# NTSB CEN11LA448: Cessna 140, N2332V, Burlington, WI, June 29, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 29, 2011, 14:30 local (19:30 UTC) - Place: Burlington, WI - Coordinates: 42.690555, -88.304443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.6906&lon=-88.3044&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report May 3, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Milwaukee FSDO - NTSB case key (mKey): 80992 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA448 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/80992/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=80992 - Page: https://openairdocs.org/ntsb/CEN11LA448 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 140, 3 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=2071602), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Other (probable cause); cases with it: [Cessna 140, 1 case](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=2071602), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot; cases with it: [Cessna 140, 3 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2071602), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 140, 9 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2071602), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: 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) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 140, 9 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2071602), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## 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](https://openairdocs.org/aircraft/N2332V), registered now, S/N 14568, built 1948 (OpenAirDocs) - Reported make and model: CESSNA 140 - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 14568 - Airframe hours: 4748 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 82; injuries: serious; 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 ## 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 20110629013069A](https://openairdocs.org/incident/20110629013069A), Jun 29, 2011: Cessna 140, Burlington, WI, Substantial damage. On June 29, 2011 at 1615 CDT, a Cessna 140, N2332V, registered to stick & rudder of lake bluff, Illinois experienced an intermediate power loss on takeoff from… ## Docket (10 files) The files NTSB released with the investigation on April 2, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=80992. 13.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 589 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363911&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Interview - Heinrich Knauz (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364021&FileExtension=.PDF&FileName=Witness%20Interview%20-%20Heinrich%20Knauz-Master.PDF - Witness Interview - Louis Bevaqua (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364018&FileExtension=.PDF&FileName=Witness%20Interview%20-%20Louis%20Bevaqua-Master.PDF - FAA Record of Phone Conversation (item 4, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363913&FileExtension=.PDF&FileName=FAA%20Record%20of%20Phone%20Conversation-Redacted.PDF - Cessna 140 Fuel System Information (item 5, .PDF, 717 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363969&FileExtension=.PDF&FileName=Cessna%20140%20Fuel%20System%20Information-Master.PDF - Diagram of Fuel Selector Valve Settings (item 6, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363914&FileExtension=.PDF&FileName=Diagram%20of%20Fuel%20Selector%20Valve%20Settings-Master.PDF - Photo 1: Photo of fuel selector placards (item 7, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364511&FileExtension=.PDF&FileName=Photo%201%3A%20Photo%20of%20fuel%20selector%20placards-Master.PDF - Photo 2: Photo of fuel tank selector handle on the right tank (item 8, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364512&FileExtension=.PDF&FileName=Photo%202%3A%20Photo%20of%20fuel%20tank%20selector%20handle%20on%20the%20right%20tank-Master.PDF - Photo 3: Photo of Left Fuel Tank Indicator (item 9, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364028&FileExtension=.PDF&FileName=Photo%203%3A%20Photo%20of%20Left%20Fuel%20Tank%20Indicator-Master.PDF - Photo 4: Photo of Right Fuel Tank Indicator (item 10, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364029&FileExtension=.PDF&FileName=Photo%204%3A%20Photo%20of%20Right%20Fuel%20Tank%20Indicator-Master.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.