# NTSB CEN17LA356: Cessna R182, N1835R, Worland, WY, September 12, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 12, 2017, 16:30 local (22:30 UTC) - Place: Worland, WY - Coordinates: 43.962776, -107.950553 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.9628&lon=-107.9506&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 5, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards - NTSB case key (mKey): 96026 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA356 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96026/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96026 - Page: https://openairdocs.org/ntsb/CEN17LA356 ## Probable cause The pilot's decision to operate an airplane with unreliable fuel gauges and the worn fuel cap seal that allowed fuel to siphon from the left wing fuel tank, which ultimately resulted in a total loss of engine power due to fuel exhaustion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna R182, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072734), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna R182, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072734), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fuel system: fuel quantity indicator](https://openairdocs.org/ntsb-findings/01022841): Aircraft › Aircraft systems · Inoperative (probable cause); cases with it: [Cessna R182, 1 case](https://openairdocs.org/ntsb-findings/01022841/cases.md?model=2072734), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01022841/cases.md) - [Fuel system: fuel storage](https://openairdocs.org/ntsb-findings/01022810): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Cessna R182, 1 case](https://openairdocs.org/ntsb-findings/01022810/cases.md?model=2072734), [All aircraft, 60 cases](https://openairdocs.org/ntsb-findings/01022810/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna R182, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072734), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna R182, 3 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2072734), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna R182, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072734), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The commercial pilot reported that, about halfway through the planned pipeline surveillance flight, the engine experienced a total loss of power and he performed a forced landing to a dirt road. A postaccident examination revealed that both fuel tanks appeared to be empty; the left wing fuel tank cap seal appeared to be worn, and the left wing exhibited fuel staining aft of the fuel cap, consistent with fuel siphoning from the tank in flight. The airplane was fueled the preceding night, and the pilot had assumed the fuel tanks were full upon departing on the first flight of the day. The airplane was flown 2.7 hours on the morning of the accident before it was refueled. The pilot did not recall visually confirming the fuel level following that refueling. An additional 4.1 hours of flight time elapsed from the time the airplane was refueled until the accident. According to the pilot, the airplane's fuel gauges were unreliable. To compensate, he had adopted the practice of completely filling the fuel tanks during each refueling, tracking the intervening flight time, and calculating fuel burn based on the airplane's average fuel consumption rate. Two days before the accident, an individual refueling the airplane informed him that the left fuel cap seal was torn. A new fuel cap seal had not yet been installed. Although the amount of fuel lost through the cap could not be quantified, the unreliable fuel gauges did not allow the pilot to monitor either the normal fuel consumption nor alert him to the potentially abnormal rate of consumption due to the siphoning fuel. In addition, the pilot failed to verify the amount of fuel onboard before departure, which further rendered his method of tracking fuel consumption inaccurate. ## Factual narrative On September 12, 2017, about 1630 mountain daylight time, a Cessna R182 airplane, N1835R, was substantially damaged during a forced landing following a loss of engine power near Worland, Wyoming. The pilot was not injured. The airplane was registered to and operated by Meridian Flying Service as a 14 Code of Federal Regulations Part 91 aerial observation flight. Visual meteorological conditions prevailed. The flight was not operated on a flight plan. The flight originated from the Sloulin Field International Airport (ISN), Williston, North Dakota and was destined for the Worland Municipal Airport (WRL), Worland, Wyoming.On the day of the accident, the pilot intended to continue a pipeline surveillance patrol that began the previous day. The initial flight of the day was from the Sidney-Richland Regional Airport (SDY) to ISN to pick-up a passenger. After departing from ISN, two sections of the pipeline system near ISN were observed and then the flight proceeded to the Stanley Municipal Airport (08D) to obtain fuel. After fueling, the pilot departed for ISN to drop off the passenger. After departing ISN again, he planned to fly directly to the next pipeline system near WRL. However, smoke from forest fires prevented a direct flight as planned. He deviated as required, ultimately arriving at the start of the pipeline patrol route. About 1620, approximately halfway through the patrol, the engine lost power. The pilot turned toward a road in the area in preparation for a forced landing. The engine regained power momentarily, but it quit again. He turned toward a highway and during that time the engine regained power and quit three or four more times. He recalled thinking that plenty of fuel should have been onboard as he attempted to determine the source of the problem. When he was unsuccessful restoring engine power, he setup for a forced landing to a dirt road. To clear a set of power lines, he "stretched" the glide causing the airspeed to decay and the airplane began to stall. He ultimately executed a forced landing to the dirt road with the landing gear retracted. The pilot noted that the airplane fuel gauges were unreliable. Attempts to repair the gauges in the months before the accident were not successful and replacement of the entire gauge cluster was required; however, the airplane owner reportedly did not have the financial resources to complete the work. To compensate, the pilot had adopted the practice of completely filling the fuel tanks during each refueling and tracking the intervening flight time. Two days before the accident an individual refueling the airplane informed the pilot that the left fuel cap seal was torn. The pilot was in the process of obtaining a new fuel cap seal but had not been able to have one installed. The pilot stated that the airplane was fueled at SDY the preceding night. He assumed that the fuel tanks were full upon his departure from SDY the morning of the accident. The airplane fuel capacity was 75 gallonsuseable. When the airplane was subsequently fueled at 08D, the self-service fuel pump required prior input of the desired amount of fuel. As a result, he decided to dispense 40 gallons based on the anticipated burn that morning. However, he did not recall visually confirming the fuel level. The pilot reported that the flight time from SDY until refueling at 08D was 2.7 hours. An additional, 4.1 hours elapsed from the time the airplane was refueled at 08D until the accident. A Federal Aviation Administration inspector reported that the airplane sustained firewall and fuselage damage. The upper surface of the left wing exhibited fuel staining aft of the fuel cap. The upper surface of the right wing was clean. The left and right fuel tanks appeared to be empty; no fuel was present when the sump drains were opened. The left fuel cap seal was worn; the right fuel cap seal appeared to be intact. The fuel selector was set to both tanks at the time of the examination. No other anomalies consistent with a preimpact failure or malfunction were observed. FAA regulations (14 CFR 91.205) required an operable fuel gauge indicating the quantity of fuel in each tank for any powered civil aircraft with a standard category airworthiness certificate. ## Aircraft - Registration: [N1835R](https://openairdocs.org/deregistered/N1835R-2018-10-25), registration cancelled 2018-10-25, S/N R18200576, built 1978 (OpenAirDocs) - Reported make and model: CESSNA R182 - Registry model: [Cessna R182](https://openairdocs.org/model/cessna-r182) (registry code 2072734) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: R18200576 - Year built: 1978 - Airframe hours: 2083.4 - Engines: Lycoming O-540-J3C5D 235 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Meridian Flying Services Inc. - Registered owner: Meridian Flying Services Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2017, 24 hours before - Departed: ISN, Williston, ND - Destination: WRL, Worland, WY - Airport: WRL, Worland Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review April 30, 2017; seat: left; restraint: 3-point; flight hours: 2,067 total, 661 in this make and model, 1,957 as pilot in command, 138 in the last 90 days, 61 in the last 30 days, 12 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 39 °F - Altimeter: 29.94 inHg - Observed at: WRL, 12 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 20170912010619A](https://openairdocs.org/incident/20170912010619A), Sep 12, 2017: Cessna R182, Worland, WY, Substantial damage. Fuel syphoned from left wing. Fuel cap was not sealing. Aircraft ran out of gas. Pilot landed gear up. ## Docket (2 files) The files NTSB released with the investigation on January 8, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96026. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459182&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Regulations - Excerpts (item 2, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459183&FileExtension=.PDF&FileName=FAA%20Regulations%20-%20Excerpts-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.