FTW01FA188

NTSB accident investigation · Cessna 152 · Weatherford, TX · August 22, 2001

Accident · FatalField investigationFinal report
Date
August 22, 2001, 09:10 local (14:10 UTC)
Place
Weatherford, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N4755BCessna 152
Weather
Visual (VMC) · Day
Status
Completed · report May 13, 2003
Report
Approved by Office Director
Parties
FAA FSDO, Textron Lycomiing, Cessna Aircraft Company, National Transportation Safety Board
FAA report
20010822037949A
Case key
53082

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

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Probable cause

The student pilot's improper decision making in that he landed with a tailwind and failed to execute a go-around, which resulted in a runway overrun. Contributing factors were the inaccurate reading of the left fuel gage as a result of improper maintenance by the operator/maintenance personnel, and the tailwind condition.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise
Fuel system,tank - leak
Maintenance,installation - improperCompany maintenance personnelFactor
Engine instruments,fuel quantity gage - inaccurateFactor
Maintenance,service bulletin/letter - not complied withCompany/operator management
OverrunLanding - roll
Became lost/disorientedPilot in command
In-flight planning/decision - inadequatePilot in commandCause
Weather condition - tailwindFactor
Wrong runway - selectedPilot in commandCause
Go-around - not performedPilot in commandCause
In flight collision with objectLanding - roll
Object - vehicle

Analysis

During his second solo cross-country instructional flight, the student pilot reported to the controller that he was lost and low on fuel. The student told the controller that the left fuel gage indicated FULL and the right fuel gage indicated EMPTY. The controller issued the student suggested headings to the nearest airport. The student pilot located the airport and entered the traffic pattern for a landing on runway 17. During the landing roll to the south, the airplane bounced, exited the runway into the grass, and the student performed a go-around. Subsequently, the student landed the airplane to the north on runway 35. Witnesses reported the airplane remained on the runway with the elevators up, flaps retracted, and the propeller turning, before it rolled off the end of the runway at an "estimated speed of 30 mph." Witnesses never saw or heard any indication of braking, nor the addition of power. The airplane struck a vehicle traveling east at 60 mph on an interstate highway located north of the airport. Winds at the time of the accident were from the south at 20 knots. The accident flight time was 2.3 hours. Examination of the airplane's fuel system and its maintenance records revealed that the original left fuel tank transmitter (manufactured by Stewart Warner) was replaced in October 1999 with a new transmitter (manufactured by Rochester). Research revealed that by 1991, the Stewart Warner transmitters and fuel gages were no longer procurable for the airplane, and the Rochester transmitters and gages were to be installed by Service Bulletin (SB)/Service Kit (SK). According to the SB/SK, installation of a Rochester transmitter also requires installation of a Rochester gage. Neither the SB nor the SK had been complied with on the accident airplane. The Rochester gage assembly requires an aluminum back plate. Both fuel gages found in the airplane were Stewart Warner and the back plate was steel. According to the manufacturer representative, "with the Rochester transmitter installed with the Stewart Warner fuel gage, the gage indication would increase as the fuel level in the tank got lower." Physical evidence of fuel leakage from the left tank was found at the tank, the tank fitting, and the inboard wing where the tank was installed. No evidence was found of an in-flight mechanical and or flight/control malfunction that would have rendered the airplane uncontrollable prior to the impact.

Factual narrative

History of flight

On August 22, 2001, approximately 0910 central daylight time, a Cessna 152 airplane, N4755B, overran runway 35 during the landing roll at the Parker County Airport (WEA), near Weatherford, Texas, and impacted a tractor/trailer vehicle on Interstate 20. The airplane was owned by a private individual and operated by Aer Mistral, Inc., of Fort Worth, Texas, under 14 Code of Federal Regulations (CFR) Part 91. The student pilot, sole occupant, received fatal injuries, the airplane was destroyed, and the vehicle sustained substantial damage. Visual meteorological conditions prevailed for the planned cross-country flight, and a flight plan was not filed. The solo instructional flight departed the Fort Worth Meacham International Airport (FTW), Fort Worth, approximately 0652, for the planned round robin flight to the Kickapoo Downtown Airpark (T47), Wichita Falls, Texas.

During interviews, conducted by the FAA inspector, the flight instructor stated that the CFR Part 61 student pilot was endorsed for the solo cross-country flight from FTW to T47 with a return to FTW. This was the student's second solo cross-country flight. He had made a solo cross-country flight from FTW to Gainesville Municipal Airport (GLE), Gainesville, Texas, to FTW on August 20, 2001. Further, the student pilot and his instructor had flown the cross-country flight from FTW-T47-FTW the previous day.

The air traffic control data and transcripts were reviewed by the NTSB investigator-in-charge (IIC) and all times were converted to central daylight time unless otherwise noted.

At 06:40:05, the student pilot contacted the local controller at FTW for taxi clearance to Runway 16. At 06:52:00, the pilot requested a northwest departure and was cleared for takeoff. No radar data was obtained for the departure from FTW. At 07:19:13, radar tracked an airplane squawking 1200 on a northwest heading 36 nautical miles north of FTW. The airplane track continued on a northwest heading until 07:39:17, approximately 13 nautical miles southeast of T47. No radar track was observed for an aircraft landing at Kickapoo Airport (T47).

A person at the airport in Wichita Falls (T47), reported to the FAA inspector, that she recalled an airplane making a touch and go landing approximately 0730 on the morning of the accident; however, she could not be certain that the airplane was N4755B. Further, she stated that N4755B had not been refueled that morning at T47.

Approximately 07:39 the radar track of the airplane (4,400 feet msl) turned to a southerly heading and continued in a southeasterly arc flight path. At 0840:58, the pilot contacted the Fort Worth Air Traffic Control Tower (FTW ATC Tower) and reported to the controller that he was flying the airplane from the Kickapoo Airport and that he was lost. At 0841:10, the pilot was assigned a transponder code of 0427. At 0845:02, the controller informed the pilot that the airplane was about 30 nautical miles west of FTW and suggested a heading of 090 degrees. At 0854:40, the airplane (altitude 2,200 feet msl) was approximately 7 nautical miles west of WEA, and the controller asked the pilot what the fuel quantity gages indicated. At 0854:48, the pilot transmitted that the left fuel tank gage indicated full, and the right fuel tank gage indicated empty. At 0855:24, the airplane was approximately 5 nautical miles west of WEA and the controller suggested a heading of 060 degrees to follow Interstate 20 to FTW. At 0901:50, the pilot transmitted that "I was lost and I think that I'm ah low on fuel." At 0901:57, the controller told the pilot that WEA was just to the right of the airplane, and the wind at FTW was from 170 degrees at 18 knots. At 0902:03, the pilot told the controller that he would land the airplane at WEA. No additional communications with the pilot were recorded. According to radar data, the airplane flew to the north and west of WEA, and then entered a final approach for Runway 17.

One witness/pilot at the airport (WEA) observed the airplane land on runway 17 into the wind (20 knots from south) and bounce several times before departing the east side of the runway into the grass. Subsequently, the pilot added power, executed a go-around, made a 270 degree turn to the west, and approached runway 35 for landing. The airplane touched down about the middle (GPS 32 degrees 44.41 minutes North; 097 degrees 40.56 minutes West) of runway 35 (2,889-foot long by 40-foot wide) and remained on the runway. The elevators were up, flaps retracted, propeller turning, and the aircraft speed was "estimated at 40 mph." The airplane was approximately 300 feet from the end of runway [17] threshold, and the witness "never heard the brakes or power applied." The airplane rolled off the end of runway [35] at an "estimated speed of 30 mph."

Another witness/pilot at the airport (WEA) observed the airplane make a "rough" downwind landing (more than 1/2 way down the runway) at an "estimated landing speed of 75 mph." The airplane continued down the runway, slowed to "45-50 mph;" however, the witness "never saw or heard any indication of braking, nor did the pilot add power to takeoff." The airplane continued down the runway until it "ran off the end crushing into a flatbed 18 wheeler truck." The wind was 15-20 knots from the south.

A third witness/student pilot observed the airplane, with all three wheels (GPS 32 degrees 44.46 minutes N; 097 degrees 40.56 minutes West) on the runway, moving from south to north. The wind was "strong from the south." This witness observed the airplane near the north end of the runway, "shake left and right, then disappear from the end" of runway 35.

The driver of the tractor/trailer truck reported that his vehicle was traveling eastbound in the center lane of Interstate 20 when he saw the airplane coming from the south "like is taken off." The driver stated the "[air]plane come straight to my cab, hit back of sleeper," and subsequently, the airplane "hit right side of trailer" and then looked "like roll over like half turn." The driver reported the "speed of his truck was 60 mph."

Personnel information

On June 18, 2001, Aer Mistral, Inc., notified the Honorable US Consulate General, US Embassy, India in writing that the pilot's flight and ground training would be followed according to Federal Aviation Regulations Part 61, Part 91, and Part 141, and would also meet the flight requirements as per the Indian DGAC.

According to the pilot's logbook and the FAA records, reviewed by the NTSB IIC, the pilot was issued an FAA student pilot certificate and a first class medical certificate on June 22, 2001. There were no limitations on the medical certificate. The pilot's initial dual flight was performed on July 17, 2001. The student pilot, with an accumulated flight time of 18.8 hours dual instruction in the make and model of the accident aircraft, was endorsed for solo flights on August 6, 2001. During the pilot's initial solo flight of 0.9 hour on August 10, 2001, he logged 3 landings. The student pilot's logbook accumulated flight time was 27.1 hours of which 2.2 were solo. The pilot's logbook indicated 4 solo landings prior to the day of the accident. Approximately 8 additional hours (undeterminable dual or solo) were estimated from the company pilot log for July and a page of flight times found in the accident airplane.

On August 18, 2001, the initial dual cross-country flight was performed from FTW to GLE to FTW. The student pilot was endorsed for solo cross-country flights on August 18, 2001, and he performed his first solo cross-country flight on August 20, 2001, from FTW to GLE to FTW. The second dual cross country flight was conducted on August 21, 2001, from FTW to T47 with a return leg to FTW. The accident flight occurred the following morning during the return leg (T47 to FTW) of the student pilot's solo flight from

Aircraft

Registration
N4755B
Reported as
Cessna 152
Category
Airplane
Serial number
15283618
Airframe hours
11,633
Engine
Lycoming O-235-L2C, 110 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Operator
Aer Mistral, Inc.
Registered owner
Ashish V. Coswami
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · July 26, 2001 · 51.6 hours before
Departed
T47 · Wichita Falls, TX
Destination
FTW · Fort Worth, TX
Airport
WEA · Parker County, runway 35, 2,889 × 40 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
20
Injuries
Fatal
Certificate
Student
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
37 total · 37 in this make and model · 5 as pilot in command · 37 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 20 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F

Docket · 64

The files NTSB released with the investigation on March 27, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 87.2 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 2.3 MBWitness Statements (5)Item 2 · .PDF · 1.8 MBWreckage DiagramsItem 3 · .PDF · 137 KBReports from Federal Agency (FAA)Item 4 · .PDF · 1.7 MBReports from State Agency (Texas Department of Public Safety)Item 5 · .PDF · 3.7 MBPortion of the Report from Party to the Investigation (Cessna)Item 6 · .PDF · 12.2 MBAm-Safe Inc., ReportItem 7 · .PDF · 5.9 MBReport from Party to the Investigation (Lycoming)Item 8 · .PDF · 2.8 MBAerodrome DataItem 9 · .PDF · 356 KBRefueling RecordItem 10 · .PDF · 206 KBPilot RecordsItem 11 · .PDF · 7.1 MBService Bulletins (Cessna)Item 12 · .PDF · 6.6 MBPortions of Maintenance RecordsItem 13 · .PDF · 23.4 MBStatement of Party Representatives to NTSB InvestigationItem 14 · .PDF · 468 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 15 · .PDF · 1.5 MBToxicological ReportItem 16 · .PDF · 70 KBPhoto 01: View of airplane with initial impact area in foreground.Item 17 · .PDF · 249 KBPhoto 02: View of airplane.Item 18 · .PDF · 349 KBPhoto 03: View of airplane.Item 19 · .PDF · 214 KBPhoto 04: View of airplane.Item 20 · .PDF · 339 KBPhoto 05: View of airplane.Item 21 · .PDF · 341 KBPhoto 06: View of airplane.Item 22 · .PDF · 406 KBPhoto 07: View of airplane.Item 23 · .PDF · 257 KBPhoto 08: View of airplane.Item 24 · .PDF · 333 KBPhoto 09: View of airplane.Item 25 · .PDF · 317 KBPhoto 10: View of cockpit.Item 26 · .PDF · 339 KBPhoto 11: View of inboard left wing.Item 27 · .PDF · 196 KBPhoto 12: View of inboard right wing.Item 28 · .PDF · 330 KBPhoto 13: View of inboard right wing, fuel cap, and flap.Item 29 · .PDF · 203 KBPhoto 14: View of inboard left wing, fuel cap, and flap. (Courtesy of Cessna)Item 30 · .PDF · 293 KBPhoto 15: View of flap handle and cockpit indicator. (Courtesy of Cessna)Item 31 · .PDF · 347 KBPhoto 16: View of fuel quantity gages. (Courtesy of Lycoming)Item 32 · .PDF · 338 KBPhoto 17: View of engine controls. (Courtesy of Lycoming)Item 33 · .PDF · 540 KBPhoto 18: View of left seat and lapbelt.Item 34 · .PDF · 359 KBPhoto 19: View of lapbelt webbing. (Courtesy of Cessna)Item 35 · .PDF · 533 KBPhoto 20: View of left wing inboard leading edge and strut.Item 36 · .PDF · 207 KBPhoto 21: View of right wing inboard leading edge.Item 37 · .PDF · 301 KBPhoto 22: View of engine. (Courtesy of Cessna)Item 38 · .PDF · 630 KBPhoto 23: View of right main wheel. (Courtesy of Cessna)Item 39 · .PDF · 294 KBPhoto 24: View of propeller spinner.Item 40 · .PDF · 372 KBPhoto 25: View of propeller. (Courtesy of Lycoming)Item 41 · .PDF · 863 KBPhoto 26: View of propeller blade.Item 42 · .PDF · 465 KBPhoto 27: View of propeller blade.Item 43 · .PDF · 492 KBPhoto 28: View of propeller blade and vehicle trailer.Item 44 · .PDF · 334 KBPhoto 29: View of vehicle trailer.Item 45 · .PDF · 328 KBPhoto 30: View of trailer. (Courtesy of Lycoming)Item 46 · .PDF · 554 KBPhoto 31: View of vehicle trailer. (Courtesy of Lycoming)Item 47 · .PDF · 522 KBPhoto 32: View of vehicle trailer. (Courtesy of Lycoming)Item 48 · .PDF · 504 KBPhoto 33: View of runway 35 looking North.Item 49 · .PDF · 169 KBPhoto 34: View looking North with end of runway 35 in foreground.Item 50 · .PDF · 400 KBPhoto 35: View of embankment, service road, and Interstate 20.Item 51 · .PDF · 420 KBPhoto 36: View of runway 17. (Courtesy of Cessna)Item 52 · .PDF · 483 KBPhoto 37: View of fuel from airplane.Item 53 · .PDF · 287 KBPhoto 38: View of right fuel cap.Item 54 · .PDF · 155 KBPhoto 39: View of left fuel cap.Item 55 · .PDF · 152 KBPhoto 40: View of right fuel transmitter.Item 56 · .PDF · 315 KBPhoto 41: View of left fuel transmitter.Item 57 · .PDF · 379 KBPhoto 42: View of left fuel tank. (Courtesy of Cessna)Item 58 · .PDF · 426 KBPhoto 43: View of left fuel tank. (Courtesy of Cessna)Item 59 · .PDF · 250 KBPhoto 44: View of fuel quantity gage backplate. (Courtesy of Cessna)Item 60 · .PDF · 611 KB
All 64 files on NTSB’s docket

FAA reports on this event · 1

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

Other investigations on N4755B · 1

Matched to the same aircraft by N-number and date.