Pilot Debrief

CESSNA 140 near Burlington, WI — 2011-06-29

Final reportCEN11LA448
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Date
2011-06-29
Location
Burlington, WI, USA
Airport
BUU
Aircraft
CESSNA 140
Registration
N2332V
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

The improper installation of the fuel selector indicator handle, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

The pilot reported that he departed with the fuel selector set to the right fuel tank, which was full of fuel. About 30 minutes after departure, he made a touch-and-go landing and takeoff at his destination airport. During the initial climb, the engine started to lose power when the airplane was about 100 feet above the runway. The pilot entered a left turn and attempted to land on an adjacent grass runway, but the airplane impacted the terrain short of the runway. Postaccident examination of the airplane’s fuel system revealed that the left fuel tank was empty and the right fuel tank was full of fuel. Examination of the airplane’s fuel selector revealed that the fuel selector indicator handle was improperly installed. When the fuel selector indicator handle was placed in the right fuel tank position, the fuel was actually coming from the left fuel tank. There was no record in the airplane’s maintenance logbook that indicated replacement of the fuel selector valve, the fuel selector indicator handle, or the fuel selector placard. It was not determined who performed the maintenance on the fuel selector and had improperly installed the fuel selector indicator handle.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have checked fuel selector before takeoff to ensure proper tank was selected.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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