel onboard. After flying about 3.1 hours, the pilot landed at an intermediate airport before continuing to his destination, which was about 34 miles away. He did not purchase fuel at the intermediate stop. Shortly after takeoff, the pilot declared an emergency with air traffic control and stated that the airplane was not getting fuel out of the right main fuel tank. The pilot was cleared to land at the nearest airport (the intermediate airport) and radio contact with the airplane was lost shortly thereafter.

A witness in a boat on a lake saw and heard the airplane overhead. He stated that the engine was sputtering like it was running out of gas. He further stated that the airplane flew past the lake, made a 180° turn and flew back toward the lake; it appeared to impact trees on the lakeshore, then impacted the water.

The airplane was recovered from the lake; the intact, unbreached main fuel tanks each contained about 2 gallons of fuel, and the single auxiliary tank also contained about 2 gallons of fuel. According to the owner's manual, the unusable fuel in each main fuel tank was 2.5 gallons and 0.5 gallons in the auxiliary tank. The fuel selector was found in the right main tank position. A test run of the engine using the fuel from onboard the airplane revealed no anomalies. Onboard engine monitor data from the accident flight showed that the cylinder head and exhaust gas temperatures decreased 2 minutes before the data ended.

The data also showed the fuel flow rate spiked during the same time, likely due to air introduced into the fuel lines as the engine was starved of fuel.

Probable Cause and Findings

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

Findings

Personnel issues Fuel planning - Pilot
Aircraft Fuel - Fluid management

Factual Information

HISTORY OF FLIGHT

On June 12, 2019, about 1102 eastern daylight time, a Cessna 182E, N3051Y, was substantially damaged when it was involved in an accident near Maitland, Florida. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

Earlier on day of the accident, the pilot and passenger flew the airplane from Oconee County Regional Airport (CEU), Clemson, South Carolina, to Executive Airport (ORL), Orlando, Florida. A fuel receipt revealed that the pilot purchased 21.1 gallons of fuel before departing CEU, and the pilot's filed flight plan indicated that the airplane departed CEU with 4 hours of fuel on board. According to radar data from the Federal Aviation Administration (FAA), the duration of the flight from CEU to ORL was 3.10 hours. The pilot did not purchase fuel at ORL before departing about 1055 for his next destination, Massey Ranch Airpark (X50), New Smyrna Beach, Florida.

Air traffic control radio communication information provided by the FAA revealed that the pilot declared an emergency with air traffic control at 1101 and stated that the airplane was not getting fuel out of the right tank. The pilot asked for the nearest airport and the controller provided vectors back toward ORL. The controller cleared the pilot to land and instructed him to contact the tower controller at ORL. The pilot also reported to the tower controller that the airplane was not getting fuel out of the right tank. The controller cleared the pilot to land on runway 13, but the pilot did not respond, and no further communications were received from the accident airplane.

A witness stated that he was in a boat on the northeast side of Lake Maitland when he heard and saw an airplane flying overhead. The engine was sputtering "like it was running out of gas." He watched the airplane fly over the lake to the north then make a 180° turn back toward the lake; he thought the pilot was trying to perform a water landing. The witness stated that it looked like the airplane may have hit treetops at the edge of the water because it nosed over and descended straight into the water, impacting "very hard." He immediately went over to the airplane, which was still above water; however, it quickly sank.

PERSONNEL INFORMATION

The pilot's logbook was not located.

AIRCRAFT INFORMATION

Each wing was equipped with a bladder-type fuel cell, each with a capacity of 32.5 gallons. The airplane was also equipped with an auxiliary fuel tank installed behind the rear seat, with a capacity of 18 gallons. When the auxiliary fuel switch was selected on, fuel was transferred to the right fuel tank.

According to the airplane's owner's manual, the unusable amount of fuel for each wing tank was 2.5 gallons, and the amount of unusable fuel in the auxiliary tank was 0.5 gallons.

METEOROLOGICAL INFORMATION

WRECKAGE AND IMPACT INFORMATION

The airplane was located in Lake Maitland at a depth of 20 ft. Two gallons of fuel were removed from each wing tank and from the single auxiliary tank. The left and right wings remained attached to the airframe, and their respective control surfaces remained attached. Both left and right main fuel tanks remained intact and unbreached; the fuel caps were in place and secure. The rudder, elevator, and vertical stabilizer were attached and not damaged. The main landing gear was attached and not damaged.

The instrument panel was intact; however, the panel was separated from its mounts. The throttle, mixture, and propeller controls were in the forward position. The fuel selector valve was in the right main fuel tank position. The auxiliary fuel pump switch was in the off position. The lap belts and shoulder harnesses remained attached. Flight control continuity was established from the cockpit to all flight control surfaces.
 
The propeller was attached to the engine; one blade was bent forward, one blade tip was bent forward, and the third blade was straight. The bottom engine cowl displayed impact damage. The muffler and airbox were crushed. The top engine cowling was not damaged. The engine remained attached to the engine mounts and not damaged.

The airplane was recovered to a salvage facility and secured to a trailer in preparation for an engine run. The fuel that was removed from the airplane was used to conduct a postaccident engine operational check. The engine started without hesitation and ran continuously for about 3 minutes at various power settings.

A JPI 700 engine monitor was recovered from the airplane and sent to the National Transportation Safety Board Vehicle Recorders Laboratory for data download. The data showed the cylinder head temperatures (CHT) and exhaust gas temperatures (EGT) decreasing 2 minutes before the data ended. The data also revealed that the fuel flow rate spiked during that time consistent with air introduced into the fuel lines.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Office of the Office of the Medical Examiner, Orlando, Florida. The report listed the cause of death as craniocervical trauma.

Toxicology testing was performed on the pilot by the FAA Forensic Sciences Laboratory. The results were negative for drugs and alcohol.

History of Flight

Initial climb Fuel starvation (Defining event)
Emergency descent Off-field or emergency landing
Emergency descent Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Private
Age: 67, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None 
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None 
Toxicology Performed: Yes
Medical Certification: Class 2 With waivers/limitations 
Last FAA Medical Exam: October 1, 2018
Occupational Pilot: No 
Last Flight Review or Equivalent: November 15, 2017
Flight Time: 1234 hours (Total, all aircraft), 33 hours (Total, this make and model)

Passenger Information

Certificate: Age: 44,Male
Airplane Rating(s): 
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: Unknown
Instrument Rating(s): 
Second Pilot Present: No
Instructor Rating(s):
Toxicology Performed: No
Medical Certification: 
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N3051Y
Model/Series: 182 E 
Aircraft Category: Airplane
Year of Manufacture: 1962
Amateur Built: No
Airworthiness Certificate: Normal 
Serial Number: 18254051
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: April 4, 2019 Annual
Certified Max Gross Wt.: 2348 lbs
Time Since Last Inspection: 
Engines: 1 Reciprocating
Airframe Total Time: 5835.49 Hrs as of last inspection
Engine Manufacturer: Continental
ELT: C91 installed, not activated
Engine Model/Series: O-520 SERIES
Registered Owner:
Rated Power: 375 Horsepower
Operator: On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KORL,112 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 10:53 Local 
Direction from Accident Site: 169°
Lowest Cloud Condition: Few 
Visibility: 10 miles
Lowest Ceiling: None 
Visibility (RVR):
Wind Speed/Gusts: 12 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.89 inches Hg 
Temperature/Dew Point: 24°C / 22°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Orlando, FL (ORL) 
Type of Flight Plan Filed: None
Destination: New Smyrna Beach, FL (X50)
Type of Clearance: None
Departure Time: 10:55 Local 
Type of Airspace: Class D

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A 
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 28.620277,-81.349166 (est)







15 comments:

  1. why was this fatal ,intact airplane landing on the water ???

    ReplyDelete
    Replies
    1. No shoulder harness. That's why.

      Delete
    2. The cause of death was stated to be craniocervical trauma; in other words, their necks were broken.

      Even if they somehow managed to survive, they were nose-down submerged in water, with broken necks. They were never getting out.

      Delete
  2. Dan Boggs = The BEST of the BEST!

    ReplyDelete
  3. The doctor was saving money hand over fist by not purchasing fuel at ORL.

    ReplyDelete
  4. Looks like once again, aftermarket shoulder harnesses possibly could have saved a couple of lives.

    ReplyDelete
    Replies
    1. Yup, just like the Musketeer from a few weeks ago. The student perished and the CFI has very serious facial and head injuries from bashing the panel.

      Delete
    2. Sounds like some basic common sense and fuel planning would have kept both of them alive……

      Delete
  5. According to the report "The lap belts and shoulder harnesses remained attached". Further, "it nosed over and descended straight into the water, impacting "very hard."" Unfortunately, hitting the water is like hitting a concrete, so blunt multiple trauma comes into play. When you are without power, close to the ground, there is an urge to pull back. Perhaps they tried to get to the lake, pulled back to avoid the trees and stalled in, hard. There but for the grace of goodness go all of us.

    ReplyDelete
  6. Whenever I read about a plane going down due to fuel starvation, related to running the tanks dry, I am perplexed. Fuel management has got to be the easiest thing to manage and reduce risk. When you consider all of the inflight factors that could go sideways on you, no matter what you fly, having enough fuel plus reserves is a zero brainer.
    As an aside, when your thrust quits fly the airplane right down and through the crash. Water landings in a fixed gear airplane are generally rough, the plane will abruptly lose speed and flip. Pick a spot very close to shoreline if possible. This is old advice from my early training.
    Of all the AD’s out there, the FAA should mandate Shoulder harnesses for all aircraft. Such a simple solution to save lives. I would never fly a plane without them. I have 4 point harnesses in my bonanza, with a quick release latch. It was the fist thing I added during the post purchase process, before I ever flew it.

    ReplyDelete
  7. JP's comment reveals that many of us missed where the report clearly states "The lap belts and shoulder harnesses remained attached".

    The accident aircraft had been upgraded by adding shoulder harnesses, which limit forward motion of the torso. Forces at water impact were severe. Movement of the head relative to the restrained torso resulted in craniocervical trauma (think "extreme whiplash") as listed by the medical examiner. In this accident they didn't impact the panel but the benefit of having shoulder harnesses was overcome by the circumstances.

    ReplyDelete
  8. It doesn't matter how well you are strapped in. If your head still moves in a violent impact, you risk extreme shaking head injury and even neck snapping. That's also what killed Dale Earnhardt and why NASCAR quickly adapted to the HANS device after two more fatals post-Earnhardt. The device is now is used by all other sanctioned racing series around the world including the pinnacle of auto racing, Formula 1.


    Obviously we can't use HANS in the cockpit as it would severely limit our head movement outside the cockpit for traffic - because you have to use a helmet with it. Your best bet? Fly the damn plane based on what the operating handbook numbers tell you to. They are there for a reason.

    ReplyDelete
  9. An O-520 with 375hp??? Did they super-charge it?

    ReplyDelete
  10. Practice your touch and goes. Pulling back to the stops while touching the water is critical. Any excess energy can only make the resulting deceleration worse.

    ReplyDelete