# NTSB GAA19CA426: North American T28, N28CU, Hollister, CA, June 20, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: June 20, 2019, 12:00 local (19:00 UTC) - Place: Hollister, CA - Coordinates: 36.893333, -121.410278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.8933&lon=-121.4103&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99867 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA426 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99867/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99867 - Page: https://openairdocs.org/ntsb/GAA19CA426 ## Probable cause The pilot's improper fuel planning, which resulted in fuel exhaustion and the subsequent total loss of engine power. ## 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: [North American T-28B, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=6402506), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [North American T-28B, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=6402506), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection; cases with it: [North American T-28B, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=6402506), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel quantity indicator](https://openairdocs.org/ntsb-findings/01022841): Aircraft › Aircraft systems · Incorrect service/maintenance; cases with it: [North American T-28B, 1 case](https://openairdocs.org/ntsb-findings/01022841/cases.md?model=6402506), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01022841/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [North American T-28B, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=6402506), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192); cases with it: [North American T-28B, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=6402506), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [North American T-28B, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=6402506), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot reported that, after takeoff and while the airplane was about 500 ft above ground level, he retracted the landing gear and that, shortly thereafter, the engine sputtered and lost power. He adjusted the fuel mixture, but it did not have any effect. He attempted to return to the airport, but after realizing that the airplane would not reach the runway, he decided to land in a dirt field near the airport with the landing gear retracted. He recalled that he had the airplane refueled about a week before the accident. The airplane sustained substantial damage to the fuselage. The Federal Aviation Administration inspector who examined the airplane reported that he only removed about 1 or 2 cups of fuel out of the fuel system. The airplane was equipped with only one fuel gauge, which had a single switch that had left, right, and center positions. In the left position, it showed empty; in the center position, which showed the total fuel onboard, it showed 900 lbs; and in the right position, it also showed 900 lbs. No fuel leaks were found, and there were no signs of fuel on the ground. The pilot reported as a safety recommendation to "always top off fuel." ## Factual narrative The pilot reported that, after takeoff, about 500 ft above the ground he retracted the landing gear and shortly thereafter, the engine sputtered and lost power. He adjusted the fuel mixture, but it did not have any effect. He attempted to return to the airport but noticed he would not make the runway and decided to land in a dirt field near the airport with the landing gear retracted. He recalled having refueled the airplane about a week prior. The pilot further reported that as a safety recommendation to "Always top off fuel." The airplane sustained substantial damage to the fuselage. The Federal Aviation Administration inspector who examined the airplane reported that, upon sumping the center tank and both wing tanks, he was only able to obtain about a cup or two of fuel out of the system. He further checked the fuel gauge; there was only one gauge for the fuel with a single switch which has left, right, and center positions. In the left position, it showed empty, in the center position, which showed total fuel, it read 900 lbs. and on the right position, it also showed 900 lbs. He further added that the mechanic that assisted with the recovery, said there was no fuel leaks and there were no signs of fuel on the ground. He also stated that they did not remove any fuel from the aircraft. ## Aircraft - Registration: [N28CU](https://openairdocs.org/aircraft/N28CU), registered now, S/N 200302, built 1956 (OpenAirDocs) - Reported make and model: North American T28 (B) - Registry model: [North American T-28B](https://openairdocs.org/model/north-american-t-28b) (registry code 6402506) (OpenAirDocs) - Registry engine: [Wright R-1820 series](https://openairdocs.org/engine/wright-r-1820-series) (registry code 67020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 200302 - Year built: 1956 - Airframe hours: 15673.9 - Engines: Wright R-1820-86B 1425 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, September 10, 2018 - Departed: CVH, Hollister, CA - Destination: CVH, Hollister, CA - Flight plan: Unknown - Airport: CVH, Hollister Muni, runway 31, 6,350 × 100 ft, asphalt - Equipment: Electronic primary flight display, Electronic multifunction display, Auto-pilot, Stall warning system, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: minor; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review July 14, 2018; seat: front; restraint: 4-point; flight hours: 1,653 total, 1,000 in this make and model, 1,610 as pilot in command, 9 in the last 90 days, 7 in the last 30 days, 0.6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 9 knots - Visibility: 10 statute miles - Temperature: 64 °F, dew point 57 °F - Altimeter: 29.94 inHg - Observed at: KCVH, 1 nm away ## 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 20190620007639A](https://openairdocs.org/incident/20190620007639A), Jun 20, 2019: North American T-28B, Hollister, CA, Substantial damage. Aircraft departed runway 31 when approximately 200? AGL the engine sputtered and quit, he began a turn to downwind, the engine began to run for a few second… ## Docket (4 files) The files NTSB released with the investigation on October 3, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99867. 667 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 332 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476417&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Phone Conversation (Pilot) (item 2, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476418&FileExtension=.PDF&FileName=Record%20of%20Phone%20Conversation%20(Pilot)-Master.PDF - Record of E-mail Correspondence (FAA) (item 3, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476419&FileExtension=.PDF&FileName=Record%20of%20E-mail%20Correspondence%20(FAA)-Master.PDF - Damage Photo (item 4, .PDF, 1 photo, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476420&FileExtension=.PDF&FileName=Damage%20Photo-Master.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.