# NTSB CEN19LA311: Cessna 172, N5347T, Grassy Butte, ND, September 10, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 10, 2019, 12:30 local (17:30 UTC) - Place: Grassy Butte, ND - Coordinates: 47.378612, -103.589721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.3786&lon=-103.5897&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) - 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 - NTSB case key (mKey): 100230 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA311 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100230/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100230 - Page: https://openairdocs.org/ntsb/CEN19LA311 ## Probable cause A total loss of engine power due to water contamination of the fuel, and the pilot's failure to conduct a preflight inspection. ## 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 · Inadequate inspection (probable cause); cases with it: [Cessna 172E, 9 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072412), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Cessna 172E, 9 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072412), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Cessna 172E, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072412), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Cessna 172E, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072412), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Cessna 172E, 2 cases](https://openairdocs.org/ntsb-events/193/sequence.md?model=2072412), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 172E, 3 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2072412), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The student pilot reported that he recently fueled the airplane with fuel from an external supply tank on his ranch. On the day of the accident, the pilot taxied the airplane to a north-south road and started the takeoff roll to the north. The airplane lifted off and climbed to about 40 ft above ground level when the engine experienced a total loss of power. The pilot made a left turn to land in a parallel field; the airplane landed hard and came to rest upright, sustaining substantial damage to the left wing and fuselage. Postaccident examination revealed a significant amount of water in the carburetor and in the airplane's fuel tanks. Water was also found in the supply tank from which the pilot fueled the airplane. The pilot reported that he did not check the airplane's fuel tanks for contamination before departing on the flight, nor had he checked the fuel supply tank for contamination. The circumstances of the accident are consistent with a total loss of engine power due to water contamination of the fuel system. ## Factual narrative On September 10, 2019, about 1230 central daylight time, a Cessna 172, N5347T, impacted terrain shortly after takeoff from a road near Grassy Butte, North Dakota. The pilot sustained serious injuries and the airplane was substantially damaged. The airplane was registered to (registration expired) and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight was originating at the time of the accident. According to local law enforcement and the responding Federal Aviation Administration (FAA) inspector, the pilot used the airplane to monitor the cattle on his ranch. The pilot stated that he was departing from the road to the north and climbed to about 40 ft above ground level when the engine experienced a total loss of power. The pilot made a left turn and landed hard in the field parallel to the road. Figure 1 shows the airplane where it came to rest in the field. Figure 1 – The accident airplane upright in a field The FAA inspector completed a preliminary examination of the airplane. He reported that a significant amount of water was found in the carburetor and the airplane's fuel tanks. Also, water was found in the supply fuel tank from which the pilot fueled the airplane. A local mechanic who had possession of the maintenance logbooks stated that a recent annual inspection had not been completed and the airplane was not in good shape overall. After the accident the pilot stated that before takeoff he did not check the airplane's fuel tanks for contamination nor did he check the external fuel supply tank for contamination. ## Aircraft - Registration: [N5347T](https://openairdocs.org/deregistered/N5347T-2022-12-31), registration cancelled 2022-12-31, S/N 17251247 (OpenAirDocs) - Reported make and model: Cessna 172 (E) - Registry model: [Cessna 172E](https://openairdocs.org/model/cessna-172e) (registry code 2072412) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17251247 - Year built: 1964 - Engines: Continental O-300 SER 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: Grassy Butte, ND - Destination: Grassy Butte, ND ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: serious; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 250 total ## Weather - Conditions: Visual (VMC), Day - Observed at: KS25, 29 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 20190910018619A](https://openairdocs.org/incident/20190910018619A), Sep 10, 2019: Cessna 172E, Grassy Butte, ND, Destroyed. [privacy data omitted] Fueled the aircraft at his ranch and took off from the gravel road infront of his ranch. During climbout the aircraft lost power and… ## Other investigations on N5347T (1) 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. - [NTSB UNK64X4097](https://openairdocs.org/ntsb/UNK64X4097), Sep 22, 1964: Cessna 172E (N5347T), Festus, MO, substantial damage ## Docket (4 files) The files NTSB released with the investigation on January 29, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100230. 550 KB in all. - Law Enforcement Statement (item 1, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480347&FileExtension=.PDF&FileName=Law%20Enforcement%20Statement-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480348&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation - FAA Inspector (item 3, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480349&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - Record of Conversation - Mechanic (item 4, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480350&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Mechanic-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.