# NTSB CEN21LA194: Cessna A185F, N19D, North Vernon, IN, April 17, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: April 16, 2021, 20:30 local (Apr 17, 2021, 00:30 UTC) - Place: North Vernon, IN - Coordinates: 39.054943, -85.598748 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.0549&lon=-85.5987&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 102937 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA194 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102937/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102937 - Page: https://openairdocs.org/ntsb/CEN21LA194 ## Probable cause The pilot’s improper installation of the fuel selector handle, which resulted in a total loss of engine power due to fuel starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Pilot; cases with it: [Cessna A185F, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2072821), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Cessna A185F, 8 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072821), [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. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna A185F, 9 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072821), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna A185F, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072821), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna A185F, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072821), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna A185F, 5 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2072821), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis After a 100-hour inspection, which the pilot assisted with, he conducted an operational check of the airplane, which included a run-up of the airplane. The mechanic had to leave before the inspection was complete, and the pilot installed portions of the interior which included the fuel selector handle. He then departed the airport and after retracting the landing gear and flaps, the engine lost power. During the forced landing the airplane sustained substantial damage to the empennage and aft section of the fuselage. Examination of the airplane revealed that fuel was available in the left and right fuel tanks. The examination also found that the fuel selector handle had been installed incorrectly by 90° on the fuel selector shaft. The position of the shaft as found would have restricted all fuel flow from the left and right fuel tanks. The shaft was “keyed” such that the fuel selector handle should only be installed one way; however, the handle partially fit over the stem when not aligned with the key on the shaft and allowed the attaching screw to partially engage on the stem. An engine test run was conducted; the engine started normally and with the engine at full throttle, the fuel selector was placed in the left, right, and both positions. The engine continued to run with no anomalies noted. The airplane was factory equipped with a small header tank that fuel accumulated in before being fed to the engine. The accident is consistent with the fuel selector shaft being in the off position while the selector handle pointed to the left fuel tank. Once the fuel in the airplane’s header tank was exhausted, the engine lost power due to fuel starvation. ## Factual narrative On April 16, 2021, about 2030 eastern daylight time, a Cessna A185F amphibian airplane, N19D, was substantially damaged when it was involved in an accident near North Vernon, Indiana. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he assisted a mechanic with a 100-hour inspection, and he then conducted an operational check of the airplane, which included an inspection and a run-up of the airplane. He then departed and after retracting the landing gear and flaps, the engine lost power. Unable to make it back to the airport, he selected a nearby golf course for the forced landing. The airplane sustained substantial damage to the empennage and aft section of the fuselage. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the left fuel tank contained 10 gallons of fuel and the right fuel tank contained 15 gallons of fuel. The inspector reported that the mechanic had to leave work early, and the pilot installed portions of the interior which included the fuel selector handle. Examination of the fuel selector handle found that the handle had been installed incorrectly by 90° on the fuel selector shaft. The fuel selector shaft was “keyed” so that the fuel selector handle could be installed in only one way; however, the handle partially fit over the stem and allowed the attaching screw to partially engage on the shaft. The inspector removed the fuel selector handle and provided a photo of the selector as orientated, when found (see Figure 1). The fuel selector handle was on the left tank position, but the orientation of the fuel selector shaft as positioned restricted all fuel flow to the engine. Figure 1: Fuel valve selector (FAA photo) A post-accident engine test run was conducted with the engine operated at full throttle; the fuel selector was placed in the left, right, and both positions. The engine operated with the fuel selector in each of these positions with no anomalies noted. The airplane was factory equipped with a small header tank that collected fuel before being fed to the engine. ## Aircraft - Registration: [N19D](https://openairdocs.org/aircraft/N19D), registered now, S/N 18504097, built 1980 (OpenAirDocs) - Reported make and model: CESSNA A185F - Registry model: [Cessna A185F](https://openairdocs.org/model/cessna-a185f) (registry code 2072821) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18504097 - Year built: 1980 - Airframe hours: 12825 - Engines: Continental IO-550D reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Echelon Right LLC - Registered owner: Echelon Right LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, April 16, 2021 - Departed: OVO, North Vernon, IN - Airport: OVO - Equipment: Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 13, 2021; seat: left; restraint: 4-point; flight hours: 1,107 total, 384 in this make and model, 992 as pilot in command, 72 in the last 90 days, 35 in the last 30 days ## Weather - Conditions: Visual (VMC), Dusk - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 39 °F - Altimeter: 29.92 inHg - Observed at: KIMS, 18 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 20210416001449A](https://openairdocs.org/incident/20210416001449A), Apr 16, 2021: Cessna A185F, North Vernon, IN, Substantial damage. On April 16, 2021, at approximately 2030 eastern standard time, a Cessna CE-A185F aircraft, N19D, landed on a golf course immediately after departing the North… ## Docket (5 files) The files NTSB released with the investigation on January 6, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102937. 5.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 12 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12557354&FileExtension=pdf&FileName=NTSB%20Form%206120.1%20-%20signed_Redacted-Rel.pdf - Fuel selector handle with valve position (item 2, PDF, 2 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12595315&FileExtension=pdf&FileName=Fuel%20Selector-Rel.pdf - Exam memo (item 3, PDF, 1 page, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13083878&FileExtension=pdf&FileName=Exam%20Memo-Rel.pdf - Photos (item 4, PDF, 3 pages, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12480589&FileExtension=pdf&FileName=Photo%201-Rel.pdf - Fuel system ipc (item 5, PDF, 4 pages, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12480903&FileExtension=pdf&FileName=IPC%20Fig%2099B%20fuel%20system-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. --- 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.