# NTSB ANC19LA032: Cessna 172, N9919V, Newport, OR, July 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: July 7, 2019, 17:00 local (Jul 8, 2019, 00:00 UTC) - Place: Newport, OR - Coordinates: 44.580276, -124.058052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.5803&lon=-124.0581&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration - NTSB case key (mKey): 99813 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC19LA032 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99813/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99813 - Page: https://openairdocs.org/ntsb/ANC19LA032 ## Probable cause The pilot's improper verification of the fuel quantity during the preflight inspection, which resulted in fuel exhaustion and a subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause) ## Analysis The pilot and two passengers were returning from a sightseeing flight. While cruising at an altitude of about 1,200 ft, the engine began to surge between 2,100 and 2,600 rpm. To correct for the surging engine, the pilot switched fuel tanks, enriched the fuel mixture, and applied full throttle, to no avail. Unable to maintain altitude and to avoid undue harm to persons on the ground, he selected an area of hilly, sand-covered terrain for an emergency landing. During the emergency landing, the airplane sustained substantial damage to the wings and fuselage. The pilot stated that, the day before the accident, the left and right fuel gauges indicated about 3/4 full and 1/4 full respectively; however, he said it was possible that he had run out of fuel. The airplane had not undergone an annual inspection in 4 years. Postaccident examination revealed that the main fuel line to the carburetor had separated at the carburetor casing and the strainer cable had stretched, releasing any contents that may have been present in the gascolator during the accident sequence. The carburetor half screws were in and safetied but loose and did not appear to be torqued. Brown deposits were observed on the exterior of the carburetor emanating from the carburetor half seam. Although it is evident that the carburetor had been leaking for an undetermined time, blue streaking would have been more likely if a significant and recent fuel loss had occurred. No fuel was found in the remainder of the fuel system, including the wing tanks, associated lines, and carburetor bowl. Based on the lack of fuel present in the fuel system, it is likely that the pilot miscalculated the amount of fuel onboard before the flight, which resulted in fuel exhaustion and a subsequent loss of engine power. ## Factual narrative On July 8, 2019, at about 1700 Pacific daylight time, a Cessna 172 airplane, N9919V, sustained substantial damage during a forced landing following a loss of engine power while in cruise flight near Newport, Oregon. The private pilot and one passenger sustained minor injuries and one passenger sustained serious injuries. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight departed Newport Municipal Airport (KONP), Newport, Oregon for a local whale watching flight. According to the pilot, after locating and circling a pod of whales for viewing, they had decided to return to KONP. While in level cruise flight about 1,200 ft above mean sea level (MSL) the engine began to surge with the rpm fluctuating between 2,100 and 2,600 rpm. In an effort to correct for the surging engine, the pilot switched fuel tanks, enrichened the fuel mixture and applied full throttle, to no avail. Unable to maintain altitude, and in an effort to avoid undue harm to persons on the ground, he selected an area of hilly, sand covered terrain for an emergency landing. During the emergency landing the airplane sustained substantial damage to the wings and fuselage. In a telephone conversation with a Federal Aviation Administration (FAA) aviation safety inspector (ASI), the pilot stated that the airplane had not had an annual inspection in about 3 years, he had not had a biennial flight review in 5 or 6 years and he did not have a current medical certificate. A review of FAA records revealed that the pilot's most recent third-class medical was issued July 30, 2004 with the limitation that he must wear corrective lenses and would have expired on July 31, 2006. Title 14 Code of Federal Regulations Part 61.23 – Medical Certificate; requirement and durations, states in part: (a) Operations requiring a medical certificate. Except as provided in paragraphs (b) and (c) of this section, a person (3) Must hold at least a third-class medical certificate - (i) When exercising the privileges of a private pilot certificate, recreational pilot certificate, or student pilot certificate, except when operating under the conditions and limitations set forth in §61.113(i); Title 14 Code of Federal Regulations Part 61.56 – Flight Review, states in part: (c) Except as provided in paragraphs (d), (e), and (g) of this section, no person may act as pilot in command of an aircraft unless, since the beginning of the 24th calendar month before the month in which that pilot acts as pilot in command, that person has - (1) Accomplished a flight review given in an aircraft for which that pilot is rated by an authorized instructor and (2) A logbook endorsed from an authorized instructor who gave the review certifying that the person has satisfactorily completed the review. According to the National Transportation Safety Board's (NTSB)Pilot/Operator Aircraft Accident/Incident Report submitted by the pilot the airplane's last annual inspection was completed on June 2, 2015. Title 14 Code of Federal Regulations Part 91.409 Inspections, states in part: (a) Except as provided in paragraph (c) of this section, no person may operate an aircraft unless, within the preceding 12 calendar months, it has had— (1) An annual inspection in accordance with part 43 of this chapter and has been approved for return to service by a person authorized by §43.7 of this chapter; or (2) An inspection for the issuance of an airworthiness certificate in accordance with part 21 of this chapter. Wreckage recovery personnel independently confirmed that no fuel was recovered from the airplane's wing tanks, or fuel lines that were removed for recovery. In a conversation with the NTSB investigator-in-charge (IIC) the pilot stated that the carburetor float had been replaced, and previous mechanical problems with the airplane included a fuel drain on the engine that was difficult to close, and the carburetor leaking fuel. In addition, he stated that he had visually verified two days before the accident that the airplane had about ½ tanks and the day before the accident the fuel gauges indicate about ¾ full and ¼ full respectively; however, it was possible he had run out of fuel. An examination of the airplane by an ASI with the FAA revealed that the main fuel line to the carburetor had separated at the carburetor casting during the accident sequence, and the strainer cable had stretched releasing any contents that may have been present in the gascolator. However, no fluid was discovered in the remainder of the fuel system including the carburetor bowl. In addition, during removal of the carburetor bowl it was discovered that the carburetor half screws were in and safetied but loose and did not appear to be torqued, with evidence of fuel leakage at the carburetor half seem. The closest weather reporting facility is Newport Municipal Airport (KONP), Newport, Oregon. At 1750, a METAR from KONP was reporting in part: wind, 310 at 8 knots; visibility, 10 statute miles; sky condition, clear; temperature, 62° F; dew point 57° F; and an altimeter setting of 30.02 inches of mercury. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) ## Aircraft - Registration: [N9919V](https://openairdocs.org/deregistered/N9919V-2022-02-11), registration cancelled 2022-02-11, S/N 17264555, built 1974 (OpenAirDocs) - Reported make and model: Cessna 172 (M) - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17264555 - Year built: 1974 - Engines: Lycoming O-320 SERIES reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 2, 2015 - Departed: Newport, OR - Destination: Newport, OR - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 1,105 total, 985 in this make and model, 1,105 as pilot in command, 1 in the last 90 days, 1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 57 °F - Altimeter: 30.02 inHg ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190708009429A](https://openairdocs.org/incident/20190708009429A), Jul 8, 2019: Cessna 172M, Newport, OR, Substantial damage. Pilot reported that the engine began surging on the return to airport portion of the flight. Aircraft engine quit, aircraft was losing altitude and PIC elected… ## Docket (4 files) The files NTSB released with the investigation on April 21, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99813. 5.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482755&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (FAA) (item 2, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482756&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(FAA)-Master.PDF - Record of Conversation (Pilot) (item 3, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482757&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF - Photos (item 4, .PDF, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482758&FileExtension=.PDF&FileName=Photos-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.