CEN11LA448

NTSB accident investigation · Cessna 140 · Burlington, WI · June 29, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
June 29, 2011, 14:30 local (19:30 UTC)
Place
Burlington, WI
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2332VCessna 140
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report May 3, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Milwaukee FSDO
FAA report
20110629013069A
Case key
80992

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

The improper installation of the fuel selector indicator handle, which resulted in a total loss of engine power due to fuel starvation.

Findings · 3

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.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect service/maintenanceCessna 140: 3 casesAll aircraft: 176 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · OtherCessna 140: 1 caseAll aircraft: 99 casesProbable cause

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 pilot reported that he departed with the fuel selector set to the right fuel tank, which was full of fuel. About 30 minutes after departure, he made a touch-and-go landing and takeoff at his destination airport. During the initial climb, the engine started to lose power when the airplane was about 100 feet above the runway. The pilot entered a left turn and attempted to land on an adjacent grass runway, but the airplane impacted the terrain short of the runway. Postaccident examination of the airplane’s fuel system revealed that the left fuel tank was empty and the right fuel tank was full of fuel. Examination of the airplane’s fuel selector revealed that the fuel selector indicator handle was improperly installed. When the fuel selector indicator handle was placed in the right fuel tank position, the fuel was actually coming from the left fuel tank. There was no record in the airplane’s maintenance logbook that indicated replacement of the fuel selector valve, the fuel selector indicator handle, or the fuel selector placard. It was not determined who performed the maintenance on the fuel selector and had improperly installed the fuel selector indicator handle.

Factual narrative

On June 29, 2011, about 1430 central daylight time, a Cessna 140, N2332V, sustained substantial damage during a forced landing after a loss of engine power during the initial climb from runway 11 (4,300 feet by 75 feet, asphalt) at the Burlington Municipal Airport (BUU), Burlington, Wisconsin. The pilot received serious injuries. The airplane was registered to Stick and Rudder LLC and operated by the pilot on a personal flight under the 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. The flight originated from the Kenosha Regional Airport (ENW), Kenosha, Wisconsin, about 1400. The pilot reported he departed ENW and flew to BUU and did a touch-and-go landing on runway 11. After he started the initial climb from the touch-and-go landing, the engine started to lose power when the airplane was about 100 feet above the runway. The pilot determined that there was not enough runway remaining to land on runway 11. He entered a left turn and attempted to land on runway 19, which was a grass runway, but the airplane impacted the terrain short of the runway. The airplane landed hard on the left wheel and then on the right wheel, which resulted in substantial damage to the airplane. A Federal Aviation Administration airworthiness inspector examined the airplane. The inspection revealed that the fuel selector handle indicated that the right fuel tank was selected. However, the right tank was full of fuel, and the fuel gauge located in the right wing root above the pilot also indicated that the right tank was full. The left fuel tank was empty, and the fuel gauge located in the left wing root above the pilot also indicated that the left tank was empty. The examination of the fuel selector revealed that the fuel selector placard complied with the airplane’s operations manual. However, the inspection revealed that the fuel selector indicator handle was improperly installed. When the fuel selector indicator handle was placed on the right fuel tank, the fuel was actually coming from the left fuel tank. The pilot reported that he departed with the fuel selector set to the right tank, and that he did not switch tanks during the flight. The airplane was purchased by a flying club from a private owner. The private owner reported that he bought the airplane in 1990. The fuel placard that came with the airplane at that time did not comply with the placard found in the airplane’s operations manual. Although the blue/grey colored placard was not the same as the one found in the operations manual, it did work. The previous owner reported that when he was preparing to sell the airplane to the flying club, he decided to make a fuel selector placard that was identical to the one found in the operations manual. He reported that he made the placard and provided it to the mechanic of the flying club so that the mechanic could install it. However, the mechanic at the flying club reported that he did not install thefuel selector placard, and that the previous owner had installed it prior to the airplane being purchased. There was no record in the airplane’s maintenance logbook that indicated when, or by whom, the fuel selector placard was replaced. The pilot held a private pilot certificate with single-engine land and single-engine sea ratings. He reported that he had approximately 4,000 total flight hours with 10 hours in make and model. His last medical was on April 4, 2008, and his last biennial flight review was conducted on September 15, 2008. The pilot indicated on the National Transportation Safety Board’s accident report form that his medical certificate was his “Driver’s License (Sport Pilot only).” The Cessna 140’s maximum gross weight is 1,450 pounds, which exceeds the light-sport airplane maximum gross weight limitation of 1,320 pounds.

Aircraft

Registration
N2332V
Reported as
Cessna 140
Category
Airplane
Serial number
14568
Airframe hours
4,748
Engine
Continental C-90-12F, 90 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Stick and Rudder
Registered owner
Stick and Rudder
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 3, 2010
Departed
ENW · Kenosha, WI
Destination
BUU · Burlington, WI
Airport
BUU · Burlington Municipal Airport, runway 19, 2,410 × 130 ft, grass/turf

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
82
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine sea, Single-engine land
Medical
Sport pilot
Last flight review
September 15, 2008
Seat
Left
Flight hours
4,000 total · 10 in this make and model · 50 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 55 °F
Altimeter
30.07 inHg
Observed at
BUU

Docket · 10

The files NTSB released with the investigation on April 2, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.0 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.