Pilot Debrief

CESSNA 172R near Richmond, KY — 2012-04-19

Final reportERA12LA294
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Date
2012-04-19
Location
Richmond, KY, USA
Airport
I39
Aircraft
CESSNA 172R
Registration
N28BC
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

A total loss of engine power due to fuel exhaustion. Contributing to the accident was the flight instructor’s failure to supervise the student’s preflight inspection, his inadequate fuel management and preflight and in-flight fuel planning, and the operator’s inadequate fueling policies and procedures.

Contributing factors

Contributing to the accident was the flight instructor's failure to supervise the student's preflight inspection, his inadequate fuel management and preflight and in-flight fuel planning, and the operator's inadequate fueling policies and procedures.

NTSB narrative

The flight instructor reported that, after getting in the airplane, he asked the student pilot how much fuel was in each tank. The student pilot replied that 21.5 gallons of fuel were in one tank and 20 gallons of fuel were in the other tank. The student pilot reported dipping a "fuel stick" into the fuel tanks during the preflight to check the fuel levels. Although the flight instructor noticed that the fuel quantity indicators showed that 20 gallons of fuel were in one tank and 15 gallons of fuel were in the other tank, he did not question the fuel discrepancy. A review of security camera video revealed that the flight instructor did not supervise the student pilot's preflight inspection nor conduct a walk-around inspection. After departure, the student pilot flew the airplane to another airport for a short- and soft-field training lesson. After 45 minutes of training, they departed for their home airport. Although the flight instructor noticed that the fuel gauges were reading low, he chose to continue the flight. Five miles north of the airport, the engine began sputtering, and the flight instructor took control of the airplane. He turned on the fuel pump and richened the fuel mixture, and the engine started running normally. He then decided to climb to get as much altitude as possible while continuing to fly to the airport. One minute later, the engine lost power. The flight instructor then unsuccessfully attempted to restart the engine. When he realized that the airplane would not make the runway, he decided to land in a field. During the approach and landing roll, the airplane struck power lines, and the right wing struck a tree and was substantially damaged. Examination of the fuel tanks revealed that they were empty and that neither of them was breached. No evidence of fresh fuel staining or leakage was found above or below the wings or on the belly of the airplane. After adding 5 gallons of fuel to the left wing tank, the engine was started, and it ran normally. Examination of the fuel sticks used by the operator revealed that they did not have aircraft registration markings on them to verify if the correct fuel stick was onboard the correct aircraft and that one of the airplanes in the fleet with 20-gallon tanks had a 26.5-gallon fuel stick in the cockpit. It could not be determined whether the student pilot used the proper fuel stick during the preflight inspection. Examination of the operator's fueling pad and parking ramp revealed that they were significantly sloped. Examination of its fueling and parking procedures also revealed that the airplanes were being parked and serviced with the fuel selector valves in the "both" position. According to the airplane manufacturer, the airplane should be parked in a wings-level, normal ground attitude with the fuel selector in the "left" or "right" position to ensure maximum fuel capacity and minimize cross-feeding when refueling.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Returning to I39 when fuel gauges indicated low levels.

NTSB coding

Evidence available

  • Video
  • Photos
  • 27 docket documents
View NTSB final reportView NTSB docket

Docket documents27

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