# NTSB WPR09LA374: Air Tractor AT-301, N23189, Firebaugh, CA, July 29, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 29, 2009, 04:15 local (11:15 UTC) - Place: Firebaugh, CA - Coordinates: 36.907222, -120.514999 - Nearby events: https://openairdocs.org/map.md?lat=36.9072&lon=-120.5150&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 22, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 74400 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA374 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74400/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74400 - Page: https://openairdocs.org/ntsb/WPR09LA374 ## Probable cause A total loss of engine power due to fuel exhaustion that was due to the failure of company ground personnel to refuel the airplane. Contributing to the accident was unsuitable terrain for a forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Air Tractor AT-301, 3 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=0390103), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Air Tractor AT-301, 7 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=0390103), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Ground crew (probable cause); cases with it: [Air Tractor AT-301, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=0390103), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Air Tractor AT-301, 5 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=0390103), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Air Tractor AT-301, 17 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0390103), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Air Tractor AT-301, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=0390103), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Air Tractor AT-301, 6 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=0390103), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The single-engine airplane experienced a total loss of engine power five minutes after takeoff during an aerial application flight. The pilot attempted a forced landing to an alfalfa field he was preparing to spray, but after touching down, the airplane impacted an angle ditch and nosed over. The airplane sustained substantial damage to its empennage. A Federal Aviation Administration (FAA) safety inspector examined the airplane on the morning of the accident and reported finding that both wing tanks were void of any fuel, and there was no evidence of any leakage. When the inspector revealed this to the pilot, the pilot stated that company personnel had fueled the airplane about 10 minutes prior to the accident. The pilot added that company policy is for the ground crew to fuel after each load, normally with 30 gallons of fuel to each wing tank while loading the plane with pesticide. The pilot supplied a company fuel log that indicated the airplane was fueled 4 times on the day of the accident. A subsequent examination and engine run performed by an airframe and power plant mechanic revealed no anomalies with the engine that would have precluded normal operation. ## Factual narrative On July 29, 2009, about 0415 Pacific daylight time, an Air Tractor Inc. AT-301, N23189, sustained substantial damage during a forced landing following a loss of engine power about 5 nautical miles northwest of Firebaugh, California. The commercial pilot was not injured. Visual meteorological conditions prevailed for the aerial application flight, which was conducted in accordance with 14 Code of Federal Regulations Part 137, and a flight plan was not filed. The flight departed from a private airstrip about 4 miles east of Dos Palos, California, at 0410. In a statement submitted to the Safety Board investigator-in-charge (IIC), the pilot reported that while approaching the field to be sprayed the airplane's engine lost power. The pilot stated that after making a forced landing the airplane impacted an angle ditch and nosed over, which resulted in substantial damage to the airplane's empennage. A Federal Aviation Administration (FAA) inspector, who responded to the accident site, reported that when he arrived he noted that no fuel was in either wing tank, and that no fuel was heard in the tanks, nor could he hear any sloshing of fuel in the tanks. The inspector further reported that when the fuel caps were opened no fuel exited and no fumes were present. When asked by the inspector who fueled the airplane, the pilot said that it was company personnel, that they always do both fuel and pesticide, and that they typically put 30 gallons of fuel in each tank. The pilot provided the IIC with a fuel load sheet, which indicated that the airplane was fueled prior to the 4th load after a change of airstrips took place at 0300; the accident occurred on the 4th load. A certificated FAA airframe and powerplant mechanic stated that an inspection of the engine revealed no abnormalities, either external or internal. The mechanic reported that a check of the opening and closing of the valves were normal with the rotation of the engine, that all 9 cylinders maintained adequate compression, that the blower impeller turned 10 to 1 with engine rotation, and that he dialed the crankshaft and found it within limits. The mechanic installed a serviceable propeller and conducted an engine run at full power, with normal manifold pressure and revolutions per minute (RPM) achieved; the magnetos checked normal. The mechanic stated that after the engine was shut down he removed the oil screen and found no foreign metal or debris. The mechanic reported that he found the engine to be airworthy for normal operation. ## Aircraft - Registration: [N23189](https://openairdocs.org/deregistered/N23189-2014-02-25), registration cancelled 2014-02-25, S/N 301-0366, built 1981 (OpenAirDocs) - Reported make and model: AIR TRACTOR AT-301 - Registry model: [Air Tractor AT-301](https://openairdocs.org/model/air-tractor-at-301) (registry code 0390103) (OpenAirDocs) - Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 301-0366 - Airframe hours: 6478 - Engines: Pratt & Whitney R-1340 600 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Bob J. Spain - Registered owner: Spain Air Inc. - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, July 24, 2009, 194 hours before - Departed: Dos Palos, CA - Destination: Dos Palos, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review December 14, 2007; seat: single; flight hours: 35,000 total, 25,000 in this make and model, 35,000 as pilot in command, 200 in the last 90 days, 100 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 57 °F - Altimeter: 29.75 inHg - Observed at: MAE, 23 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 20090729014389A](https://openairdocs.org/incident/20090729014389A), Jul 29, 2009: Airtrc AT301, Substantial damage. (-23) Aerial application southeast of dos palos, CA on 07/29/2009 at 04:15. The pilot landed in an alfalfa field and hit a soft soil water ditch, causing the… ## Docket (4 files) The files NTSB released with the investigation on May 10, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74400. 1.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 857 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40328668&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Mechanic's Statement (item 2, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40328670&FileExtension=.PDF&FileName=Mechanic%27s%20Statement-Redacted.PDF - FAA Inspector's Statement (item 3, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40328671&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Spain Air Fueling Log (item 4, .PDF, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40328672&FileExtension=.PDF&FileName=Spain%20Air%20Fueling%20Log-Redacted.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.