Pilot Debrief

CESSNA A185F near North Vernon, IN — 2021-04-17

Final reportCEN21LA194
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Date
2021-04-17
Location
North Vernon, IN, USA
Airport
OVO
Aircraft
CESSNA A185F
Registration
N19D
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

The pilot’s improper installation of the fuel selector handle, which resulted in a total loss of engine power due to fuel starvation.

NTSB narrative

After a 100-hour inspection, which the pilot assisted with, he conducted an operational check of the airplane, which included a run-up of the airplane. The mechanic had to leave before the inspection was complete, and the pilot installed portions of the interior which included the fuel selector handle. He then departed the airport and after retracting the landing gear and flaps, the engine lost power. During the forced landing the airplane sustained substantial damage to the empennage and aft section of the fuselage. Examination of the airplane revealed that fuel was available in the left and right fuel tanks. The examination also found that the fuel selector handle had been installed incorrectly by 90° on the fuel selector shaft. The position of the shaft as found would have restricted all fuel flow from the left and right fuel tanks. The shaft was “keyed” such that the fuel selector handle should only be installed one way; however, the handle partially fit over the stem when not aligned with the key on the shaft and allowed the attaching screw to partially engage on the stem. An engine test run was conducted; the engine started normally and with the engine at full throttle, the fuel selector was placed in the left, right, and both positions. The engine continued to run with no anomalies noted. The airplane was factory equipped with a small header tank that fuel accumulated in before being fed to the engine. The accident is consistent with the fuel selector shaft being in the off position while the selector handle pointed to the left fuel tank. Once the fuel in the airplane’s header tank was exhausted, the engine lost power due to fuel starvation.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Correctly install the fuel selector handle before flight.

NTSB coding

Evidence available

  • Photos
  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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