# NTSB CEN16LA314: Aero Commander S2R, N5599X, Valley City, ND, August 5, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 5, 2016, 14:50 local (19:50 UTC) - Place: Valley City, ND - Coordinates: 46.891944, -98.193611 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.8919&lon=-98.1936&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 October 17, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 93795 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA314 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93795/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93795 - Page: https://openairdocs.org/ntsb/CEN16LA314 ## 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 level (probable cause); cases with it: [Aero Commander S2R, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=0143022), [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: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=0143022), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=0143022), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Terrain: wet/muddy terrain](https://openairdocs.org/ntsb-findings/03021035): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-findings/03021035/cases.md?model=0143022), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/03021035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=0143022), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) ## Analysis The commercial pilot reported that, before departure for the agricultural application flight, the airplane was loaded with 300 gallons of water and spray solution and an undetermined amount of fuel was added to the left fuel tank. The pilot did not visually check the fuel tanks during the preflight inspection. After departure, he flew 5 miles south of the private strip and proceeded to spray a 130-acre field. When the spray solution was depleted, the pilot flew back toward the private strip and noticed that the fuel quantity indicators showed 1/4 full in the right tank and 1/8 full in the left tank. The pilot stated that, about 1.5 miles southeast of the private strip and about 400 ft above ground level, the engine "sputtered" and experienced a loss of power. He made a forced landing to a field, and the airplane entered a swampy area and then nosed over. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. During a postaccident examination of the airplane, no fuel was found in the fuel lines to the engine or in the fuel tanks. Based on the evidence, it is likely that the airplane was not fueled with sufficient fuel to complete the flight and that this, combined with the pilot's failure to check the fuel quantity before departure and ensure that sufficient fuel was onboard for the flight, resulted in fuel exhaustion. ## Factual narrative On August 5, 2016, about 1450 central daylight time, an Aero Commander S2R airplane, N5599X, made a forced landing to a swampy field following a total loss of engine power. The commercial pilot was not injured and the airplane sustained substantial damage. The airplane was registered to and operated by Lakeview Aviation Inc., under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight departed from a private grass strip at an unknown time. The pilot reported that prior to the departure the airplane was loaded with 300 gallons of water and spray solution and an undetermined amount of fuel. After departure, the pilot flew 5 miles south of the private strip and proceeded to spray a 130 acre field. When the spray solution was depleted, the pilot flew back toward the private strip and noticed the fuel quantity indicators showed 1/4 remaining in the right tank and 1/8 remaining in the left tank. About 1.5 miles southeast of the private strip and about 400 ft above ground level the engine "sputtered" and experienced a loss of power. He made a forced landing to a field and the airplane nosed over when it entered a swampy area. The pilot noted that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. According to the pilot's statement, the person who fueled the airplane stated that before the fueling process began, the fuel indicators were reading ½ full in the right tank and ¼ full in the left tank. The fueler only added fuel to the left tank, but he could not remember the exact amount added and assumed the fuel system would equalize the amount both tanks. The pilot stated the capacity of each fuel tank is 53 gallons and if the fueler only added fuel to the left tank then he couldn't have added more than 40 gallons. The pilot did not visually check the fuel tanks before departure for the flight that reportedly lasted over an hour. The responding Federal Aviation Administration (FAA) inspector examined the engine and found no presence of fuel in the fuel lines to the engine. The fuel filler caps were removed and no fuel was present. The propeller blades did not sustain any leading edge damage or chordwise scratches. The inspector noted that the airplane sustained substantial damage to the left wing and fuselage. ## Aircraft - Registration: [N5599X](https://openairdocs.org/aircraft/N5599X), registered now, S/N 1699R, built 1972 (OpenAirDocs) - Reported make and model: AERO COMMANDER S2R (-) - Registry model: [Aero Commander S2R](https://openairdocs.org/model/aero-commander-s2r) (registry code 0143022) (OpenAirDocs) - Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1699R - Year built: 1972 - Airframe hours: 11395 - Engines: Pratt & Whitney R1340-59 600 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Lakeview Aviation Inc - Registered owner: Lakeview Aviation Inc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: 100 hour, July 25, 2016 - Departed: Sanborn, ND - Destination: Sanborn, ND - Airport: -, Private Strip - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review June 25, 2016; seat: single; restraint: 3-point; flight hours: 2,110 total, 575 in this make and model, 2,043 as pilot in command, 280 in the last 90 days, 73 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 11 knots, gusting 17 - Visibility: 10 statute miles - Temperature: 75 °F, dew point 54 °F - Altimeter: 30.10 inHg - Observed at: KBAC, 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 20160805013309A](https://openairdocs.org/incident/20160805013309A), Aug 5, 2016: Aero Commander S2R, Sanborn, ND, Substantial damage. Travelled to rural Sanborn, ND, with FAA inspector kelly bosch. Met with [privacy data omitted] at approx. 8:30AM August 9, 2016. [privacy data omitted]… ## Docket (5 files) The files NTSB released with the investigation on August 21, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93795. 5.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455553&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Additional Pilot Statements (item 2, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455554&FileExtension=.PDF&FileName=Additional%20Pilot%20Statements-Master.PDF - Maps or Charts of Accident Area from the Pilot (item 3, .PDF, 861 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455555&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area%20from%20the%20Pilot-Master.PDF - Photos (item 4, .PDF, 2 photos, 376 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455556&FileExtension=.PDF&FileName=Photos-Master.PDF - FAA Inspector's Statement Excerpt (item 5, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455557&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement%20Excerpt-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.