Pilot Debrief

CESSNA T207A near Page, AZ — 2022-08-13

Final reportWPR22FA303
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Date
2022-08-13
Location
Page, AZ, USA
Aircraft
CESSNA T207A
Registration
N9582M
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Cruise

Probable cause

The total loss of engine power for undetermined reasons during low altitude cruise flight, which resulted in a water ditching. Contributing to the severity of the accident was the pilot’s failure to extend the flaps during the ditching, which increased the impact forces to the occupants.

Contributing factors

Contributing to the severity of the accident was the pilot’s failure to extend the flaps during the ditching, which increased the impact forces to the occupants.

NTSB narrative

The airplane departed on an air tour scenic flight and after about 30 minutes, the engine lost power. Unable to restart the engine, the pilot ditched the airplane into a lake. Two of the five passengers onboard were unable to exit the airplane and the airplane sank to the bottom of the lake. The pilot had no recollection of the circumstances of the flight or his actions to restart the engine following the loss of power. Postaccident examination of the airplane did not identify any mechanical failures or malfunctions that would have resulted in the loss of engine power. The airplane was underwater for weeks before it was recovered, therefore the amount of fuel present in each fuel tank could not be determined. A photo taken just before the flight showed the left fuel tank quantity indicator was on full and the right tank indicator showed the tank contained less than 10 gallons of fuel. The company refueling procedure at that time was to refuel the left tank to 25 gallons and the right tank to 10 gallons. This procedure allows the pilots to use the left fuel tank only for the shorter scenic routes with quicker refueling after the flight. The Engine Failure – Restart Checklist called for the pilot to turn the auxiliary fuel pump ON and change the fuel selector to the other tank if fuel is available. The fuel pump was found in the ON position and the fuel selector was positioned to the left tank when the airplane was recovered. Since the fuel pump was ON, it appears that the pilot initiated the engine restart procedures. It is unknown if the pilot switched fuel tanks during the restart procedure. Had the pilot flown the entire flight on the right fuel tank the fuel supply in that tank would have been exhausted about the time of the power loss. Because of the pilot’s lack of recall of the accident circumstances and his actions during the flight, the investigation was unable to determine the position of the fuel selector when the loss of power occurred. Additionally, the submersion of the wreckage in water compromised the amount of fuel in the tanks, precluding the investigation from assessing the airplane’s fuel state and potentially other evidence of the engine failure. The flaps were determined to have been in the retracted position. With limited time available because of the low altitude, the pilot likely continued to attempt an engine restart and did not run the ditching checklist, which stated to lower the flaps to 30° for a water landing. The Federal Aviation Administration (FAA) Airplane Flying Handbook states “that an airplane that is ditched at minimum speed and in normal landing attitude does not immediately sink upon touchdown.” With the flaps set to the retracted position, the airspeed would not have been as slow as possible when the airplane contacted the water, potentially lessening the impact forces and injuries to the occupants.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked fuel levels before the flight to ensure adequate fuel.

NTSB coding

Evidence available

  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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