# NTSB ERA11LA405: Cessna U206G, N910TA, Matinicus Island, ME, July 17, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 17, 2011, 16:25 local (20:25 UTC) - Place: Matinicus Island, ME - Coordinates: 44.69466, -69.382141 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.6947&lon=-69.3821&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: Serious injuries - Injuries: 1 serious, 3 minor - Status: Completed, report November 7, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors Inc, Cessna Aircraft Company, FAA/FSDO - NTSB case key (mKey): 81132 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA405 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81132/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81132 - Page: https://openairdocs.org/ntsb/ERA11LA405 ## Probable cause The pilot’s improper fuel management, 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. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna U206G, 2 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073356), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna U206G, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=2073356), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cessna U206G, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073356), [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: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna U206G, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2073356), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Cessna U206G, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=2073356), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis After takeoff from the island airport for the air taxi flight, the pilot made the initial power reduction when the airplane was at an estimated 200 feet above the ocean. At that time, the engine lost total power, and the pilot ditched the airplane. The pilot and the three passengers were able to exit the airplane before it sank. For about 1 hour until rescuers reached them, they held onto a section of the airplane’s belly cargo pod that had separated during the water impact. At the time of the wreckage recovery, the left and right fuel tank filler caps were found securely installed. The fuel selector was found in the right fuel tank position. About 25 gallons of sea water and 1 pint of aviation fuel were drained from the right fuel tank. About 27 gallons of aviation fuel and 2 gallons of sea water were drained from the left tank. Examination of the wreckage did not reveal any discrepancies that would have prevented normal operation of the airplane. The physical evidence indicates that the engine lost power as a result of fuel starvation due to the position of the fuel selector on the empty right tank. The operator required the pilot to provide the passengers a safety briefing before takeoff. However, none of the passengers were briefed or were aware that life vests were onboard the airplane. If a piece of wreckage had not been available for the passengers to hold on to, the failure of the pilot to notify the passengers of the availability of life vests could have increased the severity of the accident. As a result of the accident, the operator made numerous safety changes including mandating that the pilot read out loud a pre-takeoff briefing referencing the onboard passenger briefing guide card and offering all passengers a personal flotation device to wear during flights. ## Factual narrative On July 17, 2011, about 1625 eastern daylight time, a Cessna U206G, N910TA, registered to and operated by Waters Aero Marine, Inc., doing business as Penobscot Island Air, ditched in the ocean near Matinicus Island Airport (35ME), Matinicus Island, Maine. The pilot and two of three passengers received minor injuries, and the third passenger received serious injuries; the airplane sustained substantial damage. Visual meteorological conditions prevailed, and a company flight plan was filed for the on-demand air taxi flight, conducted under the provisions of 14 Code of Federal Regulations Part 135. The flight originated from 35ME, about 1623, with a destination to Knox County Regional Airport (KRKD), Rockland, Maine. The pilot stated they departed 35ME with good weather with a light wind. The airplane did not show any abnormal indications on the takeoff roll. At approximately 200 feet into the climb, as he was reducing to climb power, the engine began to lose power. He immediately advanced the throttle and turned on the auxiliary fuel pump with no results. The engine lost total power and the pilot ditched the airplane into the ocean. All onboard were able to exit the airplane before it sank. They clung onto a section of the airplane’s belly cargo pod that separated during the water impact. When the flight did not report in on the company’s frequency as required by the operator’s General Operations Manual (GOM), a search and rescue operation was activated. At about 1655 an emergency locater transmitter (ELT) signal was heard. At 1724 the pilot and three passengers were located in the water by a search plane. At 1737 all were rescued by a fishing boat and taken to shore for medical attention. The pilot held an Airline Transport pilot certificate with ratings for airplane multiengine land, airplane single-engine land and sea, and rotorcraft helicopter; with type rating for B-757, B767, and BH-212. In addition, he held a flight instructor certificate with ratings for airplane-single engine and instrument airplane. The pilot reported that he accumulated 25,300 total hours of flight experience, of which, 1,000 hour were in the same make and model as the accident airplane. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on May 24, 2010. The Cessna U206G, a six place all metal, high wing, single-engine airplane, variable-pitch propeller, with fix landing gear, serial number U20604102, was manufactured in 1978, and issued a standard airworthiness certificate, in the normal category. The airplane was powered by a Continental IO-520-F, 300-horsepower engine, with a McCauley three bladed propeller. The airplane was equipped with a belly cargo pod and had extended range fuel tanks, with a capacity for 80 gallons of fuel, which 78 gallons are usable. The airplane’s engine was overhauled on June 29, 2009. The engine’s last inspection was performed on July 7, 2011, at which the engine had a total of 1,244.9 hourssince major overhauled. The airplane’s last inspection was July 7, 2011 and the airplane had a total of 10,434.6 hours at that time. The airplane was on an annual/100 hour maintenance schedule. At the time of the accident, the airplane had accumulated a total of 10,437 hours. The wreckage was recovered 5 days after the accident from an estimated ocean floor depth of 80 feet and taken to a storage facility under FAA oversight. The left and right fuel tank filler caps were secured in their respective place. The fuel selector was observed in the right fuel tank position. Approximately 25 gallons of sea water was drained from the right fuel tank and about a pint of aviation fuel was observed. Approximately 27 gallons of aviation fuel and about two gallons of sea water were drained from the left tank. The fuselage reservoir sump tanks were filled with sea water. There was no indication of fuel slick observed on the water’s surface during the recovery. A wreckage examination by the airframe and engine manufacturer was conducted with FAA oversight. Flight control continuity was confirmed and no preimpact discrepancies were noted with the airframe that would have prevented normal operation. The engine was impact damaged and revealed saltwater submersion corrosion. The alternator, propeller governor, fuel pump, vacuum pump, and upper sparks plug were removed to facilitate an inspection of the engine. The corrosion prevented a rotational continuity confirmation of the accessory gears, valve train, cylinders, fuel system, ignition system, and induction system. The visual inspection of this engine did not reveal any abnormalities that would have prevented normal operation. Information provided by the pilot and operator to FAA and the manufacturers revealed the airplane began the day’s flight schedule with an estimated 60 gallons of fuel onboard and 10 gallons were later serviced prior to the flight to 35ME. The airplane flew 5 flights prior to the accident; a total of 2.7 hours. The Cessna Pilots Operating Handbook (POH), performance charts, indicates the airplane’s fuel consumption is 16 gallons per hour with two gallons for taxi and takeoff, and one gallon to climb to 2,000 feet for each flight. Utilizing the performance data, the fuel consumption was 58.2 gallons. The airplane’s fuel capacity is 78 gallons usable. The calculated total estimated fuel consumption for the five flights (58.2 gallons) plus the recovered fuel (27 gallons) reflects a total of 85.2 gallons. Based on the operator’s information an exact amount of onboard fuel, and quantities for each fuel tank, could not be determine. The operator’s FAA approved GOM, section 10, Passenger Handling, requires the pilot to give an oral safety briefing before each takeoff, which includes the location of the onboard survival equipment. In addition, a safety information card must be onboard in a location convenient for use by each passenger onboard. Interviews with the passengers revealed no safetybriefing was provided before the takeoff. None of the passengers were aware that life vests or the safety information card were onboard the airplane. As a result of this accident the operator has implemented several changes to their GOM with respect to the fleet’s fueling and tracking onboard fuel quantities, guidance when to make initial engine power reduction after takeoff, revised the onboard passenger’s guide card, mandated pilot’s to read out loud a pre-takeoff briefing referencing to the onboard passenger briefing guide card, modified all the fleet’s airplanes ELT the capability to be activated from the cockpit, equipped the fleet’s airplanes with emergency egress air bailout bottles, mandated all of the company’s pilots to attend a offshore survival training course, and offer the passengers the Mustang personnel flotation device (PFD) to wear during the flight. ## Aircraft - Registration: [N910TA](https://openairdocs.org/deregistered/N910TA-2018-01-10), registration cancelled 2018-01-10, S/N U20604102, built 1978 (OpenAirDocs) - Reported make and model: CESSNA U206G - Registry model: [Cessna U206G](https://openairdocs.org/model/cessna-u206g) (registry code 2073356) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: U20604102 - Airframe hours: 10435 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Penobscot Island Air - Registered owner: Waters Aero-Marine Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 7, 2012, 2 hours before - Departed: Matinicus Island, ME - Destination: KRKD, Rockland, ME - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: minor; airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 27, 2010; seat: left; flight hours: 25,300 total, 1,000 in this make and model, 18,000 as pilot in command, 40 in the last 90 days, 28 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 6 knots - Visibility: 10 statute miles - Temperature: 84 °F, dew point 63 °F - Altimeter: 29.92 inHg - Observed at: KRKD, 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 20110717021649A](https://openairdocs.org/incident/20110717021649A), Jul 17, 2011: Cessna U206G, Matinicus, ME, Substantial damage. July 17, 2011 at 2038Z or 1638 local, N910TA serial number U20604102 departed Matinicus island me under visual meteorological conditions (VMC). At a reported… ## Docket (21 files) The files NTSB released with the investigation on September 7, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81132. 22.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 673 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374058&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Other Pertinent Forms and Report: Operator's Accident Report (item 2, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374101&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Report%3A%20Operator%27s%20Accident%20Report-Redacted.PDF - Miscellaneous:Excerpts From The Operator's GOM Dispatch Emergency Procedures. (item 3, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375505&FileExtension=.PDF&FileName=Miscellaneous%3AExcerpts%20From%20The%20Operator%27s%20GOM%20Dispatch%20Emergency%20Procedures.-Master.PDF - Pilot's Statement (item 4, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374074&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Redacted.PDF - Records of Conversation (item 5, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375506&FileExtension=.PDF&FileName=Records%20of%20Conversation-Master.PDF - Miscellaneous: Excerpts From the Operator's GOM Before the Accident. (item 6, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375504&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20From%20the%20Operator%27s%20GOM%20Before%20the%20Accident.-Master.PDF - Reports from Federal Agencies: FAA Inspector's Statement. (item 7, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374061&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20FAA%20Inspector%27s%20Statement.-Master.PDF - Excerpt from Cessna Report (item 8, .PDF, 333 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374065&FileExtension=.PDF&FileName=Excerpt%20from%20Cessna%20Report-Master.PDF - Excerpt from Continental Motors Report (item 9, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374066&FileExtension=.PDF&FileName=Excerpt%20from%20Continental%20Motors%20Report-Master.PDF - Excerpt from Airplane's Flight Log Records (item 10, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374071&FileExtension=.PDF&FileName=Excerpt%20from%20Airplane%27s%20Flight%20Log%20Records-Redacted.PDF - Miscellaneous : Fuel Consumption Calculations, Fueling Recods, & Excerpt from the Airplane's Performance & Fuel System Section) (item 11, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374068&FileExtension=.PDF&FileName=Miscellaneous%20%3A%20Fuel%20Consumption%20Calculations,%20Fueling%20Recods,%20%26%20Excerpt%20from%20the%20Airplane%27s%20Performance%20%26%20Fuel%20System%20Section)-Master.PDF - Excerpt from Model U206G Emergency Procedures POH Section (item 12, .PDF, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374063&FileExtension=.PDF&FileName=Excerpt%20from%20Model%20U206G%20Emergency%20Procedures%20POH%20Section-Master.PDF - Excerpt from 206 Series Service Manual Fuel System Section (item 13, .PDF, 824 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374094&FileExtension=.PDF&FileName=Excerpt%20from%20206%20Series%20Service%20Manual%20Fuel%20System%20Section-Master.PDF - Excerpt from Airplane's Maintenance Records (item 14, .PDF, 783 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374072&FileExtension=.PDF&FileName=Excerpt%20from%20Airplane%27s%20Maintenance%20Records-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 15, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374073&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 16, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374075&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Miscellaneous: Safety Implementation to the Operator's GOM. (item 17, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375507&FileExtension=.PDF&FileName=Miscellaneous%3A%20Safety%20Implementation%20to%20the%20Operator%27s%20GOM.-Redacted.PDF - Photo 1: Airplane Being Recovered from the Water. Courtesy of the FAA. (item 18, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374097&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20Being%20Recovered%20from%20the%20Water.%20Courtesy%20of%20the%20FAA.-Master.PDF - Photo 2 : Overview of Airplane After Recovery. Courtesy of the FAA (item 19, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374096&FileExtension=.PDF&FileName=Photo%202%20%3A%20Overview%20of%20Airplane%20After%20Recovery.%20%20Courtesy%20of%20the%20FAA-Master.PDF - Photo 3: Airplane in Hangar for Examination. Courtesy of Cessna. (item 20, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374102&FileExtension=.PDF&FileName=Photo%203%3A%20Airplane%20in%20Hangar%20for%20Examination.%20Courtesy%20of%20Cessna.-Master.PDF - Photo 4: Overview of Airplane as it was Recovered. Courtesy of FAA. (item 21, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374103&FileExtension=.PDF&FileName=Photo%204%3A%20Overview%20of%20Airplane%20as%20it%20was%20Recovered.%20Courtesy%20of%20FAA.-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.