# NTSB ERA24LA124: Cirrus Design SR20, N485DA, Sanford, FL, February 27, 2024 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: February 27, 2024, 18:22 local (23:22 UTC) - Place: Sanford, FL - Coordinates: 28.778515, -81.2488 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.7785&lon=-81.2488&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Continental Aerospace Technologies, FAA/FSDO, Cirrus Aircraft - NTSB case key (mKey): 193858 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA24LA124 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193858/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193858 - Page: https://openairdocs.org/ntsb/ERA24LA124 ## Probable cause A total loss of engine power due to fuel starvation and the flight crew’s mismanagement of the available fuel. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Cirrus Design SR20, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2130000), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Cirrus Design SR20, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2130000), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2130000), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR20, 39 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130000), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N485DA), registered now, S/N 1830, built 2007 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Continental IO-360-ES](https://openairdocs.org/engine/continental-io-360-es) (registry code 17160, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1830 - Year built: 2007 - Airframe hours: 12390 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: serious; 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 - Flight instructor; age 31; injuries: minor; 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 - Pilot-rated passenger; age 19; injuries: none; 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 ## 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 20240227001889A](https://openairdocs.org/incident/20240227001889A), Feb 27, 2024: Cirrus Design Corp SR20, Sanford, FL, Substantial damage. Prior to the accident the student pilot was flying under simulated IMC conditions using IFR training foggles practicing an ILS approach to runway 9R. Aircraft… ## Docket (27 files) The files NTSB released with the investigation on March 5, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193858. 86.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17629393&FileExtension=pdf&FileName=ERA24LA124%20NTSB%206120_Redacted-Rel.pdf - Flight instructor statement (item 2, PDF, 1 page, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627550&FileExtension=pdf&FileName=Onzem%20Papa%20Nouveau%20Statment_Redacted-Rel.pdf - Pilot receiving instruction statement (item 3, PDF, 2 pages, 9.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627948&FileExtension=pdf&FileName=Allan%20Villon%20Statement_Redacted-Rel.pdf - Passenger statement (item 4, PDF, 1 page, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17626376&FileExtension=pdf&FileName=Gavin%20Coppenhaver%20Statement_Redacted-Rel.pdf - Flight instructor interview (item 5, PDF, 2 pages, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17626603&FileExtension=pdf&FileName=ERA24LA124%20Instructor%20Interview_Redacted-Rel.pdf - Flight instructor interview (follow-up) (item 6, PDF, 3 pages, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627958&FileExtension=pdf&FileName=ERA24LA124%20Instructor%20Follow-up%20Interview-Rel.pdf - Pilot receiving instruction interview (item 7, PDF, 2 pages, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627862&FileExtension=pdf&FileName=ERA24LA124%20Pilot%20Receiving%20Instruction%20Interview_Redacted-Rel.pdf - Pilot receiving instruction interview (follow-up) (item 8, PDF, 1 page, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17626613&FileExtension=pdf&FileName=ERA24LA124%20Pilot%20Receiving%20Instruction%20Follow-up%20Interview-Rel.pdf - Passenger interview (item 9, PDF, 2 pages, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627968&FileExtension=pdf&FileName=ERA24LA124%20Passenger%20Interview_Redacted-Rel.pdf - Passenger interview (follow-up) (item 10, PDF, 1 page, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627872&FileExtension=pdf&FileName=ERA24LA124%20Passenger%20Follow-up%20Interview-Rel.pdf - Witness statement (item 11, PDF, 1 page, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627560&FileExtension=pdf&FileName=ERA24LA124%20Witness%20Interview-Rel.pdf - First responders statements (item 12, PDF, 2 pages, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627757&FileExtension=pdf&FileName=ERA24LA124%20First%20Responder%20Interview_Redacted-Rel.pdf - Video file angle 1 (item 13, MP4, 20.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17632351&FileExtension=mp4&FileName=Alert%20video%203-Rel.mp4 - Video file angle 2 (item 14, MP4, 19.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17631462&FileExtension=mp4&FileName=Alert%20video%204-Rel.mp4 - Fuel records (item 15, PDF, 12 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627882&FileExtension=pdf&FileName=Fueling%20Records-Rel.pdf - Descent checklists (item 16, PDF, 2 pages, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17626623&FileExtension=pdf&FileName=Decent%20Checklists-Rel.pdf - Investigative photos (item 17, PDF, 7 pages, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627201&FileExtension=pdf&FileName=ERA24LA124%20Photo%20Array_Redacted-Rel.pdf - Wreckage examination (item 18, PDF, 13 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17627333&FileExtension=pdf&FileName=ERA24LA124%20Wreckage%20Examination-Rel.pdf - Airframe manufacturer correspondence summary (item 19, PDF, 2 pages, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18345181&FileExtension=pdf&FileName=ERA24LA124%20Cirrus%20Communication-Rel.pdf - SR20 airplane flight manual temporary change excerpt (item 20, PDF, 6 pages, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17687593&FileExtension=pdf&FileName=TPOH%20Fuel%20System-Rel.pdf - Cockpit display - recorded flight data - specialist's factual report (item 21, PDF, 15 pages, 7 photos, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17286440&FileExtension=pdf&FileName=Cockpit%20Display%20-%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Cockpit display - recorded flight data - specialist's factual report - ATTACHMENT1 - PFD tabular data (item 22, CSV, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287463&FileExtension=csv&FileName=Cockpit%20Display%20-%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report%20-%20Attachment1%20-%20PFD%20Tabular%20Data-Rel.csv - Cockpit display - recorded flight data - specialist's factual report - ATTACHMENT2 - MFD tabular data (item 23, CSV, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287595&FileExtension=csv&FileName=Cockpit%20Display%20-%20Recorded%20Flight%20Data%20-%20Specialist%27s%20Factual%20Report%20-%20Attachment2%20-%20MFD%20Tabular%20Data-Rel.csv - Statement of party representatives to NTSB investigation (item 24, PDF, 27 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=18139824&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 25, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17687151&FileExtension=pdf&FileName=Retention%20-%20Release%20of%20Wreckage%20Form_sjh_Redacted-Rel.pdf - Evidence control form PFD (item 26, PDF, 1 page, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17632473&FileExtension=pdf&FileName=ERA24LA124%20PFD%20FINAL%20Evidence%20form_Redacted-Rel.pdf - Evidence control form MFD (item 27, PDF, 1 page, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17633067&FileExtension=pdf&FileName=ERA24LA124%20MFD%20FINAL%20Evidence%20form_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.