CEN15LA392

NTSB accident investigation · Cessna T240 · Houston, TX · August 31, 2015

Accident · No injuriesLimited investigationFinal report
Date
August 31, 2015, 12:30 local (17:30 UTC)
Place
Houston, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N452CSCessna T240
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report March 14, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, FAA, Textron Aviation
FAA report
20150831013659I
Case key
91895

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The total loss of engine power due to fuel starvation, which resulted from the pilot’s inadequate fuel management and the flight instructor’s failure to verify the fuel level and fuel selector position in flight.

Findings · 5

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCessna T240: 1 caseAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna T240: 1 caseAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna T240: 2 casesAll aircraft: 1,391 casesProbable cause
Attention/monitoring: monitoring equip/instrumentsPersonnel issues › Psychological · Instructor/check pilotCessna T240: 1 caseAll aircraft: 142 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomeCessna T240: 1 caseAll aircraft: 933 cases

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 flight instructor reported that, before the instructional flight with the private pilot began, the fuel tanks were filled to capacity and he visually checked the quantity of the fuel in the tanks during the preflight. The flight instructor reported that, after taking off and completing the instrument flight rules training procedures, they returned to the airport and performed three full-stop landings. During the final takeoff, as the airplane was about 300 ft above ground level, the engine experienced a total loss of power. The flight instructor took control of the airplane and subsequently conducted a forced landing to a field. The airplane landed, continued moving into trees, and then came to rest upright with the right main landing gear collapsed. A postaccident examination and three engine test runs were conducted, and no anomies were noted that would have precluded normal operation. The left fuel tank was found empty, and the right fuel tank contained about 25 gallons. Although the fuel selector valve was found in the "left off" position, it is likely that the left tank was selected during the accident flight and that the engine was starved of the available fuel.

Factual narrative

On August 31, 2015, about 1230 central daylight time, a Cessna T240 airplane, N452CS, made a forced landing after departure from the West Houston Airport (IWS), Houston, Texas. The flight instructor and private pilot receiving instruction were not injured. The airplane sustained substantial damage. The airplane was registered to H2 Aviation LLC and operated by the West Houston Airport under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed. The local flight was departing at the time of the accident. According to the flight instructor, they were conducting an instructional flight which included IFR training procedures. After the IFR training was completed, they returned to IWS and performed three full stop landings. On the final takeoff from IWS, they were about 300 ft above ground level when the engine experienced a total loss of power. The flight instructor took control and conducted a forced landing to a field beyond the departure end of the runway. The airplane landed and continued into trees where it came to rest upright with the right main landing gear collapsed. The instructor secured the airplane and called for assistance using a handheld radio. He reported that before the flight began, the fuel tanks were filled to capacity, which was 102 usable gallons. During the preflight inspection, the fuel quantity was verified and there were no contaminants observed. During the flight, both pilots switched the fuel selector in order to maintain fuel balance in the left and right tanks. Before the final takeoff, the fuel quantity gauges reportedly indicated 20 gallons on the left and 21 gallons on the right. Prior to the loss of power there were no digital or aural warnings noted from the crew-alerting system (CAS). He reported that the flight only lasted 1.81 hours and the average fuel consumption was 30 gallons per hour (gph); the airplane would have consumed about 54 of the 102 available gallons, leaving 48 gallons remaining. Several law enforcement officers arrived shortly after the accident and secured the scene. It was reported that fuel was leaking from the right wing fuel vent at the accident site. A plug was placed in the vent and no other fuel leakage was reportedly observed. The amount of fuel that leaked from the right tank was unknown. The responding Federal Aviation Administration (FAA) inspector reported that after the accident, the fuel selector knob was on the left OFF position and the emergency fuel pump was ON. The investigation could not determine when the emergency fuel pump was switched to ON. According to the FAA air traffic control (ATC) report, the airplane departed about 0953, the IFR flight plan was canceled at 1151 and the accident occurred about 39 minutes later. The flight was about 2.5 hours total. Using the pilot's average fuel consumption number (30 gph), the airplane would haveconsumed about 75 of the 102 available gallons, leaving 27 gallons remaining. On September 10, 2015, three engine test runs were conducted under the supervision of the Federal Aviation Administration (FAA) inspector. The Continental Motors engine remained attached to the airframe with no significant damage noted. The accident propeller had been replaced with another propeller for the test runs. The engine oil level was noted at 5 quarts. The airplane master switch was turned ON and the left fuel quantity gauge indicated 0 gallons, the right fuel quantity gauge indicated 25 gallons. All three test runs were conducted with the remaining fuel in the right tank. During the first engine run, the engine was warmed up at idle and a magneto check was completed in accordance with the checklist. No anomalies were noted. The engine power was then increased to 25 inches of mercury (in.hg) manifold pressure (MAP) and the engine was allowed to stabilize. The throttle was then advanced to the full forward position. Due to the condition of the engine mounts, it had been predetermined that after full power was reached the throttle would be reduced back to 25 in.hg MAP. As the throttle was reduced, a propeller pitch oscillation was noted. The engine was subsequently allowed to stabilize and cool down at idle before it was shut down in accordance with the checklist. Due to the pitch oscillation, a second engine run was conducted. During this run, a magneto check was again completed and the propeller was cycled. The engine was again advanced to maximum power. No propeller oscillation was heard during the throttle reduction. The engine power was set to 25 in.hg MAP and the electric boost pump was actuated. The engine subsequently experienced a total loss of power. A third engine run was conducted. With the engine at 25 in.hg MAP, the fuel selector was moved to the LEFT tank position; within one minute the engine experienced a total loss of power. The digital instruments and CAS functioned normally during the engine runs. The engine examination did not reveal any anomalies that would have precluded normal operation. As stated pilot's operating handbook, if the emergency fuel pump switch is switched to the ON position with the engine-driven fuel pump operating normally, total loss of engine power may occur. The engine manufacturer stated that when the engine is producing high power and the emergency fuel pump is ON, the engine can generally handle the extra fuel and the engine won't lose power. If the engine is at a lower power setting and the emergency fuel pump is ON, the engine is more likely to lose power.

Aircraft

Registration
N452CS
Reported as
Cessna T240 (NO SERIES)
Category
Airplane
Serial number
T24002052
Built
2014
Airframe hours
204
Engine
Continental Motors TSIO 550C, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
West Houston Airport
Registered owner
H2 Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 12, 2015
Departed
IWS · Houston, TX
Destination
IWS · Houston, TX
Flight plan
IFR
Airport
IWS · West Houston, runway 15, 3,953 × 75 ft, asphalt
Equipment
Auto-pilot, Electronic multifunction display, Electronic primary flight display, Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
63
Injuries
None
Certificates
Foreign, Commercial, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 10, 2015
Seat
Right
Restraint
3-point
Flight hours
5,798 total · 19 in this make and model · 5,418 as pilot in command · 167 in the last 90 days · 56 in the last 30 days · 3 in the last 24 hours
Role
Pilot
Age
62
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 19, 2013
Seat
Left
Restraint
3-point
Flight hours
1,051 total · 6 in this make and model · 951 as pilot in command · 6 in the last 90 days · 3 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 73 °F
Altimeter
30.04 inHg
Observed at
KSGR, 11 nm away

Docket · 10

The files NTSB released with the investigation on January 29, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.5 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.