# NTSB ANC21LA033: Cessna 140, N77219, Anchorage, AK, April 26, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 25, 2021, 18:28 local (Apr 26, 2021, 02:28 UTC) - Place: Anchorage, AK - Coordinates: 61.409106, -149.52749 - Nearby events: https://openairdocs.org/map.md?lat=61.4091&lon=-149.5275&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: Cessna Aircraft, Federal Aviation Administration - NTSB case key (mKey): 102986 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC21LA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102986/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102986 - Page: https://openairdocs.org/ntsb/ANC21LA033 ## Probable cause The pilot’s mismanagement of fuel which resulted in fuel starvation and total loss of engine power during a go-around. Contributing to the accident was the improperly marked fuel quantity gauges that failed to indicate a fuel quantity takeoff limitation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 140, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2071602), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna 140, 6 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2071602), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel quantity indicator](https://openairdocs.org/ntsb-findings/01022841): Aircraft › Aircraft systems · Related operating info (probable cause); cases with it: [Cessna 140, 1 case](https://openairdocs.org/ntsb-findings/01022841/cases.md?model=2071602), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01022841/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna 140, 6 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2071602), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis The pilot reported that, after lining up on the final approach to landing and nearing the runway, he was unhappy with the approach, and elected to conduct a go-around. He applied full power, pushed in the carburetor heat, accelerated to 60 knots airspeed, and initiated a climb. When the airplane was about 100 ft above the treetops on the south end of the airport, the engine lost all power. He attempted to restart the engine but was not successful. The airplane touched down in an area of muskeg and bounced several times before it nosed over, sustaining substantial damage to the left lift strut. The airplane Flight Manual, Power Plant Instrument, stated in part: Fuel Quantity Gauge – Do not takeoff on a fuel tank less than ¼ full. Examination of the wreckage by a mechanic found no anomalies to explain the loss of engine power and found the fuel selector placed to the right tank position. Although the right fuel gauge indicated less than 1/4 fuel, and the aircraft flight manual warned not to takeoff on a fuel tank less than 1/4 full, the fuel onboard at the time of the accident could not be determined due to the disposition of the wreckage. The airplane was equipped with 2 -12.5-gallon fuel tanks with left, right, or off, fuel selector positions. According to a representative from the aircraft manufacturer, the fuel quantity limitation for takeoff was due to the location of the fuel pickup tubes in the fuel tanks. Fuel unporting was possible at takeoff and climb attitudes when the fuel was less than ¼ full. No markings were present on the fuel gauges to indicate a takeoff limitation when the fuel tank was less than ¼ full, which would be about 3.125 gal per fuel tank. According to the operation manual for the airplane, a cruise power setting between sea level and 10,000 mean seal level would yield a fuel burn of about 4.2 gallons per hour. The pilot indicated that the 1.9-hour flight departed with 15 gallons of fuel and he performed numerous maneuvers during the flight. Flight track data showed the airplane’s altitude varied between 7,400 ft and 100 ft. A 4.2 gph fuel burn over a span of 1.9 hours equates to about 8 gallons of fuel burned, which would have left about 3.5 gal of fuel in each of the two wing fuel tanks if the fuel was used evenly between the two tanks. Although a postaccident examination found some contaminates within the fuel system, the amount and size were not enough to cause a total loss of engine power. The temperature and dewpoint at the time of the accident placed the airplane on the edge of the regime for carburetor icing at glide power; however, carburetor icing is unlikely to have been an issue since the pilot applied carburetor heat during the approach to land. It is therefore likely that insufficient fuel remained for takeoff which resulted in unporting of the fuel pickups and a total loss of engine power. ## Factual narrative On April 25, 2021, about 1828 Alaska daylight time, a Cessna 140, N77219, sustained substantial damage when it was involved in an accident near the Birchwood Airport, Birchwood, Alaska. The pilot and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the cross-country flight originated at the Birchwood Airport (BCV) with stops at Quartz Creek Airport (JLA), Cooper Landing, Alaska, and a planned fuel stop in Homer Airport (HOM) Homer, Alaska. While in Homer, 13 gallons of fuel was added before the airplane departed at 1633 for BCV with a total of 15 gallons of fuel onboard (see figure 1). Figure 1 – Flight track for last leg of accident flight. Before reducing the engine power and initiating the descent into BCV, the pilot applied the carburetor heat, which remained on throughout the entire descent and the traffic pattern for runway 20L. After lining up on the final approach to land, he was unhappy with the approach, and elected to conduct a go-around by simultaneously pushing the carburetor heat to “cold” and applying full power before reducing the flap setting. He accelerated to 60 knots airspeed and initiated a climb. When the airplane was about 100 ft above the treetops on the south end of the airport, the engine lost all power. the pilot lowered the nose and banked the airplane towards an area of tidal mud flats. During the descent, he attempted to restart the engine but was not successful. The airplane touchdown in an area of muskeg and bounced several times before it nosed over, sustaining substantial damage to the left lift strut. The airplane Fight Manual, Power Plant Instrument, stated in part: Fuel Quantity Gauge – Do not takeoff on a fuel tank less than 1/4 full. The airplane’s Type Certificate Data Sheet did not contain a required placard for the fuel quantity no takeoff range; however, the drawing for the fuel quantity gauge from the manufacturer did contain markings for the no takeoff range. According to a representative from the aircraft manufacturer, the fuel quantity limitation for takeoff was due to the location of the fuel pickup tubes in the fuel tanks. Fuel unporting was possible at takeoff and climb attitudes when the fuel was less than ¼ full. No markings were present on the accident airplane’s fuel gauges to indicate a takeoff limitation when the fuel tank was less than 1/4 full. The airplane was equipped with a Continental C-85 engine. The gascolator was drained and a very small amount of contaminants consistent with sand and a few drops of liquid consistent with water were found. A postaccident wreckage examination revealed no other mechanical irregularities or malfunctions with the airplane that would have precluded normal operation. The pilot stated that he used a cruise power setting of 2200 rpm on the accident flight; however, he also stated that he performed numerous maneuvers, e.g., stalls, steep turns, etc. andflight track data revealed that the cruise altitude for the accident flight varied from 7,400 - 100 ft. According to the Operation Manual for the Cessna 140, a cruise setting between sea level and 10,000 mean sea level would yield a fuel burn of about 4.2 gallons per hour. The pilot indicated that the flight departed HOM with 15 gallons of fuel. The duration of the flight from HOM to BCV was about 1.9 hours for a total fuel burn of about 8 gallons, leaving about 7 gallons or 3.5 gallons per side of fuel remaining. The airplane is equipped with 2 -12.5-gallon fuel tanks with one tank located in each wing, for a total of 25-gallons with left, right, or off, fuel selector positions. One quarter of the total fuel would be about 6.25 gallons or 3.125 gallons per side. The exact amount of fuel remaining could not be determined due to the disposition of the wreckage. ## Aircraft - Registration: [N77219](https://openairdocs.org/aircraft/N77219), registered now, S/N 11681, built 1946 (OpenAirDocs) - Reported make and model: CESSNA 140 - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 11681 - Year built: 1946 - Airframe hours: 2890.5 - Engines: CONT MOTOR C85 SERIES 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: William S Day - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 10, 2020 - Departed: Homer, AK - Destination: Same as departure - Airport: BCV, Birchwood, runway 02R/20L, 1,800 × 50 ft, asphalt - Equipment: Satellite tracking device, Handheld GPS, Electronic flight bag or handheld device, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review August 23, 2020; seat: left; restraint: 4-point; flight hours: 134 total, 38 in this make and model, 105 as pilot in command, 57 in the last 90 days, 34 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 6 knots - Visibility: 10 statute miles - Temperature: 54 °F, dew point 25 °F - Altimeter: 29.86 inHg - Observed at: PABV, 1 nm away - METAR: PABV 260156Z AUTO 27006KT 10SM CLR 12/M04 A2986 RMK AO2 SLP117 T01221039 ## 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 20210426007319A](https://openairdocs.org/incident/20210426007319A), Apr 26, 2021: Cessna 140, Chugiak, AK, Substantial damage. Pilot departed hom with 15 gallons of fuel. The aircraft burns 4 gallons per hour. At the time of descent, the aircraft flew 2.3 hours to bcv. The pilot stated… ## Docket (10 files) The files NTSB released with the investigation on October 20, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102986. 13.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12371052&FileExtension=pdf&FileName=6120%20dms_Redacted-Rel.pdf - Opsvue flight track (item 2, PDF, 1 page, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14058962&FileExtension=pdf&FileName=Flight%20Track%20OpsVue%20dms-Rel.pdf - ADS-B data (item 3, CSV, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14185525&FileExtension=csv&FileName=20210426_AA7312_452626221_ADSB-Rel.csv - Cessna 140 type certificate data sheet (item 4, PDF, 9 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14059309&FileExtension=pdf&FileName=140%20TCDS-Rel.pdf - Cessna 140 fuel gage drawing (item 5, PDF, 1 page, 359 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14070236&FileExtension=pdf&FileName=C140%20Fuel%20Gage_Redacted-Rel.pdf - Airplane flight manual (item 6, PDF, 1 page, 549 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12372298&FileExtension=pdf&FileName=AFM%20dms_Redacted-Rel.pdf - Airplane operations manual excerpt (item 7, PDF, 3 pages, 768 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14058326&FileExtension=pdf&FileName=140%20OM%20Excerpt-Rel.pdf - Wreckage examination summary (item 8, PDF, 1 page, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12374122&FileExtension=pdf&FileName=Wrexkage%20Examination%20Summary-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 1 page, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12372226&FileExtension=pdf&FileName=NTSB%20Party%20Form%20ANC21LA033_Redacted-Rel.pdf - Photos (item 10, PDF, 2 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14581629&FileExtension=pdf&FileName=Photo%20array%20-Rel.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.