# NTSB CEN10CA305: Cessna 337, N2267X, Custer, SD, June 5, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 5, 2010, 10:21 local (16:21 UTC) - Place: Custer, SD - Coordinates: 43.733333, -103.617774 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.7333&lon=-103.6178&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 20, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Rapid City FSDO - NTSB case key (mKey): 76232 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10CA305 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76232/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76232 - Page: https://openairdocs.org/ntsb/CEN10CA305 ## Probable cause A partial loss of engine power due to fuel starvation as a result of the pilot's inadequate fuel mismanagement. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2075702), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2075702), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2075702), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [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 337, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2075702), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=2075702), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) - [Terrain: wet/muddy terrain](https://openairdocs.org/ntsb-findings/03021035): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-findings/03021035/cases.md?model=2075702), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/03021035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna 337, 2 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=2075702), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=2075702), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2075702), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=2075702), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Cessna 337, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=2075702), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## 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](https://openairdocs.org/aircraft/N2267X), registered now, S/N 337-0167, built 1965 (OpenAirDocs) - Reported make and model: Cessna 337 - Registry model: [Cessna 337](https://openairdocs.org/model/cessna-337) (registry code 2075702) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 337-0167 - Airframe hours: 4811 - Engines: Teledyne Continental Motors IO-360-C 210 horsepower reciprocating; Teledyne 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; 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 ## 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 20100605035819A](https://openairdocs.org/incident/20100605035819A), Jun 5, 2010: Cessna 337, Custer, SD, Substantial damage. June 5, 2010, pilot[privacy data omitted] was out practicing touch and go landings in his Cessna 337 at Custer, SD. On his second takeoff, and about two-thirds… ## Docket (4 files) The files NTSB released with the investigation on August 19, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76232. 1.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 883 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334856&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334850&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Pilot Email Correspondence (item 3, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334853&FileExtension=.PDF&FileName=Pilot%20Email%20Correspondence-Redacted.PDF - FAA Inspector Statements (item 4, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334852&FileExtension=.PDF&FileName=FAA%20Inspector%20Statements-Redacted.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.