Pilot Debrief

CESSNA 180 near Harrisburg, PA — 2023-05-31

Final reportERA23FA252
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Date
2023-05-31
Location
Harrisburg, PA, USA
Airport
CXY
Aircraft
CESSNA 180
Registration
N3178D
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot’s inadequate preflight fuel planning and improper in-flight decision-making, which resulted in a total loss of engine power due to fuel exhaustion and a subsequent collision with terrain and objects.

NTSB narrative

The pilot fully serviced his airplane to its 55-gallon-usable fuel capacity before departing on the 3-leg, cross-country flight. Automatic Dependent Surveillance-Broadcast (ADS-B) captured 3.6 hours of flight; however, the approaches and initial climbs on each leg were below ADS-B coverage, and the flight time and fuel consumption rates during those portions were estimated. About 30 miles from his home airport on the 3rd and final leg of the flight, the pilot announced his intention to divert to a nearby airport. Before reaching the airport, the pilot announced that the airplane had sustained a loss of engine power. The airplane was aligned with and about 1 mile from the runway when it collided with terrain and a utility vehicle in a highway interchange toll plaza. Including the 3 takeoff climbs and other segments of the flights that were below ADS-B coverage, the airplane flew for an estimated 4.0 hours. The pilot estimated the airplane’s fuel consumption to be 12 gallons per hour (gph). A chart in the airplane’s pilot operating handbook (POH) revealed that the airplane would have used an additional 1.5 gallons of fuel for each engine start, warm-up, and takeoff. Combined, these numbers suggested that, on the day of the accident, the airplane consumed at least 52.5 of the 55 gallons on board, without including the increased (16.5 gph) consumption rate during all 3 climbs as calculated by the airplane manufacturer. The pilot stated that he considered stopping for fuel about 40 miles from his home airport but was concerned about the availability of fuel at that airport, so he continued the flight. Records showed that fuel was available at the airport. Examination of the airplane at the scene revealed only trace evidence of fuel and no mechanical anomalies that would have precluded normal operation. A test run of the engine also revealed no anomalies. Given the amount of fuel on board at the time of departure, the estimated flight time and fuel consumption rate, and the lack of mechanical anomalies found after the accident, the loss of engine power was likely the result of fuel exhaustion. The extent of the pilot’s preflight fuel planning could not be determined, nor was it determined whether the pilot visually verified the airplane’s fuel levels before departing on each leg of the flight. The accident may have been prevented if the pilot had been more closely monitoring the airplane’s fuel state as the flight progressed.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have refueled at Carlisle Airport instead of continuing to CXY.

NTSB coding

Evidence available

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

Docket documents10

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