# NTSB ERA21LA383: Cessna 172, N4118L, Miramar, FL, September 28, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: September 27, 2021, 22:38 local (Sep 28, 2021, 02:38 UTC) - Place: Miramar, FL - Coordinates: 25.982483, -80.278637 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.9825&lon=-80.2786&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, FAA/FSDO - NTSB case key (mKey): 103981 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA383 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103981/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103981 - Page: https://openairdocs.org/ntsb/ERA21LA383 ## 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 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 · Instructor/check pilot (probable cause); cases with it: [Cessna 172G, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072420), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 172G, 8 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072420), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 172G, 7 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072420), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 172G, 6 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2072420), [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 172G, 12 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072420), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/aircraft/N4118L), registered now, S/N 17254187, built 1966 (OpenAirDocs) - Reported make and model: CESSNA 172 (G) - Registry model: [Cessna 172G](https://openairdocs.org/model/cessna-172g) (registry code 2072420) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17254187 - Year built: 1966 - Airframe hours: 4370.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 23; injuries: serious; 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 - Flight instructor; age 35; injuries: serious; 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 ## 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 20210928013079A](https://openairdocs.org/incident/20210928013079A), Sep 28, 2021: Cessna 172G, Miramar, FL, Destroyed. Aircraft N4118SP was on a cross country night instructional flight from north perry airport to naples municipal airport. Aircraft N4118 returned from the… ## Docket (10 files) The files NTSB released with the investigation on July 26, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103981. 20.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 - submitted by student pilot (item 1, PDF, 13 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12879016&FileExtension=pdf&FileName=6120%20Fm%20BB%20Recd%2010%2029%202021_Redacted-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 - submitted by flight instructor (item 2, PDF, 11 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12905290&FileExtension=pdf&FileName=6120%20Fm%20CFI_Recd_11_4_2021_Redacted-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 - submitted by operator (item 3, PDF, 11 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13448977&FileExtension=pdf&FileName=6120%20Fm%20Operator_Redacted-Rel.pdf - Statement from student pilot (item 4, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12879262&FileExtension=pdf&FileName=Statement%20from%20Student_Redacted-Rel.pdf - Record of NTSB conversations (item 5, PDF, 16 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13586099&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted-Rel.pdf - Documents from operator (item 6, PDF, 7 pages, 4 photos, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13586444&FileExtension=pdf&FileName=Documents%20From%20Operator_Redacted-Rel.pdf - Investigative photographs (item 7, PDF, 3 pages, 3 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13601272&FileExtension=pdf&FileName=Investigative%20Photographs-Rel.pdf - Memorandum for record - airframe and engine inspection following recovery (item 8, PDF, 1 page, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13600552&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20Airframe%20%26%20Fuel%20System%20Inspection-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 9 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12880414&FileExtension=pdf&FileName=Party%20Form%20w%20Attachments_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 649 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13585422&FileExtension=pdf&FileName=Fully%20executed%20Wreckage%20Release%20Form_ERA21LA383_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.