CEN10CA305

NTSB accident investigation · Cessna 337 · Custer, SD · June 5, 2010

Accident · No injuriesData collectionFinal report
Date
June 5, 2010, 10:21 local (16:21 UTC)
Place
Custer, SD
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2267XCessna 337
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Rapid City FSDO
FAA report
20100605035819A
Case key
76232

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

A partial loss of engine power due to fuel starvation as a result of the pilot's inadequate fuel mismanagement.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Inadequate inspectionCessna 337: 1 caseAll aircraft: 1,695 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 337: 1 caseAll aircraft: 551 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna 337: 1 caseAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 337: 1 caseAll aircraft: 1,391 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna 337: 1 caseAll aircraft: 442 cases
Terrain: wet/muddy terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna 337: 1 caseAll aircraft: 110 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The accident occurred during the first flight since an annual inspection was performed on the airplane. The pilot reported that the airplane was last fueled approximately 5 months before the accident flight, at which time the fuel tanks were topped-off. According to the pilot, after being refueled the airplane was flown about 30 minutes to the accident airport where the annual inspection was performed. The Inspector Authorization (IA) mechanic who performed the annual inspection stated that he ran the engines for about 30 minutes before the annual and about 40 minutes after the inspection was completed. The IA mechanic did not refuel the airplane after the annual inspection. The pilot told a Federal Aviation Administration (FAA) inspector that he did not visually check the fuel tank levels before the accident flight. The pilot stated that after takeoff he remained in the traffic pattern and performed a full stop landing. He then back-taxied on the runway before his next takeoff. After the second takeoff, during initial climb, the pilot noticed that the rear engine was losing power. He applied full power to the forward engine and was able to maintain sufficient altitude to clear a tree line, but the airplane was losing airspeed. He then performed an off-field landing approximately 4 miles from the departure airport. The airplane landed in a soft field, during which the landing gear collapsed and the fuselage, left wing, and left stabilizer were substantially damaged. The pilot stated that after the accident he visually inspected the right main fuel tank and found it empty. He indicated that he had been running the rear engine on the right main fuel tank during the accident flight. A postaccident inspection by a FAA inspector revealed the left main and left auxiliary fuel tanks contained 14 gallons and 17 gallons, respectively. The right main and right auxiliary fuel tanks contained 3 ounces and 3 gallons, respectively. The fuel selectors were all found turned off at the accident site. The rear engine was started and operated between an idle power setting and 1,500 rpm without anomalies. The engine responded to throttle inputs and both of its magnetos were operational during the test run.

Factual narrative

The accident occurred during the first flight since an annual inspection was performed on the airplane. The pilot reported that the airplane was last fueled approximately 5 months before the accident flight, at which time the fuel tanks were topped-off. According to the pilot, after being refueled the airplane was flown about 30 minutes to the accident airport where the annual inspection was performed. The Inspector Authorization (IA) mechanic who performed the annual inspection stated that he ran the engines for about 30 minutes before the annual and about 40 minutes after the inspection was completed. The IA mechanic did not refuel the airplane after the annual inspection. The pilot told a Federal Aviation Administration (FAA) inspector that he did not visually check the fuel tank levels before the accident flight. The pilot stated that after takeoff he remained in the traffic pattern and performed a full stop landing. He then back-taxied on the runway before his next takeoff. After the second takeoff, during initial climb, the pilot noticed that the rear engine was losing power. He applied full power to the forward engine and was able to maintain sufficient altitude to clear a tree line, but the airplane was losing airspeed. He then performed an-off field landing approximately 4 miles from the departure airport. The airplane landed in a soft field, during which the landing gear collapsed and the fuselage, left wing, and left stabilizer were substantially damaged. The pilot stated that after the accident he visually inspected the right main fuel tank and found it empty. He indicated that he had been running the rear engine on the right main fuel tank during the accident flight. A postaccident inspection by a FAA inspector revealed the left main and left auxiliary fuel tanks contained 14 gallons and 17 gallons, respectively. The right main and right auxiliary fuel tanks contained 3 ounces and 3 gallons, respectively. The fuel selectors were all found turned-off at the accident site. The rear engine was started and operated between an idle power setting and 1,500 rpm without anomalies. The engine responded to throttle inputs and both of its magnetos were operational during the test run.

Aircraft

Registration
N2267X
Reported as
Cessna 337
Category
Airplane
Serial number
337-0167
Airframe hours
4,811
Engines
Teledyne Continental Motors IO-360-C, 210 horsepower, reciprocatingTeledyne Continental Motors IO-360-D, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Grover D. Fulkerson
Registered owner
Grover D. Fulkerson
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 3, 2010
Departed
KCUT · Custer, SD
Destination
KCUT · Custer, SD
Airport
KCUT · Custer County Airport, runway 26, 5,500 × 60 ft, asphalt

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
62
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, With waivers/limitations
Last flight review
June 4, 2009
Seat
Left
Flight hours
587 total · 46 in this make and model · 456 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 5 knots
Visibility
10 statute miles
Lowest ceiling
9,000 ft overcast
Temperature
63 °F, dew point 37 °F
Altimeter
30.02 inHg
Observed at
KCUT, 4 nm away

Docket · 4

The files NTSB released with the investigation on August 19, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 MB in all.

FAA reports on this event · 1

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