# NTSB CEN19LA007: Grumman AA5, N81383, Refugio, TX, October 12, 2018

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Class 3 · Limited · Final report
- Date: October 12, 2018, 13:04 local (18:04 UTC)
- Place: Refugio, TX
- Coordinates: 28.303888, -97.330833 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=28.3039&lon=-97.3308&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern base: Fuel starvation](https://openairdocs.org/ntsb-events/191)
- Highest injury: Serious injuries
- Injuries: 1 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: Federal Aviation Administration - San Antonio FSDO
- NTSB case key (mKey): 98475
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA007
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98475/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98475
- Page: https://openairdocs.org/ntsb/CEN19LA007

## Probable cause

The pilot’s improper inflight fuel management, which resulted in a total loss of engine power due to fuel starvation and the pilot’s failure to maintain adequate airspeed, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall at a low altitude.

## 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: [Grumman American Avn. AA-5B, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=3960105), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=3960105), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Grumman American Avn. AA-5B, 12 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3960105), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=3960105), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Grumman American Avn. AA-5B, 2 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=3960105), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Course deviation](https://openairdocs.org/ntsb-events/281); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-events/281/sequence.md?model=3960105), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/281/sequence.md)
- [Approach-VFR pattern base: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Grumman American Avn. AA-5B, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=3960105), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md)
- [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Grumman American Avn. AA-5B, 8 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=3960105), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Approach-VFR pattern base: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Grumman American Avn. AA-5B, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3960105), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot was conducting a personal cross-country flight when he became lost. The pilot reported that he did not understand how to navigate using the GPS that was installed in the airplane before the flight. Instead of continuing to the southeast toward the intended destination, the pilot turned south for the remainder of the flight. After flying for about 1.5 hours, the pilot became concerned about how much fuel remained and decided to land to refuel. The pilot stated that the airplane had a total loss of engine power while in the airport traffic pattern, and that he did not maintain adequate airspeed, which resulted in an aerodynamic stall during the turn from the base leg to final. The airplane sustained substantial damage to the fuselage and empennage during impact. Examination of the airplane revealed no fuel in the left fuel tank, about 7 gallons of fuel in the right fuel tank, and less than 2 fluid ounces of combined fuel from the electric boost pump, the fuel line to the carburetor, and the carburetor fuel bowl. The pilot reported that the fuel selector valve was positioned to the left fuel tank when the loss of engine power occurred. The loss of engine power was likely due to fuel starvation.

## Factual narrative

On October 12, 2018, about 1304 central daylight time, a Grumman AA-5B airplane, N81383, was substantially damaged when it was involved in an accident while maneuvering to land at Rooke Field Airport (RFG) near Refugio, Texas. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. During a telephone interview with the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC), the pilot stated that the accident occurred during the first flight after an annual inspection and the installation of a Garmin 480 GPS. The pilot estimated that the airplane had about 26 gallons of fuel onboard when he departed Silver Wings Airport (TS36), Fredericksburg, Texas, for the cross-country flight to Lane Airpark (T54), Rosenburg, Texas. The pilot reported that he did not understand how to navigate using the GPS, and as a result he became lost during the flight and turned south instead of continuing to the southeast toward T54. After flying for about 1.5 hours, he became concerned about how much fuel remained and decided to land at RFG to refuel. The pilot stated that he did not maintain adequate airspeed while in the traffic pattern for runway 14L at RFG, which resulted in an aerodynamic stall during the turn from the base leg to final. The pilot did not submit a completed NTSB Accident Report Form (6120.1) during the investigation. During a telephone interview with a Federal Aviation Administration (FAA) Airworthiness Inspector, the pilot confirmed that he became lost during the flight and that he decided to land to refuel. He selected the left fuel tank while he maneuvered to land, but the airplane had a total loss of engine power while on final approach. A witness reported seeing the airplane wreckage in a field north of the airport as he taxied his airplane toward the approach end of runway 14L at RFG. The airplane had traveled about 100-125 ft after it impacted the ground. The accident pilot reportedly told the witness that he made a “rookie mistake” while maneuvering to land for fuel. A medical helicopter was dispatched to the site to transport the pilot to a hospital for treatment of his injuries. The witness then called the FAA to report the accident. The witness stated that the left tank did not contain any fuel, but there was fuel visible in the right tank. Neither fuel tank appeared to be damaged, and the fuel selector valve handle was positioned to the right fuel tank. The mixture control was full rich, the throttle was full forward, and the ignition key was positioned on the right magneto. The flap selector was full down. A FAA Airworthiness Inspector stated that the airplane’s left fuel tank was empty at the accident site, and that the right fuel tank contained about 7 gallons of fuel. Less than 2 fluid ounces of combined fuel was recovered from the electric boost pump, the fuel line to the carburetor, and the carburetor fuel bowl. The airplane sustainedsubstantial damage to the fuselage and empennage during impact. A mechanic at the departure airport reported seeing about 8 gallons of fuel in each fuel tank (16 gallons total) before the flight. The airplane was not refueled before the flight because there was no fuel service at the departure airport. Based on available radar track data, the flight likely departed TS36 about 1120. The airplane’s ground track generally continued to the southeast toward T54 until about 1155 when it turned to the south. The airplane did not reestablish a course toward T54 for the remainder of the flight. At 1302:24, the last radar return was recorded about 0.125 mile south-southwest of RFG at 350 ft mean sea level. The accident site was located about 1,300 ft north of the approach end of runway 14L at RFG.

## Aircraft

- Registration: [N81383](https://openairdocs.org/deregistered/N81383-2019-07-10), registration cancelled 2019-07-10, S/N AA5B0522, built 1977 (OpenAirDocs)
- Reported make and model: Grumman AA5 (B)
- Registry model: [Grumman American Avn. AA-5B](https://openairdocs.org/model/grumman-american-avn-aa-5b) (registry code 3960105) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: AA5B0522
- Year built: 1977
- Engines: Lycoming O-360-A4K 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, October 12, 2018, 1.5 hours before
- Departed: TS36, Fredericksburg, TX
- Destination: RFG, Refugio, TX
- Airport: RFG, Rooke Field Airport, runway 14L, 4,361 × 60 ft, asphalt
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 73; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; flight hours: 2,600 total, 300 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 140° at 11 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 84 °F, dew point 72 °F
- Altimeter: 29.93 inHg
- Observed at: RKP, 20 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 20181012019749A](https://openairdocs.org/incident/20181012019749A), Oct 12, 2018: Grumman American Avn. Corp. AA-5B, Refugio, TX, Substantial damage. October 12, 2018 at 0900 CDT, aircraft bearing registration number N81383, impacted terrain short of the runway at rooke field airport (krfg) in Refugio, TX.…

## Docket (9 files)

The files NTSB released with the investigation on July 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98475. 1.5 MB in all.

- Memorandum of conversation (william neil eckenroth) (item 1, PDF, 1 page, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145679&FileExtension=pdf&FileName=01%20-%20Memorandum%20of%20Conversation%20(William%20Neil%20Eckenroth)_Redacted-Rel.pdf
- Memorandum of conversation (scott egesdahl) (item 2, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12146103&FileExtension=pdf&FileName=02%20-%20Memorandum%20of%20Conversation%20(Scott%20Egesdahl)-Rel.pdf
- Witness statement (michael cavanaugh) (item 3, PDF, 1 page, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145246&FileExtension=pdf&FileName=03%20-%20Witness%20Statement%20(Michael%20Cavanaugh)_Redacted-Rel.pdf
- FAA inspector email (frank fortmann) (item 4, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145353&FileExtension=pdf&FileName=04%20-%20FAA%20Inspector%20Email%20(Frank%20Fortmann)_Redacted-Rel.pdf
- Radar data (source data) (item 5, CSV, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145689&FileExtension=csv&FileName=05%20-%20Radar%20Track%20Data%20(Source%20Data)-Rel.csv
- Plots of radar data track data (item 6, PDF, 2 pages, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145594&FileExtension=pdf&FileName=06%20-%20Radar%20Data%20Track%20Plots-Rel.pdf
- Weather data (item 7, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145256&FileExtension=pdf&FileName=07%20-%20Weather%20Data-Rel.pdf
- Photo (item 8, PDF, 1 page, 1 photo, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145876&FileExtension=pdf&FileName=08%20-%20Photo-Rel.pdf
- NTSB investigator letter to pilot (william neil eckenroth) (item 9, PDF, 1 page, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12145699&FileExtension=pdf&FileName=09%20-%20NTSB%20Investigator%20Letter%20to%20Pilot%20(William%20Neil%20Eckenroth)_Redacted-Rel.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.

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