CHI03LA087

NTSB accident investigation · Aero Commander 500-B · Mankato, MN · March 20, 2003

Accident · No injuriesLimited investigationFinal report
Date
March 20, 2003, 04:40 local (10:40 UTC)
Place
Mankato, MN
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N553RAAero Commander 500-B
Weather
Instrument (IMC) · Night
Status
Completed · report December 30, 2003
Report
Approved by Office Director
Parties
FAA-Minneapolis FSDO
FAA report
20030320003929A
Case key
56653

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Fuel exhaustion due to the pilot's inadequate preflight and not verifying the airplane had been refueled.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine powerApproach
Fluid,fuel - exhaustionCause
Aircraft preflight - inadequatePilot in commandCause
Refueling - not verifiedPilot in commandCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - rough/uneven
Nose gear collapsedLanding - roll

Analysis

The airplane sustained substantial damage when it experienced a loss of power to both engines and executed a forced landing at night to a dirt road about 4 miles south of the airport. The Part 135 cargo flight could not depart to its scheduled destination due to weather, so it departed on a Part 91 positioning flight to another destination. While en route, the pilot notified ATC that the airplane's fuel gauges were indicating low fuel. The pilot attempted a VOR instrument approach to a nearby airport, but was unsuccessful. ATC issued the pilot radar vectors and a clearance for the ILS approach to another airport. While flying the approach, both engines lost power and the pilot executed a forced landing. The pilot reported that he requested the local fixed base operator to fuel the airplane. The pilot did not observe the airplane being refueled, nor did he receive a fuel receipt. He reported that when he preflighted the airplane, he checked the fuel tanks by feeling for fuel with his fingers. He could not feel any fuel with his finger. He checked the fuel gauges and reported that the fuel gauges read FULL. He reported that the fuel gauges would read FULL when there might be only 120 gallons of fuel, even though the fuel tanks held 156 gallons. An inspection of the fuel tanks at the accident site revealed that the wing tanks were empty, and the fuselage tank had 5 quarts of fuel. An inspection of the airplane revealed no fuel leaks. The company's Operations Manual, "Aircraft Refueling Procedures," stated: "No company aircraft will be fueled unless a pilot or other company employee, experienced in aircraft fueling, is present.…..The pilot shall determine the quantity of fuel to be added to the aircraft and that the aircraft is properly grounded."

Factual narrative

On March 20, 2003, at 0440 central standard time, an Aero Commander 500-B, N553RA, operated by Central Air Southwest, sustained substantial damage when the nose gear collapsed after it experienced a loss of power to both engines and executed a forced landing to a dirt road about 4 miles south of the Mankato Regional Airport (MKT), Mankato, Minnesota. The pilot was not injured. The Title 14 CFR Part 91 positioning flight departed Des Moines International Airport (DSM), Des Moines, Iowa, at 0338, and was en route to the Downtown St. Paul Airport (STP), St. Paul, Minnesota. Instrument meteorological conditions prevailed. The flight was on an instrument flight plan.

The fuel log of the fixed base operator (FBO) at Eppley Airfield (OMA), Omaha, Nebraska, where the airplane was last serviced, indicated that N553RA was fueled on March 18, 2003, at 2126, with 90.1 gallons of fuel. There were no entries in the fuel log that indicated N533RA had been fueled on March 19th. The airplane was not flown until the pilot departed on March 19th, at 2240.

The pilot reported for duty at 2000, March 19th. He reported that he requested the FBO fuel N533RA. The pilot reported that he checked the oil during the preflight, but he did not observed the airplane being fueled. The pilot reported that prior to departure, he checked the fuel level in the wing tanks. He reported that he stuck his fingers into the fuel tanks to check for fuel, but did not feel any fuel. He reported he looked at the fuel gauges and they indicated the tanks were full. The pilot reported that the fuel gauges would indicate full when the tanks had about 120 gallons of fuel, even though the fuel tanks held 156 gallons. He reported that he did not have a fuel receipt because the fuel was billed directly to the company.

The pilot reported that he departed OMA on March 19, 2003, at 2240, on a Part 135 cargo flight to DSM. The airplane flew one instrument approach and landed in DSM about 2320. The Part 135 flight did not depart to Rochester, Minnesota, at the scheduled time of 0245, due to weather. Instead, the flight departed on its Part 91 positioning flight to STP at 0338.

While en route to STP, the pilot notified air traffic control (ATC) that the airplane's fuel gauges were indicating low fuel. The pilot attempted a VOR instrument approach to the Albert Lee Municipal Airport, Albert Lee, Minnesota, but executed a missed approach due to low ceilings and visibility. ATC issued the pilot radar vectors and a clearance for the approach to MKT. The pilot was flying the ILS Runway 33 instrument approach to MKT when both engines lost power and he executed a forced landing. The pilot landed the airplane on a dirt road, but the nose gear collapsed during the landing roll.

An inspection of the fuel tanks revealed that the wing tanks were empty, and the fuselage tank had 5 quarts of fuel. An inspection of the airplane revealed no fuel leaks.

The Hobbs meter indicated the airplane had flown 1.8 hours since departing OMA.

A Federal Aviation Administration operations inspector interviewed the pilot. The pilot reported to the inspector that he had "run the airplane out of gas."

The Director of Operations of Central Air Southwest reported that the N533RA held 156 gallons of fuel. He reported that the airplane, fueled with 90 gallons of fuel, had about a 3 hour endurance range.

The company's Operation Manual stated the following concerning fueling of aircraft:

"The PIC is responsible for ensuring that the aircraft has the required quantity of fuel for the proposed flight and fueled as specified in Aircraft Fueling Procedures on page B5 of the Operations Manual."

The Operations Manual, "Aircraft Refueling Procedures," stated the following:

"No company aircraft will be fueled unless a pilot or other company employee, experienced in aircraft fueling, is present..….The pilot shall determine the quantity of fuel to be added to the aircraft and that the aircraft is properly grounded."

Aircraft

Registration
N553RA
Reported as
Aero Commander 500-B
Category
Airplane
Serial number
1315-124
Engine
Lycoming IO-540, 290 horsepower, reciprocating
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
Central Air Southwest
Airworthiness certificate
Standard, Normal
Departed
DSM · Des Moines, IA
Destination
STP · St. Paul, MN
Flight plan
IFR
Airport
MKT · Mankato Regional Airport

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
28
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
February 25, 2003
Seat
Left
Flight hours
1,800 total · 90 in this make and model · 1,700 as pilot in command · 100 in the last 90 days · 65 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night
Wind
10° at 9 knots
Visibility
5 statute miles
Lowest ceiling
400 ft overcast
Temperature
34 °F, dew point 32 °F
Altimeter
29.71 inHg
Observed at
MKT, 4 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.