# NTSB CEN15LA303: Aviat A-1C-180, N354BM, Cincinnati, OH, July 5, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 5, 2015, 17:40 local (21:40 UTC) - Place: Cincinnati, OH - Coordinates: 39.031944, -84.272499 - Nearby events: https://openairdocs.org/map.md?lat=39.0319&lon=-84.2725&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 91539 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA303 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91539/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91539 - Page: https://openairdocs.org/ntsb/CEN15LA303 ## Probable cause The pilot’s inadequate preflight inspection and fuel planning, which resulted in a loss of engine power due to fuel exhaustion. ## 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 management (probable cause); cases with it: [Aviat A-1C-200, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2210411), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1C-200, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2210411), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Aviat A-1C-200, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2210411), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Aviat A-1C-200, 2 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2210411), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Aviat A-1C-200, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=2210411), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Aviat A-1C-200, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=2210411), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Maneuvering: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Aviat A-1C-200, 5 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2210411), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Aviat A-1C-200, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2210411), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aviat A-1C-200, 6 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2210411), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was conducting a personal flight. After practicing stop-and-go landings, he departed, turned the airplane to the left, climbed to 1,800 ft mean sea level, reduced power to 40% to 45%, and activated the lean-of-peak assist feature on the engine instrumentation. As he leaned the mixture and watched for the first cylinder to reach peak exhaust gas temperature, a fuel flow sensor malfunction indicator light appeared on the engine instrumentation. The pilot subsequently enriched the mixture, but the sensor malfunction indication continued, and the engine lost power. After attempting to restart the engine, the pilot conducted a forced landing to a golf course. During the landing roll, the right wing tip and right elevator struck a tree, which resulted in structural damage. Examination of the engine, airframe, and fuel system did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuel tanks were not damaged, and there was no evidence of fuel leakage at the accident site. However, only about 2 gallons of fuel were found remaining in the airplane. The 2 gallons were unusable. The engine instrumentation system was powered up, and the "fuel remaining" indicated 17.6 gallons. Per the system pilot's guide, the pilot is required to perform a "first time set up" that includes calibrating the fuel flow transducer. This calibration has a direct input into how the system computes the airplane's remaining fuel. This task was never accomplished, which provided the pilot with an erroneous "fuel remaining" indication. The pilot reported that he did not physically check the wing tank fuel quantity tubes that were in the cockpit or "dip" the fuel tanks to verify fuel quantity. Thus, it is likely that the engine lost power due to fuel exhaustion. ## Factual narrative ***This report was modified on February 20, 2020. Please see the docket for this accident to view the original report.*** On July 5, 2015, about 1740 eastern daylight time, an Aviat Aircraft Inc., A1C-180 Husky airplane, N354BM, was substantially damaged during a forced landing following a loss of engine power near Cincinnati, Ohio. The private pilot was not injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and a flight plan was not filed. The flight originated from the Clermont County Airport (I69), Batavia, Ohio, at 1730, and its destination was the Cincinnati Municipal Airport (LUK), Cincinnati, Ohio. The pilot reported that after practicing stop and go short field landings at I69, the pilot departed for LUK. After departure, the pilot turned the airplane to the left, climbed to 1,800 ft mean sea level (about 950 ft above ground level), reduced power to 40% to 45% for slow flight, and activated the Lean-of-Peak assist feature of the JPI EDM930 Engine Instrument. As he leaned the mixture and watched for the first cylinder to reach peak exhaust gas temperature, a Fuel Flow Sensor malfunction indicator light appeared on the EDM930. The pilot subsequently enriched the mixture, but the sensor malfunction indication continued, and the engine lost power. After attempting engine restart procedures and applying carburetor heat, the engine did not respond, so the pilot set up for a forced landing to a golf course. During the landing roll, the right wing tip and right elevator struck a tree resulting in structural damage. The airplane came to rest upright and the pilot evacuated uninjured. According to a Federal Aviation Administration inspector, examination of the engine and airframe at the accident site did not reveal any mechanical or fuel delivery problems. All engine controls were functioning properly and oil quantity was normal. Additionally, the fuel tanks were not damaged and there was no indication of fuel leaking at the accident site. The aircraft was equipped with two 26-gallon (25 usable) fuel tanks, one in each wing. According to the pilot, the aircraft burned about 10 gallons per hour and the last amount of fuel put on the aircraft was 13.4 gallons, the day before the accident. The aircraft accumulated about 3.1 hours of flight time since the refueling. At the accident site, the JPI EDM930 system was powered up and the "fuel remaining" indicated 17.6 gallons. Per the EDM 930 pilot's guide, the pilot is required to perform a "first time set up" which includes calibrating the fuel flow transducer. This calibration has a direct input into how the EDM computes the aircraft's remaining fuel. This task was never accomplished, which provided the pilot with an erroneous "fuel remaining" indication. After the fuel was drained from the left wing, approximately 2 gallons were recovered from the tanks.The pilot reported that he did not physically check the wing tank fuel quantity tubes that were in the cockpit, or "dip" the fuel tanks to verify fuel quantity. Also, the pilot stated that he was "preoccupied" with trying to obtain the "rich to peak" fuel burn on the EDM930 while the engine began to lose power, and he may not have noticed the engine was losing power until it actually quit. ## Aircraft - Registration: [N354BM](https://openairdocs.org/aircraft/N354BM), registered now, S/N 3258, built 2015 (OpenAirDocs) - Reported make and model: AVIAT AIRCRAFT INC A-1C-180 (UNDESIGNAT) - Registry model: [Aviat A-1C-200](https://openairdocs.org/model/aviat-a-1c-200) (registry code 2210411) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1D6](https://openairdocs.org/engine/lycoming-io-360-a1d6) (registry code 41822, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3132 - Year built: 2011 - Airframe hours: 561 - Engines: LYCOMING O-360-A1P 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 6, 2014 - Departed: I69, Clermont, OH - Destination: LUK, Cincinnati, OH - Equipment: Electronic primary flight display, Onboard weather, Stall warning system, ADS-B, Electronic flight bag or handheld device, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review July 13, 2013; seat: front; restraint: 5-point; flight hours: 1,015.5 total, 517.5 in this make and model, 907.5 as pilot in command, 18.6 in the last 90 days, 7.5 in the last 30 days, 3.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft overcast - Temperature: 75 °F, dew point 64 °F - Altimeter: 30.07 inHg - Observed at: I69, 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 20150705009509A](https://openairdocs.org/incident/20150705009509A), Jul 5, 2015: Aviat Aircraft Inc A-1C-180, Cincinnati, OH, Substantial damage. The aircraft took off from I69 enroute to luk. After reaching an altitude of 1,800 feet, the engine began to lose power, and eventually quit. The pilot… ## Docket (3 files) The files NTSB released with the investigation on December 29, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91539. 2.1 MB in all. - NTSB Form 6120 Pilot Operator Report (item 1, .PDF, 651 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479495&FileExtension=.PDF&FileName=NTSB%20Form%206120%20Pilot%20Operator%20Report-Master.PDF - Memorandum for the Record - FAA Inspector Statement (item 2, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479496&FileExtension=.PDF&FileName=Memorandum%20for%20the%20Record%20-%20FAA%20Inspector%20Statement-Master.PDF - Photo Array (item 3, .PDF, 2 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479497&FileExtension=.PDF&FileName=Photo%20Array-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.