Pilot Debrief

CESSNA 195 near Palm Coast, FL — 2022-01-31

Final reportERA22LA112
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Date
2022-01-31
Location
Palm Coast, FL, USA
Airport
FIN
Aircraft
CESSNA 195
Registration
N597K
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Climb

Probable cause

The pilot’s inadequate fuel planning and preflight inspection, which resulted in a total loss of engine power due to fuel exhaustion.

NTSB narrative

The pilot and the pilot-rated passenger departed their home airport to fly to a nearby airport about 20 minutes away. The pilot stated that he did not add any fuel to the airplane before the flight, as he thought he had enough fuel for the intended 20-minute flight. He reported that before takeoff everything was normal. He took off, and upon reaching 1,000 feet above mean sea level (msl), he configured the airplane for cruise. The airplane was operating normally when, about 5 miles from the destination airport, the engine lost power. The propeller continued to windmill, but it produced no power. He attempted to restart the engine without success. The pilot declared an emergency and informed air traffic control (ATC) that he would be landing on an interstate. During the forced landing, the airplane’s right wing contacted a truck, and the airplane came to rest inverted off the right side of the interstate, incurring substantial damage. The passenger said that he was worried about fire, and immediately tried to get out of the airplane. Once the passenger was out of the airplane, though, he did not see any fire or smoke, and there was no smell of fuel. During the wreckage recovery, there was also no smell of fuel at the accident scene, with the exception of a slight smell of fuel near the engine. Additionally, no fuel could be recovered from the airplane. The postaccident examination of the airplane and engine also revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, the fuel strainer and the carburetor float chamber were absent of fuel. An engine monitor was installed on the airplane that recorded exhaust gas temperature (EGT), cylinder head temperature (CHT), and shock cooling rate. During the accident flight, it recorded a rapid decrease in EGT, a rapid increase in shock cooling, and a rapid decrease in CHT, all of which in combination were indications that were consistent with of a loss of fuel flow. The passenger stated that after the accident the pilot was “absolutely confident” that he had enough fuel for the 20-minute flight, and that the pilot said his fuel totalizer showed 23 gallons. However, the airplane’s fuel totalizer required that a known fuel quantity be programmed at the beginning of the flight. If an accurate quantity had not been entered by the pilot at some previous point, the information indicated by the fuel totalizer would not have been correct. Based on the available information, it is likely that the loss of power was due to the fuel system containing little or no usable fuel, as no fire occurred during the impact sequence, the passenger did not observe fire or smell fuel when he egressed, no fuel was able to be recovered on-scene during the wreckage recovery, the fuel strainer and carburetor float chamber were absent of fuel, and examination of the engine revealed no evidence of any preimpact failures or malfunctions which would have precluded normal operation. The circumstances of the accident were consistent with a total loss of engine power due to fuel exhaustion, which resulted from the pilot’s inadequate fuel planning and preflight inspection.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not refuel before the flight despite potential fuel shortage.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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