Pilot Debrief

CESSNA T210L near Madera, CA — 2009-03-28

Final reportWPR09LA170
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Date
2009-03-28
Location
Madera, CA, USA
Airport
KMAE
Aircraft
CESSNA T210L
Registration
N2445S
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

A total loss of engine power during the initial climb due to fuel exhaustion as a result of the pilot's failure to properly monitor the airplane's fuel quantity and to correctly ascertain the fuel on board the airplane prior to takeoff.

NTSB narrative

While entering the traffic pattern at his home base after a return flight, the pilot switched to the airplane's left tank. As he continued in the pattern he asked his passenger if he would like to make a landing for currency also. When the passenger said yes, the pilot changed his planned full-stop landing to a touch-and-go. During the initial climb after the touch-and-go, the engine lost all power and the pilot executed a forced landing into a grape orchard where the vegetation was supported by closely spaced posts. The investigation confirmed that both fuel tanks were empty at the time of the forced landing. It was further determined that the fuel tank dip tube that the pilot used to determine fuel levels prior to a flight earlier that day was not specifically designed for, or calibrated to, this specific airplane model. The investigation also determined that the pilot did not check the fuel quantity of the left tank when he switched to it upon entering the pattern, and that he switched to that tank only because after a previous momentary fuel flow interruption from the right tank, the owner had made switching to the left tank in the pattern a standard procedure for this airplane regardless of the fuel quantities in each tank.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not check fuel level in left tank before landing decision.

NTSB coding

Evidence available

  • 4 docket documents
View NTSB final reportView NTSB docket

Docket documents4

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