# NTSB CEN16LA112: Cirrus Design SR22, N2711M, Laguna Pueblo, NM, February 29, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: February 29, 2016, 13:25 local (20:25 UTC) - Place: Laguna Pueblo, NM - Coordinates: 35.036109, -107.367225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0361&lon=-107.3672&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed, report November 28, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Cirrus Aircraft, FAA FSDO, Continental Motors - NTSB case key (mKey): 92786 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA112 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92786/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92786 - Page: https://openairdocs.org/ntsb/CEN16LA112 ## Probable cause A total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's inadequate oversight of the airplane's refueling and her subsequent failure to verify and monitor the fuel quantity before and during the flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft](https://openairdocs.org/ntsb-findings/01010000): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Cirrus Design SR22, 2 cases](https://openairdocs.org/ntsb-findings/01010000/cases.md?model=2130001), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/01010000/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cirrus Design SR22, 2 cases](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=2130001), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/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 servicing event](https://openairdocs.org/ntsb-events/020); cases with it: [Cirrus Design SR22, 2 cases](https://openairdocs.org/ntsb-events/020/sequence.md?model=2130001), [All aircraft, 70 cases](https://openairdocs.org/ntsb-events/020/sequence.md) - [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=2130001), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cirrus Design SR22, 50 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2130001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [After landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cirrus Design SR22, 3 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2130001), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The private pilot and three passengers were on a cross-country flight and stopped en route to refuel. The pilot reported that services were limited and only self-serve fuel pumps were available. The pilot intended to add about 25 gallons of fuel to each wing tank and asked one of the passengers for assistance in reading the fuel meter and reporting the quantity as she added fuel to the airplane. The passenger stated that the sun was shining on the meter, which made it hard to read. She yelled for the pilot to stop refueling when she read 25 gallons on the meter but stated to the pilot that the amount of time had not seemed sufficient to dispense 25 gallons. The pilot replied that the pumps were not like automotive pumps. The pilot then added fuel to the other wing, and the passenger called out when the meter reached 52 gallons. Upon completion of fueling, the pilot was unable to get a fuel receipt from the pump. The pilot reported that she did her normal pre-takeoff checks and then departed. About an hour after departure at an altitude of 13,000 ft, the engine experienced a total loss of power, and the pilot deployed the airplane's parachute system. The airplane descended under canopy and impacted terrain, where it came to rest upright. Before the occupants egressed, a gust of wind caught the parachute and dragged the airplane into trees, flipping the airplane upside down. A visual inspection of the airplane at the accident site did not reveal any discrepancies with the engine. A credit card receipt for the fuel transaction indicated that the pilot purchased 5.23 gallons of fuel. Because the airplane was only filled with 5.23 gallons instead of the 52 gallons the pilot expected, the airplane did not have adequate fuel onboard to complete the flight. The before takeoff checklist includes the step "fuel quantity – confirm." The airplane's operating handbook states the airplane is equipped with a fuel gauge and a warning light that will illuminate if the fuel quantity drops below 14 gallons in each fuel tank. The investigation could not determine whether the pilot monitored the fuel system or observed a fuel warning light, but the circumstances are consistent with the pilot not verifying the fuel quantity prior to the flight, or monitoring the fuel quantity in flight, which resulted in a total loss of engine power due to fuel exhaustion. ## Factual narrative On February 29, 2016, about 1325 mountain standard time (MST), a Cirrus SR22 airplane, N2711M, descended under the canopy of the Cirrus Airframe Parachute System (CAPS) and impacted terrain near Laguna Pueblo, New Mexico. The private rated pilot and three passengers received minor injuries. The airplane was substantially damaged during the accident. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time. The flight departed the Seward Municipal Airport (KSWT), Seward, Nebraska, about 0820 MST, and was en route to the Phoenix Goodyear Airport (KGYR) Goodyear, Arizona; with an en route stop at the Las Vegas Municipal Airport (KLVS), Las Vegas, New Mexico. The pilot reported that they landed at KLVS, with about 12 gallons of fuel left onboard the airplane. She reported that there were limited services at the airport and only self-serve fuel pumps. She added that one of the passengers helped with the refueling, and they only wanted to take on about 50 gallons of fuel. One of the passengers reported that the pilot wanted to put 25 gallons in each tank, and she would read the meter. As the meter approached 25 gallons, she yelled to the pilot to stop. She added that the sun was on the fuel meter and it was hard to read. She reported that she didn't think enough time had elapsed to pump 25 gallons, but the pilot stated that the pumps are not like automotive pumps. The pilot moved over to the other fuel tank, and the passenger yelled "stop", at 52 gallons. The passenger also thought that one of the other passengers also read 52 gallons to the pilot, so that it was okay. The pilot added that she was unable to get a printed sales receipt. The pilot then reported that she did her normal take-off checks, and she and passengers departed for KGYR. About an hour after departure, and while cruising at 13,000 ft, the engine slowly lost power. The pilot informed the air traffic controller and shortly afterwards the engine stopped. The pilot looked for a plateau area and then deployed the CAPS. The airplane descended and landed near some trees; however, wind caught the parachute and pulled the airplane into the trees; flipping the airplane inverted. The responding Federal Aviation Administration (FAA) inspector reported the airplane had come to rest inverted. The wings had sustained only minor damage; however, the fuselage was buckled. Only the lower part of the engine was accessible and a visual examination of the engine did not reveal any obvious discrepancies. The inspector obtained a credit card receipt from the fixed based operator (FBO) at KLVS. The receipt indicated that the pilot had purchased 5.23 gallons of fuel. A review of radar data from FlightAware, revealed that the airplane was at an altitude above 12,500 ft for about 44 minutes, before the airplane descended below 12,500 ft. as a result of the lossof engine power. According to the airplane manufacturer's representative, the airplane was not equipped with a factory installed oxygen system. A review of the airplane's Pilot Operating Handbook and Airplane Flight Manual (POH), section 7, stated that the airplane is equipped with a fuel quantity indicator on the console, forward of the fuel selector valve; pointers indicate the quantity of fuel in the left and right fuel tanks. Additionally, when the quantity drops below 14 gallons in each tank, a FUEL caution light will illuminate on the annunciator panel. The Before Takeoff checklist in Section 4, Normal Procedures of the POH, advises Fuel Quantity – Confirm, and Fuel Selector – Fullest tank, before takeoff. Title 14 Part 91.211 Supplemental oxygen states in part: (a) General. No person may operate a civil aircraft of U.S. registry – (1) At cabin pressure altitudes above 12,500 feet (MSL) up to and including 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration; ## Aircraft - Registration: [N2711M](https://openairdocs.org/deregistered/N2711M-2016-08-31), registration cancelled 2016-08-31, S/N 2103, built 2006 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR22 (NO SERIES) - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2103 - Year built: 2006 - Airframe hours: 930.3 - Engines: CONT MOTOR IO-550-N reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 9, 2016 - Departed: KLVS, Las Vegas, NM - Destination: KGYR, Phoenix, AZ - Flight plan: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 20, 2015; seat: left; restraint: 3-point; flight hours: 493 total, 273 in this make and model, 445 as pilot in command, 23 in the last 90 days, 7 in the last 30 days ## Weather - Conditions: Visual (VMC), Day ## 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 20160229001759A](https://openairdocs.org/incident/20160229001759A), Feb 29, 2016: Cirrus Design Corp SR22, Laguna, NM, Substantial damage. On February 29, 2016, at 13:25 MDT, N2711M, a Cirrus SR-22, single engine aircraft,[privacy data omitted], was on a cross country flight from las vegas, NM… ## Docket (7 files) The files NTSB released with the investigation on September 15, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92786. 6.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444417&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Statements (item 2, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444418&FileExtension=.PDF&FileName=Statements-Master.PDF - Fuel Receipt (item 3, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444419&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Flight Track (item 4, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444420&FileExtension=.PDF&FileName=Flight%20Track-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444421&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - POH extract (item 6, .PDF, 996 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444422&FileExtension=.PDF&FileName=POH%20extract-Master.PDF - Photos (Courtesy of FAA) (item 7, .PDF, 2 photos, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40444423&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20FAA)-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.