# NTSB ERA20LA328: Rockwell S2R, N7900V, Hamilton, GA, September 21, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 21, 2020, 11:25 local (15:25 UTC) - Place: Hamilton, GA · Forest Clearing - Coordinates: 32.750019, -84.870796 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.7500&lon=-84.8708&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 102018 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20LA328 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102018/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102018 - Page: https://openairdocs.org/ntsb/ERA20LA328 ## Probable cause The pilot’s inadequate preflight planning and improper operation of the engine beyond its indicated maximum cruise power setting, which resulted in a total loss of engine power due to fuel exhaustion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Rockwell International S-2R, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7630202), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Rockwell International S-2R, 2 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7630202), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Rockwell International S-2R, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7630202), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Performance/control parameters: powerplant parameters](https://openairdocs.org/ntsb-findings/01062050): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/01062050/cases.md?model=7630202), [All aircraft, 81 cases](https://openairdocs.org/ntsb-findings/01062050/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=7630202), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Rockwell International S-2R, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7630202), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Rockwell International S-2R, 8 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7630202), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Rockwell International S-2R, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7630202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was ferrying the airplane for its new owner. According to the pilot, before the flight, he topped off the fuel and visually checked that the fuel tanks were full after allowing for equalization. He also noted that the fuel quantity indication system was inoperative. About 1 hour 35 minutes to 1 hour 45 minutes after takeoff, the airplane was cruising about 2,500 ft mean sea level when the engine lost total power. The pilot had been flying at a cruise power setting of 30 inches of manifold pressure at 2,000 rpm the entire flight. After the engine power loss, the pilot established best glide speed, shut off the fuel selector, and landed in a clearing in a forest. During the landing roll, the right wing struck a felled tree, which resulted in substantial damage to the fuselage and the right wing. Examination of the airplane and engine did not reveal any evidence of preimpact mechanical failures or malfunctions that would have resulted in a loss of power. It did reveal that the fuel tanks were empty of fuel, that the fuel strainer did not contain any fuel, and that the carburetor float bowl contained only 3 to 4 ounces of fuel. Both magnetos from the dual-magneto ignition system were tested and found to be functional. The left magneto "P" lead was found to have erratic indications when the magneto switch was placed in the BOTH or L positions. The reason for the erratic indications was an intermittent short between the shielding and the center conductor. This intermittent short would have occasionally led to intermittent operation of the left magneto; however, the right magneto would have continuously provided ignition spark during the flight. According to the previous airplane owner, if the pilot did not stop to refuel between the departure point and where the accident occurred, he was at risk of running out of fuel. He explained that the airplane’s engine was a geared radial engine that burned a large amount of fuel, typically about 50 gallons per hour. The previous owner also explained that the pilot departed before he arrived at the airport, so he did not go over the airplane with the pilot. He stated that there was a pilot’s operating handbook (POH) in the airplane. According to the new airplane owner, he had talked with the pilot the previous day and suggested the pilot study the POH regarding fuel burn and that the first leg of the flight be limited to 1 hour to ensure the actual fuel burn was as expected. The pilot later reported that, although he knew that the fuel quantity indicating system was inoperative before takeoff, he chose to fly because he "had good data as to what the aircraft's fuel burn should be per hour." The pilot also reported that although he had over 1,200 hours in the accident airplane make and model (S2R), the accident flight was the first time he had flown an S2R with a radial engine. Review of published data for the engine revealed that the maximum cruise power setting was 26 inches of manifold pressure and2,000 rpm with a fuel burn rate of about 32 gallons per hour. Therefore, the engine power setting used by the pilot during the flight (30 inches at 2,000 rpm) exceeded the published maximum setting and would have markedly increased the rate of fuel consumption. The pilot’s decision to operate the engine beyond the indicated maximum power setting was likely due to his unfamiliarity with the engine installed on the airplane. The available evidence is consistent with a total loss of engine power due to fuel exhaustion. ## Factual narrative On September 21, 2020, about 1125 eastern daylight time, a Rockwell S2R airplane, N7900V, was substantially damaged when it was involved in an accident near Hamilton, Georgia. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. According to the pilot, a new owner had purchased the airplane, and he was ferrying the airplane for him from Cross City Airport (CTY), Cross City, Florida, to LaGrange-Callaway Airport (LGC), Lagrange, Georgia. The pilot reported that before the flight he had looked in the fuel tanks and noted that they were both 1/3 full. He filled the fuel tanks with 72 gallons of fuel “over the top of the wing” and visually double checked that the fuel tanks were full after allowing for equalization. He then departed CTY about 0800. The engine lost total power 1 hour 35 minutes to 1 hour 45 minutes later. According to the pilot, the engine “abruptly quit with no warning.” The pilot established best glide speed, shut off the fuel selector, and landed in a clearing in a forest. According to witnesses, the engine made a coughing sound, and a white or light grey cloud of smoke exited from the engine area. The airplane then seemed suspended and appeared to stop. The airplane then “dipped the right wing” and spiraled into a glide in the direction from which it came. The witnesses lost sight of the airplane because of trees and moments later heard a loud noise. Examination of the accident site revealed that the airplane touched down on a magnetic heading of 030°; the right wing then struck the ground and hit a previously felled tree; and the airplane spun to the right. Both main landing gear buckled under the fuselage, and the airplane came to rest on a magnetic heading of 132°. Examination of the airplane revealed substantial damage to the right wing. The fuselage skin also displayed wrinkling adjacent to the left-wing flap. Flight control continuity was established from the cockpit to all the flight control surfaces. There was no post-impact fire, and the carburetor heat control was found to be tie-wrapped in the closed OFF position. Examination of the propeller and engine revealed that all three propeller tips were damaged; compression was present on all cylinders; and the drivetrain was intact from the front of the engine to the accessories on the back of the engine. The engine contained oil, and after draining the oil tank, no unusual debris was noted. The oil filter was removed and opened, and no metal was found in the pleated filter material. The carburetor contained 3 to 4 ounces of fuel, and the fuel strainer was clean and devoid of fuel. The spark plugs were removed from the top five cylinders (front and rear), and all appeared normal in color (light tan) and had normal wear. Both magneto "P" leads were checked for proper operation with the magneto switch. The right magneto "P" lead was found to function normally; the magneto lead positively grounded with themagneto switch in the OFF or L position of the magneto switch and open in the BOTH and R switch positions. The left magneto "P" lead was found to have erratic indications when the magneto switch was placed in the BOTH or L positions and functioned normally in the OFF or R positions of the magneto switch. The erratic operation was traced to a splice in the left magneto "P" lead. The wiring from the left magneto to the splice was a single conductor wire, and the wiring from the splice to the magneto switch was a shielded single conductor cable. The shielding was found to have been crimped by the splice, allowing an intermittent short between the shielding and the center conductor. The wiring shield was terminated to a ground terminal at the magneto switch and a ground lug attached to the airframe side bulkhead. The magnetos were removed, and no external damage or anomalies were noted. Internal examination did not find any visible damage or anomalies. After being placed on a test stand, the magnetos were operated through all rpm ranges with maximum point gap. They were then each run at 2,150 rpm for 20 minutes. No anomalies were noted during the testing. The fuel tanks in both wings were visually inspected, and the tanks did not appear to have been breached. There were no signs of fuel in either tank. The gaskets on the fuel caps were dry rotted and hard, and the caps would not fit and lock tight. The fuel tank openings showed signs of rust and scale. Both wing tank fuel drains were in the closed position. There was minor evidence of fuel staining present on the right wing coming from the tank access panels (slight seepage) and the right fuel cap. According to the previous airplane owner, “if [the pilot] didn’t get any fuel between Cross City and where they crashed, they were pushing the envelope.” He explained that the airplane’s engine was a geared 1340 radial engine that burned a lot of fuel. He said, “if you get one with a 45 [gallons per hour] gph fuel burn you’re doing good. Most of them would run in the mid 50 gph range.” He added that the airplane “had the little tanks on it, only 110 gallons or so, total.” He explained that it was an “as-is” purchase but that he was unaware of any mechanical issues with the aircraft. He also explained that he thought it was “kind of strange to not even go over the aircraft with [the pilot].” He stated that the pilot showed up a day early and left the following morning without meeting with him and going over the airplane. He explained that there was a pilot’s operating handbook (POH) in the airplane. According to the pilot, the fuel quantity indicating system was inoperative; however, he chose to fly because he "had good data as to what the aircraft's fuel burn should be per hour." He reported that he had over 1,200 hours in the airplane make and model (S2R) and that this was his first flight in an S2R with the 1340 radial engine. According to the pilot, during the entire flight, he had been cruising at2,500 ft with a cruise power setting of 30 inches of manifold pressure at 2,000 rpm. Review of the “Pratt & Whitney Engine Check Chart for the Wasp (R-1340) S3H1 and S3H1-G Engines” revealed that the maximum cruise power setting was 26.0 inches of manifold pressure and 2,000 rpm with a fuel burn rate of about 32 gallons per hour. According to the new airplane owner, he had talked with the pilot on the previous day and suggested the pilot study the POH with regards to fuel burn and suggested that the first leg of the flight be limited to 1 hour in duration to ensure the actual fuel burn was as expected. ## Aircraft - Registration: [N7900V](https://openairdocs.org/deregistered/N7900V-2020-12-03), registration cancelled 2020-12-03, S/N 2324R (OpenAirDocs) - Reported make and model: Rockwell S2R - Registry model: [Rockwell International S-2R](https://openairdocs.org/model/rockwell-international-s-2r) (registry code 7630202) (OpenAirDocs) - Category: Airplane - Serial number: 2324R - Year built: 1977 - Airframe hours: 8775.6 - Engines: Pratt & Whitney R-1340-S3H1-G 600 horsepower reciprocating - Damage: Substantial damage - Flight: Positioning, Part 91 - Operator: North Valley Aircraft Inc. - Registered owner: North Valley Aircraft Inc. - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, August 18, 2020 - Departed: CTY, Cross City, FL - Destination: LGC, Lagrange, GA - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; remote, commercial, flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review March 25, 2019; seat: single; restraint: 4-point; flight hours: 5,600 total, 1,200 in this make and model, 5,570 as pilot in command, 340 in the last 90 days, 23 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 15 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 32 °F - Altimeter: 30.33 inHg - Observed at: CSG, 16.4 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 (OpenAirDocs). - [Accident 20200921015039A](https://openairdocs.org/incident/20200921015039A), Sep 21, 2020: Rockwell International S-2R, Hamilton, GA, Destroyed. Although the pilots total time in make/model is extensive, the pilot had never operated this make/model with a radial engine. The pilot decided to fly the… ## Docket (8 files) The files NTSB released with the investigation on September 23, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102018. 19.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 6.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420855&FileExtension=pdf&FileName=NTSB%20Form%206120%20(Signed)_Redacted-Rel.pdf - Witness statements and interview summaries (item 2, PDF, 11 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420194&FileExtension=pdf&FileName=Witness%20Statements%20and%20Interview%20Summaries_Redacted-Rel.pdf - Fuel receipt (item 3, PDF, 1 page, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420135&FileExtension=pdf&FileName=N7900V%20fuel%20receipt_Redacted-Rel.pdf - Pratt & whitney engine operation guide (item 4, PDF, 2 pages, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420865&FileExtension=pdf&FileName=Pratt%20%26%20Whitney%20Engine%20Operation%20Guidance-Rel.pdf - Photo array (item 5, PDF, 12 pages, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14431943&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Satellite image of accident location (item 6, PDF, 1 page, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420145&FileExtension=pdf&FileName=Accident%20Location-Rel.pdf - Magnetos examination and testing report (item 7, PDF, 4 pages, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420155&FileExtension=pdf&FileName=Magneto%20Report%2011-5-20_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14420875&FileExtension=pdf&FileName=N7900V%20sgnd%20NTSB%20wreck%20release_Redacted-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.