# NTSB ERA09CA232: Cessna 177RG, N1838Q, Ocean Isle Beach, NC, April 4, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: April 4, 2009, 17:25 local (21:25 UTC) - Place: Ocean Isle Beach, NC - Coordinates: 33.913055, -78.428611 - Nearby events: https://openairdocs.org/map.md?lat=33.9131&lon=-78.4286&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 73599 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09CA232 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73599/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73599 - Page: https://openairdocs.org/ntsb/ERA09CA232 ## Probable cause The pilot's failure to divert to an alternate airport resulting in the total loss of engine power due to fuel exhaustion. Contributing to the accident were the pilot's incorrect determination of the fuel load prior to the flight, the lack of placards near the engine-monitoring instrument, and the pilot's reliance of the on-board engine-monitoring instrument instead of the fuel quantity gauges. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Knowledge: knowledge of procedures](https://openairdocs.org/ntsb-findings/02032010): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/02032010/cases.md?model=2073709), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/02032010/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 177RG, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2073709), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Fuel system: fuel quantity indicator](https://openairdocs.org/ntsb-findings/01022841): Aircraft › Aircraft systems · Related operating info (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/01022841/cases.md?model=2073709), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01022841/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Related records (probable cause); cases with it: [Cessna 177RG, 3 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=2073709), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Personality/attitude: confidence/reliance on equip](https://openairdocs.org/ntsb-findings/02021015): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/02021015/cases.md?model=2073709), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/02021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 177RG, 6 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073709), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Landing area undershoot](https://openairdocs.org/ntsb-events/370); cases with it: [Cessna 177RG, 2 cases](https://openairdocs.org/ntsb-events/370/sequence.md?model=2073709), [All aircraft, 201 cases](https://openairdocs.org/ntsb-events/370/sequence.md) ## Analysis The pilot visually inspected each fuel tank before departure but incorrectly believed the fuel tanks were full. Each fuel tank contained more than 22 gallons but less than 25 gallons usable fuel. When near the destination airport the engine experienced a total loss of engine power due to fuel exhaustion. The pilot proceeded towards an alternate airport, but was unable to land there and landed gear-up short of the intended runway. A total of 3 to 4 ounces of fuel were drained from the wing fuel tanks. No tank damage and no fuel leaks were noted from the fuel filler caps or fuel tank sump drain valves. Both fuel quantity gauges were noted to read empty when aircraft's battery power was applied. Although an engine-monitoring instrument with fuel flow capability was installed after the airplane was manufactured, installation instructions required placards to read that the airplane's fuel quantity gauges should be used to determine the fuel level in the tanks, and the original fuel flow gauge is the primary instrument for fuel flow. Postaccident examination of the instrument panel revealed neither placard was installed. Though the airplane was modified by installation of a turbocharger which required an increase in fuel flow, the increase was within the limits of the fuel flow transducer. The calculated average fuel flow during the accident flight was 10.3 gallons-per-hour, which was consistent with the average calculated fuel flows on two flights before the engine was overhauled. Fueling records at the intended destination reflect that on one occasion he landed with no more than 5.0 gallons of usable fuel remaining. ## Factual narrative The pilot stated that he performed a preflight inspection of the airplane which included a visual inspection of both fuel tanks. The level of fuel in each tank was ½ to ¾ inch below the fuel filler cap sealing surface. He did not report any discrepancies related to the engine start or engine run-up before takeoff. After departure from Danbury Municipal Airport (DXR), Danbury, Connecticut, the pilot slightly leaned the fuel to air ratio and climbed to 9,000 feet mean sea level (msl), where the pilot leaned the fuel to air ratio to the peak turbine inlet temperature (TIT) reading, then continued leaning lean of peak 30 degrees. The flight remained at 9,000 feet msl for a period of time then climbed to 12,000 feet msl where the pilot again leaned the fuel to air ratio lean of peak TIT. He verified that the cylinder head temperature (CHT) and exhaust gas temperature (EGT) readings were in the green arc, and monitored the fuel flow and other engine and aircraft gauges noting that the fuel appeared to be consumed evenly between the tanks. The pilot further stated that when the flight was approximately 10 minutes from the destination airport (Grand Strand Airport (CRE), North Myrtle Beach, South Carolina), while flying at 5,000 feet, the engine surged and experienced a loss of power but did not quit. He increased the mixture control to full rich and turned the auxiliary fuel pump on, and informed the controller who provided a vector to the nearest airport. He continued trouble shooting but the engine eventually quit but the propeller continued rotating. Unable to land at the vectored airport, the pilot landed gear-up on grass short of the intended runway. Inspection of the airplane before recovery by a Federal Aviation Administration (FAA) airworthiness inspector revealed a total of 3 to 4 ounces of fuel were drained from both fuel tanks which were not damaged. No fuel staining aft of either fuel filler cap or aft of either fuel tank sump drain valve were noted. After applying the aircraft’s battery, both fuel quantity indicators indicated empty. While the pilot calculated that he had 50.0 gallons usable fuel for the accident flight, based on the fuel level noted in the tanks during his preflight inspection (1/2 to ¾ inch below the top of the filler neck), and the fact that he did not observe holes in the filler neck, each tank was less than full (25.0 gallons usable), but greater than 22 gallons usable. The pilot has owned the airplane since 1998, and in 2003, it was modified in accordance with separate Supplemental Type Certificate (STC) by installation of a turbocharger and an engine-monitoring instrument with fuel flow indicating capability. Review of the maintenance records revealed the engine was overhauled on August 23, 2007, and installed into the airplane on October 4, 2007. The pilot questioned whether the fuel flow transducer, or engine-monitoring instrument could have contributed to experiencing fuel exhaustion. Safety Board review ofdocuments from the instrument manufacturer and postaccident examination of the instrument panel revealed two placards were not installed. One placard indicated not to use the instrument to determine the fuel level in the fuel tanks. The second placard indicated in summary that since the airplane was originally equipped with a primary fuel flow indicator, it should be used for reference and not the engine-monitoring instrument with fuel flow capability. The second placard conflicted with a flight manual supplement (FMS) associated with the turbocharger installation. The FMS indicated that the airplane’s primary fuel flow indicator may not accurately measure fuel flow after installation of the turbocharger. Data from the installed engine-monitoring instrument was provided to Safety Board personnel for review. Data associated with all but 14 seconds of the accident flight (4.26 hours from first to last logged data rows) revealed the instrument indicated 44.5 gallons fuel used, and the calculated average fuel flow was 10.3 gallons-per-hour (gph). The pilot also questioned whether the engine overhaul could have contributed to experiencing fuel exhaustion. Data from two complete flights before the engine overhaul revealed the calculated average fuel flow were 10.1 and 10.2 gph, while data from two complete flights after the engine overhaul revealed the calculated average fuel flow were 9.6 and 9.7 gph. The pilot explained that he had made the same trip (DXR to CRE) safely numerous times in the previous 8 years and at the completion there was 7 to 10 gallons of fuel remaining. He also reported he had flown into CRE from other destinations. Safety Board review of invoices from Ramp 66 located CRE, whose records go back to 2002, revealed only 4 invoices associated with the airplane. Three of the four invoices documented fuel purchases of 42.5, 45.0, and 31.8 gallons, respectively. The airplane’s total usable fuel capacity is 50.0 gallons when each tank is completely filled. The pilot also questioned whether fuel pressure or fuel flow changes as a result of the turbocharger installation had any affect. Information provided by the STC holder revealed that the fuel flow at full throttle and rich mixture increases from the test specification maximum of 125.2 pounds-per-hour (pph) to 132 pph, an increase of 6.8 pph. Literature associated with the fuel flow transducer revealed the gph range is 0.6 to 60, or approximately 3.6 to 360 pph, and the working pressure is 200 pounds per square inch (psi). ## Aircraft - Registration: [N1838Q](https://openairdocs.org/deregistered/N1838Q-2015-05-26), registration cancelled 2015-05-26, S/N 177RG0238, built 1971 (OpenAirDocs) - Reported make and model: CESSNA 177RG - Registry model: [Cessna 177RG](https://openairdocs.org/model/cessna-177rg) (registry code 2073709) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177RG0238 - Airframe hours: 2967 - Engines: LYCOMING IO-360-A1B6D 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Fly For Food Inc - Registered owner: Fly For Food Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 7, 2008, 10 hours before - Departed: DXR, Danbury, CT - Destination: CRE, N. Myrtle Beach, SC - Flight plan: IFR - Airport: 60J, Odel Williamson Municipal Arpt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: minor; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review August 7, 2007; seat: left; flight hours: 1,095 total, 595 in this make and model, 1,095 as pilot in command, 14 in the last 90 days, 4 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 16 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 46 °F - Altimeter: 29.90 inHg - Observed at: CRE, 15 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 20090404008739A](https://openairdocs.org/incident/20090404008739A), Apr 4, 2009: Cessna 177RG, Ocean Isle Bea, NC, Substantial damage. (-23) Aircraft departed (dxr) danbury airport, CT, traveling to north myrtle beach, south carolina, grand strand airport. Approximately 25 miles away the pilot… ## Docket (14 files) The files NTSB released with the investigation on August 25, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73599. 7.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316961&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Reports and Records (item 2, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316962&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Record of NTSB Conversations (item 3, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316963&FileExtension=.PDF&FileName=Record%20of%20NTSB%20Conversations-Redacted.PDF - Flight Planning Document (item 4, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316965&FileExtension=.PDF&FileName=Flight%20Planning%20Document-Master.PDF - Excerpts from Maintenance Records (item 5, .PDF, 741 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316971&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Redacted.PDF - Turbocharger Flight Manual Supplement (item 6, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316967&FileExtension=.PDF&FileName=Turbocharger%20Flight%20Manual%20Supplement-Redacted.PDF - Excerpts from EGT-701 Installation (item 7, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316968&FileExtension=.PDF&FileName=Excerpts%20from%20EGT-701%20Installation-Master.PDF - Excerpts from Owner's Manual (item 8, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316969&FileExtension=.PDF&FileName=Excerpts%20from%20Owner%27s%20Manual-Master.PDF - Fuel Invoices (item 9, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316970&FileExtension=.PDF&FileName=Fuel%20Invoices-Redacted.PDF - Accident Flight Data (item 10, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316975&FileExtension=.PDF&FileName=Accident%20Flight%20Data-Master.PDF - Servo Fuel Injector Test Specification Sheet (item 11, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317075&FileExtension=.PDF&FileName=Servo%20Fuel%20Injector%20Test%20Specification%20Sheet-Master.PDF - Lycoming Leaning Instructions (item 12, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317635&FileExtension=.PDF&FileName=Lycoming%20Leaning%20Instructions-Master.PDF - Photo 1: Digital Photograph Provided by Atlanta Air Salvage Personnel. View of the Instrument Panel. (item 13, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316973&FileExtension=.PDF&FileName=Photo%201%3A%20Digital%20Photograph%20Provided%20by%20Atlanta%20Air%20Salvage%20Personnel.%20View%20of%20the%20Instrument%20Panel.-Master.PDF - Photo 2: Digital Photograph Provided by Atlanta Air Salvage Personnel. View of the J.P. Instruments EGT-701. (item 14, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316974&FileExtension=.PDF&FileName=Photo%202%3A%20Digital%20Photograph%20Provided%20by%20Atlanta%20Air%20Salvage%20Personnel.%20View%20of%20the%20J.P.%20Instruments%20EGT-701.-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.