Pilot Debrief

CIRRUS DESIGN CORP SR22 near Laguna Pueblo, NM — 2016-02-29

Final reportCEN16LA112
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Date
2016-02-29
Location
Laguna Pueblo, NM, USA
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N2711M
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Climb

Probable cause

A total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's inadequate oversight of the airplane's refueling and her subsequent failure to verify and monitor the fuel quantity before and during the flight.

NTSB narrative

The private pilot and three passengers were on a cross-country flight and stopped en route to refuel. The pilot reported that services were limited and only self-serve fuel pumps were available. The pilot intended to add about 25 gallons of fuel to each wing tank and asked one of the passengers for assistance in reading the fuel meter and reporting the quantity as she added fuel to the airplane. The passenger stated that the sun was shining on the meter, which made it hard to read. She yelled for the pilot to stop refueling when she read 25 gallons on the meter but stated to the pilot that the amount of time had not seemed sufficient to dispense 25 gallons. The pilot replied that the pumps were not like automotive pumps. The pilot then added fuel to the other wing, and the passenger called out when the meter reached 52 gallons. Upon completion of fueling, the pilot was unable to get a fuel receipt from the pump. The pilot reported that she did her normal pre-takeoff checks and then departed. About an hour after departure at an altitude of 13,000 ft, the engine experienced a total loss of power, and the pilot deployed the airplane's parachute system. The airplane descended under canopy and impacted terrain, where it came to rest upright. Before the occupants egressed, a gust of wind caught the parachute and dragged the airplane into trees, flipping the airplane upside down. A visual inspection of the airplane at the accident site did not reveal any discrepancies with the engine. A credit card receipt for the fuel transaction indicated that the pilot purchased 5.23 gallons of fuel. Because the airplane was only filled with 5.23 gallons instead of the 52 gallons the pilot expected, the airplane did not have adequate fuel onboard to complete the flight. The before takeoff checklist includes the step "fuel quantity – confirm." The airplane's operating handbook states the airplane is equipped with a fuel gauge and a warning light that will illuminate if the fuel quantity drops below 14 gallons in each fuel tank. The investigation could not determine whether the pilot monitored the fuel system or observed a fuel warning light, but the circumstances are consistent with the pilot not verifying the fuel quantity prior to the flight, or monitoring the fuel quantity in flight, which resulted in a total loss of engine power due to fuel exhaustion.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot should have confirmed fuel quantity before takeoff.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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