# NTSB ERA17LA235: Cessna T337, N337J, Greenwood, SC, July 7, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 7, 2017, 07:35 local (11:35 UTC) - Place: Greenwood, SC - Coordinates: 34.25, -82.143608 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2500&lon=-82.1436&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Textron, Continental Motors - NTSB case key (mKey): 95513 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA235 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95513/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95513 - Page: https://openairdocs.org/ntsb/ERA17LA235 ## Probable cause The pilots' inadequate preflight inspection, during which they failed to adequately verify the quantity of fuel, which resulted in fuel exhaustion, a subsequent total loss of power to both engines, and a forced landing into trees. Contributing to the accident were the erroneous fuel quantity displayed by the fuel quantity indicating system fuel sender units and the operator's failure to comply with a mandatory service bulletin addressing inaccuracies in the fuel quantity indicating system. ## 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 T337D, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2075719), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Cessna T337D, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2075719), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna T337D, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2075719), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Owner/builder (probable cause); cases with it: [Cessna T337D, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2075719), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna T337D, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=2075719), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna T337D, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=2075719), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna T337D, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2075719), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor and private pilot, who did not have a multiengine rating, were conducting a familiarization flight in the centerline thrust, multiengine airplane. Following the preflight inspection, the instructor and the pilot believed that both fuel tanks were about 1/2 to 3/4 full. After practicing maneuvers uneventfully for about 30 minutes, the front engine lost all power. The instructor told the pilot to return to the departure airport; the rear engine was operating at this time. However, before reaching the airport, the rear engine lost all power. With insufficient altitude remaining to reach a runway, the pilot transferred control to the instructor, who then conducted a forced landing into trees. Postaccident examination of the accident site revealed no smell of fuel, and only about 6 gallons of fuel (of a possible 131 gallons with all fuel tanks filled to capacity, 3 gallons of which were unusable) were recovered from both wing fuel tanks. Examination of both engines revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. The four fuel quantity sender units (two for each main fuel tank) were removed and tested with an ohm meter. In the empty position, the left outboard fuel sender unit displayed a resistance value equal to an approximate 1/2-tank reading. The left and right inboard fuel sender units displayed a resistance value equal to an approximate full-tank reading. The right outboard fuel sender unit displayed inconsistent resistance readings throughout its range of travel. The airplane manufacturer published a mandatory service bulletin (SB) about 18 years before the accident, which required inspection of the fuel quantity indicating system to verify that each fuel gauge indicated the accurate fuel amount. The SB also required that an initial inspection of the system be completed within 100 hours of operation and subsequent recurring inspections every 12 months. Examination of the airplane's maintenance logbooks revealed no evidence of compliance with the SB. Given the lack of fuel found at the accident site and that postaccident examination of the engines revealed no mechanical issues, it is likely that the pilots did not adequately verify the quantity of fuel during the preflight inspection, in part due to erroneous fuel quantity indications provided by the fuel quantity indicating system, which resulted in fuel exhaustion and a subsequent loss of all engine power to both engines. The airplane operator's failure to comply with the SB precluded the pilots from being able to identify the fuel quantity in flight. ## Factual narrative On July 7, 2017, about 0735 eastern daylight time, a Cessna T337D, N337J, was substantially damaged during a forced landing near Greenwood County Airport (GRD), Greenwood, South Carolina. The flight instructor and a private pilot sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the local instructional flight. The airplane was operated under the provisions of 14 Code of Federal Regulations Part 91.The flight instructor stated that the purpose of the flight was for the single-engine rated private pilot (student) to become familiar with the accident airplane as he worked toward an instrument rating. The private pilot performed the preflight inspection with no anomalies noted. The flight instructor stated that their inspection of the fuel tanks revealed that they were ¾ full, which they verified on the airplane's fuel gauges. The student stated that during the preflight inspection they did not visually check the fuel tanks but noted that the fuel gages read between ½ and ¾ full. The engine run-up was normal and they departed from runway 27. After departure, they practiced maneuvers uneventfully for about 30 minutes and then performed one aerodynamic stall. After practicing the stall, the front engine started to surge from high power to low power and then lost all power. The flight instructor told the pilot to turn back to the airport and fly to the runway while he looked in the emergency checklist for the engine-out procedure. The rear engine was still operating normally at the time. The flight instructor turned the fuel boost pump on, switched the fuel tank from main to auxiliary, and then back to main in an attempt to restore power to the front engine, to no avail. He recalled that sometime during the flight back to the airport, the rear engine also experienced a total loss of power. The airplane was too low to reach the runway, and the pilot transferred control to the flight instructor, who performed a forced landing into trees. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest on its right side. The right wing separated from the fuselage and was found inverted on the fuselage. The left wing and strut were still attached to the fuselage. A fuel sample was taken from the left wing auxiliary sump and found to be blue in color and absent of visible debris. The right-wing fuel tanks were not accessible. The salvage crew that removed the airplane from the accident site, stated to the FAA inspector that they removed 6 gallons of fuel in the left wing and no fuel was in the right wing. The FAA inspector further stated there was no smell of fuel at the accident site. Both wings had impact marks consistent with hitting trees. The front and rear engine propellers did not exhibit rotational scoring. The landing gear were extended. Examination of both engines revealed evidence of any preaccident mechanical malfunctions or failures thatwould have precluded normal operation. The four-main fuel tank fuel quantity sender units were removed and tested with an ohm meter. In the empty position, the left outboard fuel sender had a resistance valve equal to an approximately half-full reading. The left and right inboard fuel senders had a resistance valve equal to an approximately full tank reading. The right outboard fuel sender unit displayed inconsistent resistance readings throughout its range of travel. The airplane was equipped with a main fuel tank in each wing and an auxiliary fuel tank in each wing, which combined held a total of 131 gallons of fuel, with 128 gallons of useable fuel, and 3 gallons of unusable fuel. Each main fuel tank was comprised of two metal tanks, one outboard of the other, connected with hoses. Fuel automatically flowed from the outboard tank to the inboard tank through the hoses via gravity. Each main fuel tank was equipped with two float-type fuel level sender units, one in the outboard tank and one in the inboard tank. The two sender units were connected electrically in parallel to a fuel quantity gage in the cockpit. On November 29, 1999, the airframe manufacturer released mandatory Service Bulletin MEB99-21, which was applicable several models of airplane including the accident airplane . The purpose of the service bulletin was, "To inspect the Stewart Warner manufactured fuel quantity indicating system for verification that each fuel tank quantity gauge indicates empty when the fuel tank contains only unusable fuel and indicates full when the fuel tank is full." The service bulletin dictated that an initial inspection be completed within 100 hours of operation or 12 months, whichever occurred first, and should subsequent reoccur every 12 months. The airplane's most recent annual inspection was completed on February 24, 2017 at 2,591 total airframe flight hours. Review of the airplane's maintenance logbooks revealed no evidence that MEB99-21 had been complied with. ## Aircraft - Registration: [N337J](https://openairdocs.org/deregistered/N337J-2019-01-22), registration cancelled 2019-01-22, S/N 337-1017, built 1968 (OpenAirDocs) - Reported make and model: CESSNA T337 (D) - Registry model: [Cessna T337D](https://openairdocs.org/model/cessna-t337d) (registry code 2075719) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 337-1017 - Year built: 1968 - Airframe hours: 2591.2 - Engines: Continental IO-360 300 horsepower reciprocating; Continental IO-360 300 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 24, 2017 - Departed: GRD, Greenwood, SC - Destination: GRD, Greenwood, SC - Airport: GRD, Greenwood County, runway 27, 5,001 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 42; injuries: minor; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 21, 2017; seat: right; restraint: 3-point; flight hours: 9,472 total, 8.3 in this make and model, 7,932 as pilot in command, 34 in the last 90 days, 18 in the last 30 days - Pilot; age 22; injuries: minor; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; last flight review August 6, 2016; seat: left; restraint: 3-point; flight hours: 61.9 total, 0 in this make and model, 31.8 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 68 °F - Altimeter: 30.05 inHg - Observed at: KGRD, 1 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 20170707008879A](https://openairdocs.org/incident/20170707008879A), Jul 7, 2017: Cessna T337D, Greenwood, SC, Destroyed. The aircraft departed runway 27 at Greenwood County (grd) for a local flight. Several touch and goes were performed and the aircraft departed the pattern to… ## Docket (13 files) The files NTSB released with the investigation on October 24, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95513. 16.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477048&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477049&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Correspondence from FAA Inspector (item 3, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477050&FileExtension=.PDF&FileName=Correspondence%20from%20FAA%20Inspector-Master.PDF - Memorandum for Record - Telephone Interview, Flight Instructor (item 4, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477051&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Flight%20Instructor-Master.PDF - Memorandum for Record – Telephone Interview, Student Pilot (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477060&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Student%20Pilot-Master.PDF - Cessna Correspondence Regarding Fuel Sender Examination (item 6, .PDF, 774 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477052&FileExtension=.PDF&FileName=Cessna%20Correspondence%20Regarding%20Fuel%20Sender%20Examination-Master.PDF - Pilot Operating Handbook Excerpt, Fuel System (item 7, .PDF, 491 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477053&FileExtension=.PDF&FileName=Pilot%20Operating%20Handbook%20Excerpt,%20Fuel%20System-Master.PDF - Cessna Mandatory Service Bulletin MEB99-21 Rev 1 (item 8, .PDF, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477054&FileExtension=.PDF&FileName=Cessna%20Mandatory%20Service%20Bulletin%20MEB99-21%20Rev%201-Master.PDF - Maintenance Manual (Excerpt) (item 9, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477055&FileExtension=.PDF&FileName=Maintenance%20Manual%20(Excerpt)-Master.PDF - Maintenance Records (Excerpt) (item 10, .PDF, 10.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477056&FileExtension=.PDF&FileName=Maintenance%20Records%20(Excerpt)-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477057&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Investigative Photos (item 12, .PDF, 3 photos, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477058&FileExtension=.PDF&FileName=Investigative%20Photos-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477059&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.