# NTSB WPR10LA014: Costruzioni Aeronautiche Tecna P2004 Bravo, N649BV, Franklin, CA, October 10, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 10, 2009, 13:45 local (20:45 UTC) - Place: Franklin, CA - Coordinates: 38.303333, -121.429168 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.3033&lon=-121.4292&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 28, 2012 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 74888 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74888/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74888 - Page: https://openairdocs.org/ntsb/WPR10LA014 ## Probable cause A total loss of engine power due to fuel starvation, as a result of the certified flight instructor's improper fuel system management. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=060001M), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=060001M), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=060001M), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 2 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=060001M), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=060001M), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=060001M), [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: [Costruzioni Aeronautiche Tecna P2004 BRAVO, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=060001M), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis While the student pilot was performing a touch-and-go takeoff and landing, the engine sputtered and lost power about 150 feet above ground level. The certified flight instructor (CFI) took the flight controls and continued the flight straight ahead for a forced landing to an open field. The CFI indicated that the field was rough, and during the landing roll, when the nose landing gear contacted the ground, it snapped off, and the airplane nosed over coming to rest inverted. After the accident, the CFI exited the airplane and instructed the student to turn off all the electronics, the fuel, and the ignition. The student said he attempted to turn off the pilot's side fuel selector, but found that it was already in the off position; the copilot's fuel selector was in the on position, so he turned that off before he departed the airplane. The CFI and the student pilot recalled that the left side fuel selector was turned off during the flight to the destination airport in order to balance the fuel load. Before landing, the CFI likely turned the fuel selector to the “off” position rather than the “both” position. ## Factual narrative On October 10, 2009, about 1345 Pacific daylight time, a Special-Light Sport airplane, Costruzioni Aeronautiche Tecnam P2004 Bravo, N649BV, experienced a loss of engine power while on final approach to runway 27 at Franklin Field Airport (F72), Franklin, California. Sterling Flight LLC, doing business as Sterling Flight, operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. The certified flight instructor (CFI) and student pilot were not injured. The airplane sustained substantial damage when the nose landing gear was sheared off; the airplane nosed over and came to rest inverted. Visual meteorological conditions prevailed for the instructional flight that departed Buchanan Field Airport (CCR), Concord, California, at 1315. No flight plan had been filed. In a written statement, the CFI stated that they took off with approximately 18 gallons of fuel, and at the time of the accident they had been flying about 25 minutes. While en route both pilots noted that the right fuel tank was indicating a higher fuel level, so they turned off the fuel switch on the pilot's side for the left fuel tank. Upon arrival at Franklin Field, they entered into the pattern for closed traffic. During the pre landing process, the CFI believed that he "toggled" a fuel tank switch in order to feed fuel from both tanks. They performed two uneventful touch-and-go takeoffs and landings. The CFI stated that on the third or fourth touch-and-go takeoff, the engine sputtered and quit; what he considered consistent to a fuel starvation failure. The CFI took the flight controls, and noted their altitude to be less than 150 feet. He continued straight ahead for a nearby field. As the flight approached the touchdown point, the CFI observed a barbed wire fence and adjusted the approach to clear the fence. The field was very rough, and he was not able to hold the nose wheel off the ground; when it touched down, it snapped off and the airplane came to rest inverted. The CFI further reported that the engine stopped "in a way that is consistent with fuel starvation – a second or two of sputter – not suddenly." The CFI opined that he may have inadvertently switched "off" the fuel tank that was on. According to the student, they were going to perform touch-and-go takeoffs and landings at the accident airport. There were no problems with the first touch-and-go landing; however, on the second touch-and-go landing, he misjudged the landing distance, and performed a go-around. The student reported doing two more touch-and-go takeoffs and landings prior to the accident. On the landing prior to the accident, he reported that they were a bit higher than usual, but that it was not a concern to him. He informed the CFI that he intended to land the airplane; the CFI gave him approval to do so. They landed the airplane without incident, he added full throttle for takeoff without any noticeable problems. The airplane reached an altitudeof about 150 feet and he began to hear "irregularities in the engine," which continued for a couple of seconds. The student reported that the engine slowed down, and then it returned to a full power setting. Shortly thereafter, the student stated that there was a complete engine failure and the propeller stopped spinning. The CFI took over the flight controls at the first sign of engine trouble. After the engine failed, the student reported that the CFI stated his intention to land in a field in front of the runway. The airplane descended rapidly, impacted the ground, and flipped over. The CFI exited the airplane and instructed the student to turn off all the electronics, the fuel, and the ignition. He attempted to turn off the pilot's side fuel selector, but found that it was already in the off position. The student recalls that the left side fuel selector was turned off during the flight. The copilot's fuel selector was in the on position, so he turned that off before he departed the airplane. ## Aircraft - Registration: [N649BV](https://openairdocs.org/deregistered/N649BV-2012-01-31), registration cancelled 2012-01-31, S/N 116, built 2007 (OpenAirDocs) - Reported make and model: Costruzioni Aeronautiche Tecna P2004 Bravo - Registry model: [Costruzioni Aeronautiche Tecna P2004 BRAVO](https://openairdocs.org/model/costruzioni-aeronautiche-tecna-p2004-bravo) (registry code 060001M) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 116 - Airframe hours: 694 - Engines: Rotax 912ULS reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Sterling Flight LLC - Registered owner: Devil Mountain Sport Aviation LLC - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: 100 hour, September 23, 2009, 694 hours before - Departed: CCR, Concord, CA - Destination: F72, Franklin, CA - Airport: F72, Franklin Field Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 43; injuries: none; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 834 total, 45 in this make and model, 795 as pilot in command, 32 in the last 90 days, 18 in the last 30 days, 4 in the last 24 hours - Student pilot; age 27; injuries: none; seat: left; flight hours: 8 total, 8 in this make and model, 8 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 48 °F - Altimeter: 29.79 inHg - Observed at: SAC, 12 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 20091010023169A](https://openairdocs.org/incident/20091010023169A), Oct 10, 2009: Tecnam P2004BRAVO, Elk Grove, CA, Substantial damage. The sport light was practicing takeoffs and landings at franklin field, CA. The aircraft had made multiple prior to the occurance on one of the takeoffs the… ## Docket (3 files) The files NTSB released with the investigation on February 13, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74888. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 630 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40362841&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Student Statement (item 2, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40362840&FileExtension=.PDF&FileName=Student%20Statement-Redacted.PDF - Fire Department Report (item 3, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40362847&FileExtension=.PDF&FileName=Fire%20Department%20Report-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.