# NTSB ERA22LA112: Cessna 195, N597K, Palm Coast, FL, January 31, 2022 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: January 31, 2022, 13:00 local (18:00 UTC) - Place: Palm Coast, FL · I-95 - north bound lane at Mile Marker 279.3 - Coordinates: 29.465151, -81.207648 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.4652&lon=-81.2076&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 104580 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA112 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104580/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104580 - Page: https://openairdocs.org/ntsb/ERA22LA112 ## Probable cause The pilot’s inadequate fuel planning and preflight inspection, 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. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195, 2 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073102), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2073102), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 195, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073102), [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. - [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 195, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073102), [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 195, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073102), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 195, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot and the pilot-rated passenger departed their home airport to fly to a nearby airport about 20 minutes away. The pilot stated that he did not add any fuel to the airplane before the flight, as he thought he had enough fuel for the intended 20-minute flight. He reported that before takeoff everything was normal. He took off, and upon reaching 1,000 feet above mean sea level (msl), he configured the airplane for cruise. The airplane was operating normally when, about 5 miles from the destination airport, the engine lost power. The propeller continued to windmill, but it produced no power. He attempted to restart the engine without success. The pilot declared an emergency and informed air traffic control (ATC) that he would be landing on an interstate. During the forced landing, the airplane’s right wing contacted a truck, and the airplane came to rest inverted off the right side of the interstate, incurring substantial damage. The passenger said that he was worried about fire, and immediately tried to get out of the airplane. Once the passenger was out of the airplane, though, he did not see any fire or smoke, and there was no smell of fuel. During the wreckage recovery, there was also no smell of fuel at the accident scene, with the exception of a slight smell of fuel near the engine. Additionally, no fuel could be recovered from the airplane. The postaccident examination of the airplane and engine also revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, the fuel strainer and the carburetor float chamber were absent of fuel. An engine monitor was installed on the airplane that recorded exhaust gas temperature (EGT), cylinder head temperature (CHT), and shock cooling rate. During the accident flight, it recorded a rapid decrease in EGT, a rapid increase in shock cooling, and a rapid decrease in CHT, all of which in combination were indications that were consistent with of a loss of fuel flow. The passenger stated that after the accident the pilot was “absolutely confident” that he had enough fuel for the 20-minute flight, and that the pilot said his fuel totalizer showed 23 gallons. However, the airplane’s fuel totalizer required that a known fuel quantity be programmed at the beginning of the flight. If an accurate quantity had not been entered by the pilot at some previous point, the information indicated by the fuel totalizer would not have been correct. Based on the available information, it is likely that the loss of power was due to the fuel system containing little or no usable fuel, as no fire occurred during the impact sequence, the passenger did not observe fire or smell fuel when he egressed, no fuel was able to be recovered on-scene during the wreckage recovery, the fuel strainer and carburetor float chamber were absent of fuel, and examination of the engine revealed no evidence of any preimpact failures or malfunctions which would have precludednormal operation. The circumstances of the accident were consistent with a total loss of engine power due to fuel exhaustion, which resulted from the pilot’s inadequate fuel planning and preflight inspection. ## Factual narrative On January 31, 2022, about 1253 eastern standard time, a Cessna 195 Airplane, N597K, was substantially damaged when it was involved in an accident near Palm Coast, Florida. The pilot and pilot-rated passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Spruce Creek Airport (7FL6), Daytona Beach, Florida, about 1239, destined for Flagler Executive Airport (FIN), Palm Coast, Florida. The pilot stated that before the flight, he performed a normal preflight inspection and flight planning for the flight from 7FL6 to FIN. The pilot advised that he did not take on any fuel as he had enough for the intended flight. After boarding the airplane, the pilot started the engine. The start was normal, and all the instruments indicated everything was normal. He taxied to runway 24 for takeoff, and while short of the runway he ran the engine at idle for about 5 minutes and verified all instruments were normal. Upon entering the runway for takeoff, he performed a complete run-up procedure and no abnormality was observed. He took off, and upon reaching 1,000 feet above msl, he configured the airplane for cruise. About 5 miles south of FIN, the engine lost power. The propeller continued to windmill, but produced no power. The pilot attempted to restart the engine without success. The pilot declared an emergency and informed ATC that he would be landing on Interstate 95 (I-95). While approaching and setting up for landing on I-95, the passenger informed the pilot that he had a semi-trailer truck on his right-side, so the pilot tried to maneuver to his left as much as possible. The right wing then contacted the truck, at which point the pilot lost control. The airplane cartwheeled and came to rest inverted off the right side of I-95. According to the passenger, while the pilot performed the preflight inspection of the airplane the passenger chatted with some other pilots in the hangar; he did not see the pilot performing the preflight inspection of the airplane. After the preflight was complete, the pilot assisted the passenger in boarding the airplane and getting buckled into the 5-point harness. After engine start, the pilot paused for about 5 minutes to warm up the engine oil and then performed an engine runup. Everything seemed normal. After takeoff, they turned north towards FIN and climbed to 1,000 feet. As they were approaching the area of the airport, the pilot contacted the control tower. Then they turned east towards the ocean, and the passenger started to talk about how nice it was. While he was speaking, the engine “rumbled,” and it was as if the pilot had throttled back. But the pilot said right away, “I did not do that” and turned towards the north. At this time, they were about 800 feet in altitude. The pilot immediately committed to landing on I-95, as there were trees everywhere, and told the control tower that “We will be on the highway.” When they weregetting ready to land on the highway, the passenger pointed out a truck. When they touched down, they hit the truck. The passenger then closed his eyes as the impact was very violent. When they came to rest, they were upside down and he was “dangling upside down.” The passenger said that he was worried about fire, and they tried to immediately get out of the airplane. Once the passenger was out of the airplane, he did not see any fire or smoke, and there was no smell of fuel. The passenger advised that a lot of pilots from 7FL6 would go to FIN for lunch and to buy fuel, as it was about 50-cents-per-gallon cheaper than at 7FL6. He believed that the pilot was planning to get fuel there. The passenger also advised that after the accident the pilot was “absolutely confident” that he enough fuel for the 20-minute flight, and that the pilot said his fuel totalizer showed 23 gallons. According to the lead recovery specialist, during the wreckage recovery, there was no smell of fuel on scene, except for a slight smell of fuel near the engine. Additionally, no fuel was recovered from the airplane. The airplane was equipped with an onboard engine monitor that recorded exhaust gas temperature (EGT), cylinder head temperature (CHT), and shock cooling rate. The engine monitor’s device time was programmed by the pilot. The airplane’s onboard engine monitor was downloaded by the National Transportation Safety Board (NTSB) Recorders Laboratory. The data extracted included 21 sessions from April 15, 2021, through January 31, 2022. All parameters were recorded at a rate of one sample every six seconds. The accident flight was the last flight of the recording, and its duration was approximately 25 minutes. The device began recording at an approximate device time (dt) of 12:42:46. The last recorded parameter was as at 13:07:40 dt on January 31, 2022. Review of the extracted data from the accident flight indicated that after 13:06:00 dt, the EGT rapidly decreased, the shock cooling rate rapidly increased, and the CHT rapidly decreased. The fuel totalizer would have measured with high resolution the amount of fuel that flowed into the engine. Before the flight, though, the pilot would have had to enter into the unit the known quantity of fuel aboard, and then it would keep track of all fuel delivered to the engine. Examination of the airplane and engine revealed no preimpact malfunctions or failures that would have precluded normal operation. Additionally, the fuel strainer and the carburetor float chamber were absent of fuel. ## Aircraft - Registration: [N597K](https://openairdocs.org/aircraft/N597K), registered now, S/N 7403, built 1949 (OpenAirDocs) - Reported make and model: CESSNA 195 - Registry model: [Cessna 195](https://openairdocs.org/model/cessna-195) (registry code 2073102) (OpenAirDocs) - Registry engine: [Jacobs R755A series](https://openairdocs.org/engine/jacobs-r755a-series) (registry code 35006, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7403 - Year built: 1949 - Airframe hours: 2673.9 - Engines: Jacobs R755-B2 275 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, July 24, 2021 - Departed: 7FL6, Daytona Beach, FL - Destination: FIN, Palm Coast, FL - Airport: FIN, Flagler Exec, runway 29, 5,500 × 100 ft, asphalt - Equipment: Stall warning system, ADS-B, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: minor; airline transport, commercial, private; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 12, 2021; seat: left; restraint: 5-point; flight hours: 4,415 total, 253 in this make and model, 2,364 as pilot in command, 133 in the last 90 days, 24 in the last 30 days - Pilot-rated passenger; age 56; injuries: minor; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: basicmed, with waivers/limitations; seat: right; restraint: 5-point; flight hours: 2,447 total ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 37 °F - Altimeter: 30.19 inHg - Observed at: KFIN, 3 nm away - METAR: KFIN 311750Z 27005KT 10SM CLR 18/03 A3019 ## 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 20220131004689A](https://openairdocs.org/incident/20220131004689A), Jan 31, 2022: Cessna 195, Palm Coast, FL, Substantial damage. Aircraft departed spruce creek airpark (7FL6) on a part 91 flight with one (1) friend/passenger onboard. Prior to take-off on rwy 24, a complete run-up… ## Docket (7 files) The files NTSB released with the investigation on January 30, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104580. 14.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16457117&FileExtension=pdf&FileName=NTSB%20Form%206120%20(Signed)%201_Redacted-Rel.pdf - Witness statements and interview summaries (item 2, PDF, 6 pages, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16466026&FileExtension=pdf&FileName=Witness%20Statements%20and%20Interview%20Summaries_Redacted-Rel.pdf - Photo array (item 3, PDF, 20 pages, 9.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16466641&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Memorandum for record - wreckage examination (item 4, PDF, 2 pages, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16467286&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20Wreckage%20Examination-Rel.pdf - Engine monitoring device - specialist's factual report (item 5, PDF, 6 pages, 3 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14331944&FileExtension=pdf&FileName=Engine%20Monitoring%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Engine monitoring device - specialist's factual report attachment 1 - tabular data (item 6, CSV, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14332159&FileExtension=csv&FileName=Engine%20Monitoring%20Device%20-%20Specialist%27s%20Factual%20Report%20-%20Attachment%201%20-%20Tabular%20Data-Rel.csv - Wreckage release and evidence control (item 7, PDF, 2 pages, 756 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16466370&FileExtension=pdf&FileName=Wreckage%20Release%20and%20Evidence%20Control_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.