# NTSB CEN11LA651: North American AT-6, N217RK, Nunica, MI, September 17, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 17, 2011, 18:07 local (22:07 UTC) - Place: Nunica, MI - Coordinates: 43.097221, -86.094444 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.0972&lon=-86.0944&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report February 27, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 81838 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA651 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81838/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81838 - Page: https://openairdocs.org/ntsb/CEN11LA651 ## Probable cause The loss of engine power due to fuel starvation during climbout for undetermined reasons, because postaccident examination of the fuel system did not reveal any discrepancies that would have precluded normal engine operation. Contributing to the accident was the pilot not visually checking the fuel level prior to departure. ## 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 · Fluid level (probable cause); cases with it: [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: [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis According to the pilot, the airplane had been refueled to its full capacity prior to the flight to the accident airport. The pilot indicated that the "flight to the accident airport required 50 minutes, which would have burned, with start-up, taxi, and flight time, 29 gallons.” The pilot then departed the accident airport and stated that he applied full takeoff power. On climbout, the low fuel pressure light illuminated just before gear retraction, the fuel pressure then dropped to zero, and the engine abruptly lost power. A video taken at the airport where the accident occurred revealed that the airplane lost power during takeoff, impacted a tree on the left side of the departure runway, and subsequently impacted terrain. The airplane’s engine monitor data revealed no recorded engine anomalies and fuel flow monitor data indicated 32.5 gallons of fuel used up to the time of the accident, and 77.1 gallons remaining. The pilot stated that he verified the fuel prior to departure at the accident airport by visual reference of fuel gauges and airplane fuel flow meter. Examination of the wreckage revealed that the right fuel tank was full. No anomalies were detected during the examination of the engine-driven fuel pump, gascolator, and the wobble pump. The fuel selector was found selected to the reserve position, which feeds from the reserve fuel retained within the standpipe and any additional left tank fuel above that retained reserve amount. The left main and reserve standpipes and screens were installed correctly and were free of obstructions. The left fuel tank contained about four gallons of fuel when it was defueled. The pilot did not visually check the level of the fuel tank’s contents prior to departure; had he done so, he would have recognized that the left tank’s fuel level was below what was expected. Fuel usage figures provided by both the pilot and the engine monitor data indicated there should have been over 20 gallons of fuel remaining in the left tank at the time of the accident. The reason for the discrepancy between the expected and actual fuel amounts could not be determined. ## Factual narrative On September 17, 2011, about 1807 eastern daylight time, a North American AT-6, N217RK, impacted a tree and terrain after a loss of engine power during takeoff from runway 8 (3,600 feet by 100 feet, dry turf) at the Hat Field Airport (5N7), near Nunica, Michigan. The commercial pilot received serious injuries. The airplane sustained substantial firewall, fuselage, and wing damage. The airplane was registered to Tailwinds Inc. and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual flight rules (VFR) conditions prevailed for the flight, which was not operated on a VFR flight rules flight plan. The flight was originating at the time of the accident and was destined for the Mason Jewett Field Airport, near Mason, Michigan. Review of a video taken at 5N7 revealed that the airplane was the fourth airplane in a flight of multiple airplanes to depart the airport. The video revealed that the accident airplane lost power during its takeoff, impacted a tree on the left side of the departure runway, and subsequently impacted terrain. The pilot’s accident report indicated that the airplane was "ground checked" and each aircraft took off as briefed in a single-ship sequence leaving nine seconds between each departure, which allowed any departing aircraft time to abort its takeoff roll. The pilot indicated that he applied full takeoff power. As the airplane passed about two-thirds of the runway’s length, the airplane had a positive rate of climb. The low fuel pressure light illuminated just before gear retraction, the fuel pressure dropped to zero, and the engine abruptly quit. The pilot lowered the airplane’s nose and impacted a tree during the forced descent. The impact turned the plane, causing it to hit the ground at a vertical angle tearing the engine and propeller from the plane. According to the pilot, the airplane had been refueled prior to flying to the accident airport to its full capacity of 110 gallons, of which, 106 gallons is usable. The airplane had two 55-gallon fuel tanks, one in each wing. The fuel selector has four positions; right tank on, left tank on, left tank reserve, and off. The pilot indicated that the “flight to the accident airport required 50 minutes, which would have burned, with start-up, taxi and flight time, 29 gallons. This was verified prior to departure at the accident airport by visual reference of fuel gauges and aircraft fuel flow meter.” However, the pilot did not visually check the level of the fuel tank’s contents. A Federal Aviation Administration inspector examined the wreckage. The inspector indicated he observed that the right fuel tank was full. The gascolator contained a cup of fuel and the screen was clean. The engine driven fuel pump was removed from the engine and the pump produced suction when rotated by hand. The fuel selector was found set to the reserve position. The wobble pump was able to pump fluid and produced pressure at its outputport. The left main and reserve standpipes and screens were installed correctly and were free of obstructions. The left fuel tank contained about four gallons of fuel. The airplane’s engine monitor and fuel flow monitor were shipped to the National Transportation Safety Board Recorder Laboratory for downloading. The airplane was equipped with a J. P. Instruments EDM-700 panel mounted engine monitor gauge. The gauge monitored and recorded exhaust gas temperature, cylinder head temperature, and battery voltage. The gauge was in good condition and its data was extracted normally from the device. The download contained approximately 11 hours of data over 18 power cycles. The data from the accident flight and the flight prior to it were plotted. The plot of the flight prior to the accident, on September 17, 2011, covered a time period from 14:24:00 to 15:28:12. The accident flight plot covered a time period from 17:58:46 to 18:07:10 and no recorded engine anomalies were detected in the plot. The airplane was also equipped with a Shadin Avionics Miniflo-L fuel flow monitor gauge, which was a digital fuel management system, designed to provide fuel management information under real time flight conditions to the pilot. The unit does not interface with an airplane’s fuel quantity indicating system. The unit required the pilot to enter the initial fuel on board the aircraft. All calculations and data provided by the unit were based on fuel flow. The fuel flow indicator unit was received in good condition and it reported a value of “good” when it self-tested as power was applied. Its data indicated 32.5 gallons of fuel used and 77.1 gallons remaining. The pilot’s safety recommendation, in part, stated: I do know that wearing my seat belt with shoulder harness and aviation flight helmet likely saved my life. When flying these types of planes, please always wear your safety gear. You can't choose when an accident may occur, but you can be prepared when it does. ## Aircraft - Registration: N217RK (not matched to a registry record) - Reported make and model: NORTH AMERICAN AT-6 - Category: Airplane - Serial number: 43942 - Airframe hours: 10073 - Engines: Pratt & Whitney R-1340-AN1 600 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 15, 2011 - Departed: 5N7, Nunica, MI - Destination: TEW, Mason, MI - Airport: 5N7, Hat Field Airport, runway 08, 3,600 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review August 7, 2010; seat: front; flight hours: 4,496 total, 1,209 in this make and model, 4,397 as pilot in command, 96 in the last 90 days, 27 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 43 °F - Altimeter: 30.29 inHg - Observed at: MKG, 8 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 20110917021239A](https://openairdocs.org/incident/20110917021239A), Sep 17, 2011: North American AT-6, Nunica, MI, Substantial damage. Aircraft departed runway 08. Immediately after departure, the engine lost power. Pilot stated the low fuel pressure light was illuminated. The aircraft flew… ## Docket (10 files) The files NTSB released with the investigation on January 7, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81838. 20.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382394&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Miscellaneous - Pilot Statement in addition to the 6120.1 form (item 2, .PDF, 672 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382414&FileExtension=.PDF&FileName=Miscellaneous%20-%20Pilot%20Statement%20in%20addition%20to%20the%206120.1%20form-Redacted.PDF - Miscellaneous - Communication Summary -- FAA Inspector (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383932&FileExtension=.PDF&FileName=Miscellaneous%20-%20Communication%20Summary%20--%20FAA%20Inspector-Master.PDF - Miscellaneous - North American Trainer Association article from April 1988 sent by the pilot (item 4, .PDF, 394 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382416&FileExtension=.PDF&FileName=Miscellaneous%20-%20North%20American%20Trainer%20Association%20article%20from%20April%201988%20sent%20by%20the%20pilot-Master.PDF - Miscellaneous - Video Of The Takeoff (item 5, MOV, 17.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40365607&FileExtension=mov&FileName=Miscellaneous%20-%20Video%20Of%20The%20Takeoff-Master - Retention / Release of Wreckage Form and Evidence Control Form (item 6, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366393&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form%20and%20Evidence%20Control%20Form-Redacted.PDF - Evidence Control Form - Shadin Fuel Flow Instrument (item 7, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40382391&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20-%20Shadin%20Fuel%20Flow%20Instrument-Redacted.PDF - Engine Data Monitor (EDM) - Specialist's Factual Report (item 8, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366543&FileExtension=.PDF&FileName=Engine%20Data%20Monitor%20(EDM)%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Engine Data Monitor (EDM) - Attachment 1 - Tabular Data (CSV Format) (item 9, .CSV, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366544&FileExtension=.csv&FileName=Engine%20Data%20Monitor%20(EDM)%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV%20Format)-Master.csv - Engine Instrument 17 - Specialist's Factual Report (Fuel Flow Indicator) (item 10, .PDF, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381326&FileExtension=.PDF&FileName=Engine%20Instrument%2017%20-%20Specialist%27s%20Factual%20Report%20(Fuel%20Flow%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.