ERA21LA383

NTSB accident investigation · Cessna 172 · Miramar, FL · September 28, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
September 27, 2021, 22:38 local (Sep 28, 2021, 02:38 UTC)
Place
Miramar, FL
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4118LCessna 172
Defining event
Enroute-cruise: Fuel exhaustion
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, FAA/FSDO
FAA report
20210928013079A
Case key
103981

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

On this page

Probable cause

The flight instructor’s inadequate preflight and inflight fuel planning, which resulted in a total loss of engine power due to fuel starvation. Contributing to the flight instructor’s injury was her failure to wear the shoulder harness.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotCessna 172G: 4 casesAll aircraft: 1,391 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 172G: 8 casesAll aircraft: 1,695 casesProbable cause
Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Instructor/check pilotCessna 172G: 7 casesAll aircraft: 3,098 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane’s fuel tanks were filled to capacity and the airplane was flown 1.2 hours before the flight instructor and student pilot departed on the accident flight. The student and instructor flew to a nearby airport, where they performed 11 stop-and-go landings, then departed to return to the departure airport. About 3 miles from the airport, the engine lost total power. The instructor switched the fuel selector from BOTH to the LEFT, then RIGHT tank positions, but engine power was not restored. The airplane impacted trees and a stop sign during the forced landing, resulting in substantial damage. The flight instructor reported that she was not wearing a shoulder harness, which contributed to the extent of her injury. Based on the hour meter, the airplane was operated about 4.5 hours since the fuel tanks had been filled. Following the accident, about 2.5 gallons of fuel were drained from the left fuel tank, which was 1 gallon more than the unusable amount, and no fuel was noted in the right fuel tank. The fuel strainer and carburetor bowl were absent of fuel. Based on the available information, the loss of engine power was the result of fuel starvation. The instructor stated that she did not use the fuel dipstick to confirm fuel quantity before departing on the flight. Had she done so, it is likely that she would have noted the airplane’s fuel state and fueled the airplane before returning to the departure airport, thus preventing the accident.

Factual narrative

On September 27, 2021, about 2238 eastern daylight time, a Cessna 172G, N4118L, was substantially damaged when it was involved in an accident near Miramar, Florida. The flight instructor and student pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot stated that, as part of the preflight inspection, she noted that the airplane had been operated for 1.2 hours since the fuel tanks were filled. She visually inspected both fuel tanks and could see fuel inside but did not have a fuel dipstick available. She informed the flight instructor that the fuel level was a “little less” than full. She further reported that the flight instructor also performed a preflight inspection of the airplane but did not check the fuel tanks. The flight instructor stated that she checked the right fuel tank, which she verified by feel as full, but she did not check the left fuel tank, nor did she use the fuel dipstick. She added that the student pilot checked the left fuel tank and informed her that it was full. After proceeding to a nearby airport with the mixture control full rich, the student pilot performed 11 stop-and-go landings, then proceeded to return to the departure airport with the mixture control full rich. She indicated that, had she known the left fuel tank was not full, she would have fueled before returning to the departure airport. About 3 miles from the airport, the engine lost total power. At that time, she noted that both fuel gauges were stuck between 1/2 and empty. She repositioned the fuel selector from the BOTH position, where it had remained since engine start, to the LEFT and then the RIGHT tank positions but that did not restore engine power. She informed her student of the impending forced landing to a street and after touchdown on the road, she turned to avoid traffic and impacted another tree. She was not wearing the shoulder harness, which she said contributed to her injury. The airplane came to rest upright with substantial damage to the fuselage and right horizontal stabilizer. Neither fuel tank was breached. The right fuel tank was empty, while about 2.5 gallons of fuel were drained from the left fuel tank. The fuel selector was found between the BOTH and RIGHT fuel tank positions. The airplane’s published total unusable fuel amount was 3.0 gallons; 1.5 gallons in each fuel tank. The engine was removed from the airframe for recovery and only “drops” of fuel were noted in the fuel line between the fuel strainer and carburetor. No fuel was noted in the airframe fuel strainer. Extensive impact damage precluded operational testing of the fuel quantity indicating system; the fuel transmitters were not tested. No fuel was noted in the carburetor bowl. Based on the hour meter, the airplane had been operated for about 4.5 hours since the fuel tanks had been filled.

Aircraft

Registration
N4118L
Reported as
Cessna 172 (G)
Category
Airplane
Serial number
17254187
Built
1966
Airframe hours
4,370.5
Engine
Continental O-300-D, 145 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Jacobs Flight Services LLC
Registered owner
Uan Venture Partners LLC
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · September 17, 2021 · 30.6 hours before
Departed
APF · Naples, FL
Destination
HWO · Pembroke Pines, FL
Equipment
Stall warning system, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
23
Injuries
Serious
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
81.6 total · 41.8 in this make and model · 11.4 as pilot in command · 41.8 in the last 90 days · 25.4 in the last 30 days · 2.2 in the last 24 hours
Role
Flight instructor
Age
35
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 20, 2021
Seat
Right
Restraint
Lap only
Flight hours
993 total · 800 in this make and model · 831 as pilot in command · 86 in the last 90 days · 45 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
20° at 4 knots
Visibility
10 statute miles
Lowest ceiling
4,300 ft broken
Temperature
79 °F, dew point 66 °F
Altimeter
30.05 inHg
Observed at
KHWO, 2 nm away
METAR
KHWO 280253Z AUTO 02004KT 10SM BKN043 26/19 A3005 RMK AO2 SLP176 T02560189 50005

Docket · 10

The files NTSB released with the investigation on July 26, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.