ERA24LA124

NTSB accident investigation · Cirrus Design SR20 · Sanford, FL · February 27, 2024

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 27, 2024, 18:22 local (23:22 UTC)
Place
Sanford, FL
Injuries
1 serious, 1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N485DACirrus Design SR20
Defining event
Landing: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Continental Aerospace Technologies, FAA/FSDO, Cirrus Aircraft
FAA report
20240227001889A
Case key
193858

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

A total loss of engine power due to fuel starvation and the flight crew’s mismanagement of the available fuel.

Findings · 2

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementCirrus Design SR20: 3 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Flight crewCirrus Design SR20: 4 casesAll aircraft: 1,391 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 was returning from a local training flight when the accident occurred. The pilot receiving instruction was flying a practice instrument approach and after removing the view-limiting device he noticed that the airplane’s altitude was low on the approach path. The flight instructor ultimately took control of the airplane and added engine power. The airplane continued to sink, and the flight instructor began to manipulate the throttle, but sensed that the airplane was no longer producing engine power. He stated that he verified the fuel selector placement, though he could not remember which position the fuel selector was in, and that the mixture lever was in the full rich position. Shortly after, the airplane impacted an unoccupied airplane short of the runway and came to rest on a grassy area adjacent to the airport ramp. A postaccident examination of the airplane’s engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, the airplane’s right fuel tank contained ¼ of a gallon of fuel and was not breached. The fuel selector was found in the right-tank position. A review of data recovered from the airplane’s avionics showed a decrease in fuel flow and subsequent loss of engine power about 1 minute before the airplane impacted the terrain. Based on this information, it is most likely that the fuel supply in the airplane’s right wing was exhausted during the landing approach, which resulted in the loss of engine power as the flight instructor attempted to add power to correct the airplane’s descent path.

Factual narrative

On February 27, 2024, at 1822 eastern standard time, a Cirrus Design Corp SR20, N485DA, was substantially damaged when it was involved in an accident near Sanford, Florida. The pilot receiving instruction was seriously injured; the flight instructor and a pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight departed Sanford International Airport (SFB), Sanford, Florida, at 1718 for an instrument training lesson. On the return flight to SFB, the pilot under instruction was utilizing a view-limiting device to conduct a practice instrument approach to runway 9R. The pilot stated that the tower controller “switched them back and forth between 9R and 9L” before the flight instructor requested runway 9C. When the flight instructor advised the pilot to remove the view-limiting device, the pilot immediately observed that the airplane was low on the approach path. The flight instructor acknowledged that the airplane was low and told the pilot receiving instruction to set up for a practice short field landing. During the approach, the flight instructor noted that they were still low, so he took control of the airplane and added power. Shortly thereafter, the engine lost all power. The airplane subsequently impacted a parked, unoccupied airplane short of the runway, and came to rest on a grassy area next to the airport ramp. The airplane caught fire, and was subsequently extinguished by first responders. The airplane sustained substantial damage to both wings and the fuselage. According to the flight instructor, prior to departing, an additional 34 gallons of fuel was added between the two fuel tanks that already had an unknown quantity of fuel in them. This brought the fuel tanks up to “tab plus 5 gallons” on each side. The flight instructor confirmed that the 34 gallons of fuel added to the airplane was divided between the two fuel tanks. A review of the fueling documents provided by the flight school showed that 34 gallons of 100LL was added to the airplane, but there was no documentation to show the total fuel quantity onboard the airplane prior to departure. The engine and flight data from the Multi-Function Display and the Primary Flight Display (PFD) were examined.. An initial reduction of fuel flow at 18:17:55 was observed from the engine during the descent. Fuel flow briefly increased at 18:18:20 before decreasing gradually starting at 18:18:30 down to 2.5gph. A loss of engine power occurred at 18:18:50. For a detailed timeline of events, reference “Cockpit Display – Recorded Flight Data – Specialist’s Factual Report” in the public docket. According to the airframe manufacturer, in SR20 series airplanes equipped with the Avidyne Entegra display system, there was no warning displayed on the MFD for fuel quantity. Fuel quantity was indicated only by a gauge forward of the fuel selector. There was an Amber “FUEL” caution light on the annunciator panel thatwould illuminate to indicate a low fuel condition. The “FUEL” caution light would illuminate when approximately 14 gallons of total useable fuel remained between both fuel tanks. This light would not illuminate if one tank was depleted to the unusable fuel level, while the other fuel tank had more than 14 gallons remaining. Furthermore, the remaining fuel caution was dependent on a pilot setting initial fuel quantity and was based on the fuel flow transducer. Postaccident examination of the engine revealed the crankshaft was capable of rotating 720° when force was applied to the propeller. Compression and suction were established on all six cylinders. Continuity of the camshaft to the crankshaft was confirmed. The rocker covers were removed from the engine cylinders and valvetrain continuity was established. The oil filter element was examined with no contamination noted. The oil level gauge measured about 6 1/2 quarts of clean oil. There were no mechanical defects or discrepancies noted with the engine that would have precluded normal operation. During the airframe examination, it was noted that the right wing fuel tank was not breached during the accident sequence. The fuel remaining in the right wing was drained and 1/4 of a gallon of clean, 100LL aviation fuel was collected from the tank. The left wing fuel tank had been breached during the accident sequence and the burn areas of the postimpact fire was primarily confined to the aft left side of the airframe. The fuel selector was found in the “right” position and was not manipulated by first responders. The first responders did manipulate the airframe boost pump toggle switch, and the fuel mixture knob to the “off” and “idle cut-off” positions, respectively. The airplane flap position switch and flap actuator were found in the 0% or “UP” position. According to the Cirrus Pilot Operating Handbook, the normal approach speed, with flaps up, is 88 knots. The total useable fuel is 56 gallons, and the total fuel capacity is 60.5 gallons. Filling the airplane to the “tabs” equates to 20 gallons per tank.The airplane PFD recorded that the airplane’s indicated airspeed was 68 knots about 6 seconds before the impact. Review of the operator’s checklist for the airplane revealed that during the landing approach, the fuel selector should be placed to the “fullest tank.”

Aircraft

Registration
N485DA
Reported as
Cirrus Design SR20
Category
Airplane
Serial number
1830
Built
2007
Airframe hours
12,390
Engine
Continental Aerospace Technologies IO-360-ES, 210 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Aerosim Academy Inc
Registered owner
Aerosim Academy Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 17, 2024 · 34 hours before
Destination
Same as departure
Airport
SFB · Orlando Sanford Intl, runway 09C, 3,578 × 75 ft, asphalt
Equipment
ADS-B, Stall warning system, Electronic multifunction display, Airframe parachute, Electronic flight bag or handheld device, Auto-pilot

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 · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
27
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Last flight review
January 23, 2024
Seat
Left
Restraint
4-point
Flight hours
70 total · 7 in this make and model · 8 in the last 90 days
Role
Flight instructor
Age
31
Injuries
Minor
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 11, 2023
Seat
Right
Restraint
4-point
Flight hours
567 total · 349 in this make and model · 451 as pilot in command · 125 in the last 90 days · 40 in the last 30 days
Role
Pilot-rated passenger
Age
19
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Seat
Rear
Restraint
Lap only

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 55 °F
Altimeter
30.09 inHg
Observed at
SFB
METAR
KSFB 272253Z 14011KT 10SM CLR 23/13 A3009 RMK AO2 SLP190 T02280133

Docket · 27

The files NTSB released with the investigation on March 5, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 86.8 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 11 pages · 5.1 MBFlight instructor statementItem 2 · PDF · 1 page · 6.2 MBPilot receiving instruction statementItem 3 · PDF · 2 pages · 9.2 MBPassenger statementItem 4 · PDF · 1 page · 2.8 MBFlight instructor interviewItem 5 · PDF · 2 pages · 65 KBFlight instructor interview (follow-up)Item 6 · PDF · 3 pages · 66 KBPilot receiving instruction interviewItem 7 · PDF · 2 pages · 65 KBPilot receiving instruction interview (follow-up)Item 8 · PDF · 1 page · 60 KBPassenger interviewItem 9 · PDF · 2 pages · 66 KBPassenger interview (follow-up)Item 10 · PDF · 1 page · 60 KBWitness statementItem 11 · PDF · 1 page · 60 KBFirst responders statementsItem 12 · PDF · 2 pages · 64 KBVideo file angle 1Item 13 · MP4 · 20.7 MBVideo file angle 2Item 14 · MP4 · 19.1 MBFuel recordsItem 15 · PDF · 12 pages · 5.1 MBDescent checklistsItem 16 · PDF · 2 pages · 157 KBInvestigative photosItem 17 · PDF · 7 pages · 5.8 MBWreckage examinationItem 18 · PDF · 13 pages · 1.6 MBAirframe manufacturer correspondence summaryItem 19 · PDF · 2 pages · 71 KBSR20 airplane flight manual temporary change excerptItem 20 · PDF · 6 pages · 732 KBCockpit display - recorded flight data - specialist's factual reportItem 21 · PDF · 15 pages · 7 photos · 3.6 MBCockpit display - recorded flight data - specialist's factual report - ATTACHMENT1 - PFD tabular dataItem 22 · CSV · 1.1 MBCockpit display - recorded flight data - specialist's factual report - ATTACHMENT2 - MFD tabular dataItem 23 · CSV · 79 KBStatement of party representatives to NTSB investigationItem 24 · PDF · 27 pages · 4.2 MBRelease of aircraft wreckage, NTSB form 6120.15Item 25 · PDF · 1 page · 137 KBEvidence control form PFDItem 26 · PDF · 1 page · 306 KBEvidence control form MFDItem 27 · PDF · 1 page · 306 KB

FAA reports on this event · 1

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