ANC98FA116

NTSB accident investigation · Cessna A185F · Ketchikan, AK · August 6, 1998

Accident · FatalField investigationFinal report
Date
August 5, 1998, 16:05 local (Aug 6, 1998, 00:05 UTC)
Place
Ketchikan, AK
Injuries
1 fatal, 2 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N5314RCessna A185F
Weather
Visual (VMC) · Day
Status
Completed · report February 16, 2001
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19980805019729A
Case key
43642

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Fuel starvation and the pilot's improper fuel tank selection. Factors associated with the accident were the pilot's failure to follow the pre-takeoff checklist and trees.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalCruise
Fluid,fuel - starvationCause
Fuel tank selector position - improperPilot in commandCause
Checklist - not followedPilot in commandFactor
Forced landingDescent - emergency
In flight collision with objectDescent - emergency
Object - tree(s)Factor
In flight collision with terrain/waterDescent - emergency
Terrain condition - swampy

Analysis

The pilot told the NTSB investigator-in-charge (IIC) during an interview on August 6, that he parked the airplane with the right wing over the dock, placed the fuel selector valve in the 'LEFT' position to prevent fuel cross-feeding while on the water, and requested the lineman fill the right wing. He told the NTSB IIC he recalled seeing the right tank fuel gauge read full, and the left tank gauge read 1/8 to 1/4 (5 gallons to 10 gallons) when he departed on the accident flight. He said he always does a 'GUMPS' (Gas-Undercarriage-Mixture-Prop) check prior to takeoff. The company wrote in a statement submitted to the NTSB IIC on May 10, 1999, and told the NTSB IIC, that the pilot did not remember placing the fuel valve to the 'LEFT' position during fueling. After about 45 minutes of flight, and one water landing and takeoff, the engine quit while the airplane was at 800 feet msl climbing toward rising terrain. The pilot said he turned on the electric fuel pump, but the engine did not start. He saw the fuel selector valve in the 'LEFT' tank position. He indicated he turned the selector valve to the 'BOTH' position, and turned the airplane 180 degrees toward lower terrain. The engine did not restart and the airplane contacted trees and marshy terrain. Investigation revealed fuel in the right wing tank, no fuel in the left wing tank, and one teaspoon of fuel in the intact fuel lines to the engine. Charted fuel consumption for 45 minutes at a cruise power setting of 2,300 rpm at 23 inches of manifold pressure is 9.4 gallons. The BEFORE TAKEOFF checklist states, in part: '(6) Fuel Selector Valve - BOTH ON, (7) Fuel Quantity Indicators - CHECK QUANTITY.' The pilot stated during interviews with the NTSB, FAA, and Alaska State Troopers, on August 6, and August 7, that he believed the rear seat passenger must have kicked the fuel selector valve to the 'LEFT' position. The NTSB IIC, the FAA coordinator, and the company representative, all sat in the rear seat of a representative Cessna 185 on August 8 and attempted to move the fuel selector to the 'LEFT' position with their feet. None of them were able to move the valve further than 1 inch (12 degrees) to the left of the 'BOTH' position.

Factual narrative

History of flight

On August 5, 1998, at 1605 Alaska daylight time, a float equipped Cessna A185F airplane, N5314R, was destroyed when it impacted terrain about 24 miles northeast of Ketchikan, Alaska, at position 55 degrees 30.98 minutes North latitude, 131 degrees 01.17 minutes West longitude. The commercial pilot and one passenger sustained serious injuries. The remaining passenger sustained fatal injuries. The flight was operated under 14 CFR Part 135, by Taquan Air Service, Inc., of Ketchikan, as an on-demand sightseeing flight. Visual meteorological conditions prevailed at the time of the accident, and a company VFR flight plan was filed. The flight departed the Ketchikan Downtown Seaplane Base at 1455, on a planned 1.5 hour sightseeing tour of Misty Fjords National Monument. Company dispatchers began attempting to contact the airplane at 1630, and declared the flight overdue at 1655. Pilots in the area of the accident site reported hearing an emergency locator transmitter (ELT) signal on 121.5 MHz. The wreckage was located at 1742.

The pilot told the NTSB investigator-in-charge (IIC) during an interview on August 6, that they had flown for 40 to 45 minutes, and landed at the confluence of the East Arm, and the West Arm, of Rudyerd Bay, locally referred to as "The Y." A normal part of the tour was to land on the water along the route, and allow passengers out on the floats to take photographs. To do this, the pilot had to slide his seat aft, get out, and allow the right front seat passenger to exit. He indicated that when he did so, he pinched the feet of the rear seat passenger, who had her legs stretched out behind his seat. After a few minutes, he reseated the front seat passenger, and took off.

The pilot said that after taking off from "The Y," about ten minutes elapsed before the engine quit. The rear seat passenger, during three separate interviews, told the Alaska State troopers, and the NTSB IIC, that there was no warning prior to the engine "sputtering and stopping." She indicated the pilot acted surprised.

The pilot told the Alaska State Troopers on August 6, and the NTSB IIC on August 7, that while climbing up the Ella Lake drainage, about 800 feet msl, the engine suddenly quit. He said he turned on the fuel boost pump, and nothing happened. He looked down and saw the fuel selector valve handle on the "LEFT" position, so he turned it to "BOTH." He indicated the airplane was too low to clear the trees ahead of them and land on Ella Lake, so he reversed direction to glide to lower terrain. The engine did not restart, and he did not have time to extend the trailing edge flaps before the airplane contacted trees and marshy terrain.

The pilot had returned to Ketchikan from an earlier charter flight at 1435, and tied the airplane with the right wing over the dock. He requested a dispatcher have the right wing tank filled, and she called the float plane dock and made that request. The pilot said during an interview on August 7 with the NTSB IIC and FAA coordinator, that prior to departing on the accident flight, he noted the right wing tank was filled, and the 40 gallon left tank was between 1/8 and 1/4 full.

According to the field notes of the NTSB IIC, and the notes of the FAA inspectors present during the interview on August 7, the pilot indicated he placed the fuel valve to the left tank position after he landed at the dock, because fuel tends to flow from one tank to the other while the airplane sits on the water. He believed the fuel selector handle was in the center position ("BOTH") prior to departing Ketchikan on the accident flight. He stated he normally does a "GUMPS" (Gas-Undercarriage-Mixture-Props) check before takeoff.

The company submitted a written statement (attached) to the NTSB IIC on May 10, 1999, stating that after reviewing a draft of this report, the statement in the above paragraph is false. During a telephone interview by the NTSB IIC on April 30, 1999, the company president stated that the pilot was under stress during the August 7 interview, and did not remember saying that he placed the fuel selector to the "LEFT" position while the plane was docked and being refueled.

During an interview with the Alaska State Troopers on August 6, and the NTSB interview on August 7, the pilot stated that the passenger in the back seat must have kicked the fuel selector valve to the "LEFT" position.

Investigation revealed that the fuel selector valve handle was in the "BOTH" position after impact. Fuel was present in the right wing tank, no fuel was present in the left wing tank. The accumulator fuel tank was ruptured, and about one teaspoon of fuel was present in the fuel lines between the accumulator tank and the engine. No rotational damage was observed on the propeller.

Injuries to persons

The passenger seated in the right-front seat sustained fatal injuries. The remaining passenger and the pilot sustained serious injuries.

The pilot told the IIC that he did not observe any severe external injuries to the fatally injured passenger. After removing both passengers from the airplane, he attempted to perform cardio-pulmonary resuscitation (CPR) on the fatally injured passenger, but did not obtain any response. He and the surviving passenger indicated that CPR was continued until the pilot was exhausted and could no longer continue.

Damage to aircraft

The airplane was destroyed by impact damage.

Personnel information

The commercial pilot held single-engine land and seaplane ratings, and an instrument rating. His second class medical certificate was issued on August 11, 1997, with the restriction that he wear corrective lenses. He possessed a Statement of Demonstrated Ability (SODA) and waiver for his eyesight, which was 20/200 correctable to 20/20 with lenses.

The pilot completed initial training with the company in the Cessna 185 on March 27, 1997. He requalified in the Cessna 185 on June 15, 1998. Both of these qualifications were oral tests only. His most recent flight test was his annual 14 CFR Part 135.293 and 135.299 check on June 15, 1998. This flight test was completed in the DHC-2 Beaver.

Aircraft information

The seaplane was configured with PK-3000 floats. It was maintained on a 100 hour inspection interval. The most recent inspection was performed on July 29, 33 hours prior to the accident. The engine had accumulated 733 hours since overhaul. A review of aircraft records revealed no recent discrepancies.

The fuel system consisted of two 40 gallon main tanks, with 37 useable gallons per wing, and a 1.5 gallon accumulator tank between the fuel selector valve and the fuel shut off valve. A two speed electric fuel boost pump provides priming and emergency fuel pressure in the event the engine driven fuel boost pump fails. Both the electric and engine driven boost pumps are located forward of the firewall, between the accumulator tank and the engine fuel distributor manifold.

Meteorological information

The weather at the Ketchikan International Airport at 1453, was winds from 110 degrees at 7 knots; 10 miles visibility; and overcast clouds at 5,000 feet. At 1553, overcast clouds were reported at 7,500 feet.

A photograph taken by the surviving passenger depicts Eddystone Rock, which is located four miles east of the accident site. In this photograph the tops of mountains are visible, and visibility is unobstructed. During an interview on August 7, the pilot stated they flew past Eddystone Rock just prior to the accident.

The pilot described the weather as VFR with high clouds until after the accident. He said weather was not a factor in the accident, but heavy rain after the accident made them cold and uncomfortable.

The pilots of several other airplanes flying in the vicinity were interviewed by the IIC. All of these pilots described areas of rain showers, and a thunderstorm which was located approximately 10 miles northwest of the acciden

Aircraft

Registration
N5314R
Reported as
Cessna A185F
Category
Airplane
Serial number
18503030
Airframe hours
15,000
Engine
Continental IO-520-D, 300 horsepower, reciprocating
Damage
Destroyed
Flight
Part 135
Registered owner
Taquan Air Service, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 29, 1998 · 32 hours before
Departed
5KE · AK
Destination
5KE · AK
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
5,800 total · 1,203 in this make and model · 136 in the last 90 days · 62 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 7 knots
Visibility
10 statute miles
Lowest ceiling
5,000 ft overcast
Temperature
66 °F, dew point 52 °F
Altimeter
30.00 inHg
Observed at
KTN, 24 nm away

Docket · 26

The files NTSB released with the investigation on June 7, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.4 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 455 KBSupplement AItem 2 · .PDF · 242 KBSupplement BItem 3 · .PDF · 409 KBSupplement SItem 4 · .PDF · 72 KBRecord of Pilot Interview with NTSBItem 5 · .PDF · 282 KBPilot Interview Record by FAAItem 6 · .PDF · 84 KBParty Comment LetterItem 7 · .PDF · 35 KBSummary of Interview by NTSBItem 8 · .PDF · 88 KBPassenger StatementItem 9 · .PDF · 142 KBSummary of Witness Interviews by FAAItem 10 · .PDF · 103 KBSummaries of Witness Interviews by NTSBItem 11 · .PDF · 299 KBMaps of AreaItem 12 · .PDF · 175 KBWreckage DiagramsItem 13 · .PDF · 62 KBWeatherItem 14 · .PDF · 97 KBDrawingsItem 15 · .PDF · 224 KBPilot ChecklistsItem 16 · .PDF · 231 KBFuel ConsumptionItem 17 · .PDF · 219 KBFAA ReportItem 18 · .PDF · 161 KBStatement of Party Representatives to NTSB InvestigationItem 19 · .PDF · 78 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 20 · .PDF · 77 KBPhoto 1. Photograph of Eddystone Rock taken by aft right seat passenger about 5 minutes prior to accident. Note weather.Item 21 · .PDF · 94 KBPhoto 2. Wreckage pathItem 22 · .PDF · 136 KBPhoto 3. Right wing separated from airplane. Note outward teardrop-shaped bulging.Item 23 · .PDF · 135 KBPhoto 4. Electric Fuel boost pump switches. Note both high and low side selected.Item 24 · .PDF · 168 KBPhoto 5. Propeller displaying crushed spinner, and aft bent blades. No evidence of scratching, or twisting.Item 25 · .PDF · 184 KBPhoto 6. Maximum deflection of fuel selector valve handle obtained in a representative Cessna A185F floatplane using feet from the aft right passenger seat.Item 26 · .PDF · 111 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.