WPR11LA266

NTSB accident investigation · Cessna 172P · Mount Pleasant, UT · June 18, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
June 18, 2011, 13:00 local (19:00 UTC)
Place
Mount Pleasant, UT
Injuries
2 serious, 3 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N65654Cessna 172P
Defining event
Maneuvering: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report November 26, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Cessna Aircraft Company, Salt Lake FSDO
FAA report
20110618011159A
Case key
80813

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

On this page

Probable cause

The pilot’s failure to determine the airplane’s fuel quantity before takeoff, which resulted in a loss of engine power due to fuel exhaustion.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 172P: 8 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 172P: 3 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Not serviced/maintainedCessna 172P: 8 casesAll aircraft: 1,695 cases
Object/animal/substanceEnvironmental issues › Physical environment · Not specifiedCessna 172P: 2 casesAll aircraft: 224 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On the day of the accident, the pilot reported that he expected the borrowed airplane’s fuel tanks to be full. Since there was no ladder available to visually view the fuel tank quantity or to use a dip stick, he relied on the fuel gauges, which indicated that the left tank was about 3/8 full and the right fuel gauge indicated full. After accomplishing two parachute drops, an individual asked the pilot to take him and his children on a local sightseeing flight. During that flight, the engine lost power and the pilot subsequently made a forced landing to a field. During the wreckage recovery, personnel reported that neither fuel tank was breached and that the tanks were empty, suggesting that the loss of engine power was due to fuel exhaustion. Throughout the day, the airplane’s fuel quantity gauges gave indications that suggested the tanks contained fuel, and the pilot, therefore, continued to fly the airplane without visually inspecting the quantity of fuel in the tanks. Postaccident examination and testing of the fuel quantity indicating system did not reveal any mechanical malfunctions or failures that would preclude normal operation. The pilot who previously flew the airplane reported that, although the protocol was that all individuals who borrowed the airplane were to fill its fuel tanks after using it, he had failed to do so and left about 5 gallons of fuel in one tank and about 3 gallons of fuel in the other.

Factual narrative

On June 18, 2011, about 1300 mountain daylight time, a 1983 Cessna 172P, N65654, impacted the terrain about three miles northeast of Mount Pleasant Airport, Mount Pleasant, Utah. The private pilot and one of his passengers received serious injuries, and the other three passengers received minor injuries. The airplane, which belonged to a friend of the pilot, sustained substantial damage. The local 14 Code of Federal Regulations Part 91 personal pleasure flight, which departed Mount Pleasant Airport about 15 minutes prior to the accident, was being operated in visual meteorological conditions. No flight plan had been filed. According to the pilot, the original reason for using the airplane that day was that his son had been asked to make a parachute jump at the Rocky Ridge, Utah, Town Days celebration. The pilot therefore borrowed his friend’s airplane, which was kept at South Valley Regional Airport, near West Jordon, Utah. After his son removed the right front seat from the airplane in order to facilitate the parachute jump, the pilot departed South County Regional Airport and flew to Rocky Ridge, a distance of about 49 miles. After some minimal maneuvering at Rocky Ridge, the pilot’s son made the parachute jump. And then, because there is no airport directly associated with the town of Rocky Ridge, the pilot continued on to Nephi Municipal Airport, Nephi, Utah, which is about 14 miles south of Rocky Ridge. The pilot waited at Nephi while his son repacked his parachute and got a ride down to the Nephi Airport. While the pilot was waiting at Nephi, he received a phone call from a friend of his who lived in Mount Pleasant, Utah, which is located about 25 miles southeast of Nephi Municipal Airport. That individual asked the pilot if it would be possible if his son could make a parachute jump that same day into a field near his house in Mount Pleasant. When the pilot’s son arrived at Nephi Municipal Airport, the pilot asked him if he would like to make the second jump at Mount Pleasant, and his son said that he would. The pilot therefore took off and flew the 25 miles to Mount Pleasant. After arriving in the Mount Pleasant area, the pilot flew down low over the field behind his friend’s house in order to make sure it was a safe place for his son to parachute into. He then climbed up to 9,800 feet mean sea level (MSL), which was about 4,000 feet higher than the elevation at the field. After some minor maneuvering for alignment, the pilot’s son parachuted from the airplane and successfully landed in the designated field. The pilot then flew about three miles south and landed at the Mount Pleasant Airport. When his friend arrived at the airport with the pilot’s son, the friend had his wife and their three children with him, and he asked the pilot if he could take him and the children for a short ride around the area. Since the pilot’s son still had to pack his parachute, the pilot agreed to take his friend and the three children for a flight aroundthe immediate area. The three children were put in the two-person rear seat, with the youngest two sharing one seatbelt and the older child using the second seatbelt. The pilot used the belt portion of his 3-point restraint system, and the pilot’s friend kneeled on the floor where the right front seat had been, and reportedly did not use any of the restraint system. The pilot then took off from Mount Pleasant Airport, flew over his friend’s house, then along a nearby ridge. His friend then asked the pilot if they could descend lower so he could take a closer look at a campground near his home. In response, the pilot reduced the power and descended toward the campground. As the pilot started to level off to pass by the campground, the airplane’s engine sputtered and stopped. The pilot then moved the fuel selector from the BOTH position to the right tank, and after priming the engine, attempted a restart. Since the restart was unsuccessful, he then switched to the left fuel tank, primed the engine, and again tried a restart. The pilot then turned toward the airport, lowered the flaps to about 15 degrees, and tried another restart with the selector on the BOTH position. Ultimately realizing that he was not going to make it to the airport, the pilot headed for a nearby road, but when a couple of cars appeared on the road, he elected to land in an open field alongside the road. As the airplane was touching down, it impacted a number of large sagebrush bushes and its right main gear impacted a rock, resulting in a deceleration rate that caused both the pilot and his friend to hit the airplane’s instrument panel hard. During the investigation it was determined that the owner of the airplane allowed a small group of his friends to fly the airplane at no cost, as long as they filled up the fuel tanks prior to putting it back in the hangar. Except for one individual, each one of the friends had to call the owner to schedule a time to use the airplane, and then they had to acquire the key to the hangar. One of the friends, who was a former partner in the airplane, had his own key to the hangar, and therefore was able to use the airplane with or without the owner’s knowledge. That individual flew the airplane without the owner’s knowledge on the day prior to the accident flight, and since his passenger was in a hurry to get going after the flight, he did not refuel the airplane prior to putting it back into the hangar. Although he did use the dip stick to measure the fuel in each tank after the flight, he did not make it back to the airport to refuel the airplane before the airplane was used again the next morning. Since the owner did not know that the airplane had been flown on the day prior to the accident, when the accident pilot called to get permission to use the airplane, the owner told him that it should be full of fuel (although according to the owner, he expected the pilot would use the dipstick to check the tanks prior to flight). Therefore,according to the dipstick measurements made by the pilot at the end of the flight on the previous day, when the accident pilot arrived at the hangar around 0800 on June 18, the airplane had about five gallons of fuel in one tank and about three gallons in the other. Although the pilot drained a small amount of fuel out of each tank to check for clarity and for the correct color, he did not physically removed the fuel tank caps to look inside, nor did he use the dipstick that was in the airplane to measure the quantity in each tank. When asked by the NTSB Investigator-In-Charge (IIC) why he had not done so, the pilot stated that he had looked around the hangar to find something safe to stand on to gain access to the top of the wings, but that he was unable to find a suitable object. He therefore relied on the fuel quantity gauge indications to determine the approximate amount of fuel that was present, and, according to the pilot, when he pulled the airplane out of the hangar and turned the power switch on, the left gauge indicated about 3/8th full and the right gauge indicated near full. During the IIC’s phone interview with the pilot, he stated that shortly after he took off from Nephi, both fuel quantity gauges indicated almost empty (although in his written statement he said that only the right fuel quantity gauge indicated near empty, and that the left indicated about 5/8th full). The pilot therefore made the decision to turn back to Nephi, but as he did so, the left fuel quantity gauge reportedly returned to near the ½ full mark, and the right gauge reportedly stayed near the 5/8 full position. The pilot therefore turned toward Mount Pleasant, and continued to his destination. When asked by the IIC what the fuel quantity indications were just prior to his takeoff from Mount Pleasant, the pilot stated that he did not remember if he had rechecked what the fuel quantity indications were at that point, and was therefore unable to say what the gauges were indicating. As part of the investigation, the fuel quantity gauges and the tank-mounted fuel quantity measurement/sender units were removed from the airplane and taken to the Avionics Shop at Tacoma Narrows Airport, Tacoma, Washington, for an NTSB directed examination and testing sequence. After performing a visual examination that found no anomalies, the technician connected both gauges to their respective measurement/sender units and applied direct current (DC) power for testing. During the test sequence, each gauge read FULL when the sender arms where in the full up position, and each gauge read below the EMPTY position when the sender arms where in the full down position (see photos). During movement of the sender arms from the full up (FULL) position to the full down (EMPTY) position and back again, there was a smooth linear transition of the needles on the gauges, with no indication of any sticking or hesitation associated with either the measurement/sending units or the gauges. Theinvestigation also determined that when recovery personal came to remove the airplane from the accident site, there was no fuel in either of the fuel tanks, and that neither tank had been breached. Also, an examination of the fuel caps determined that they were both in good condition, and that they were tight on the tank filler neck, with no staining or other signs of leakage anywhere on the airframe. It was further noted that both sides of this airplane were equipped with strut step pads, fuselage mounted steps, and fuselage mounted handles, specifically designed for accessing the fuel tank filler necks. It was also determined that all components of the four individual restraint systems remained attached to their respective fuselage attach points, with all components being in good condition, except for impact associated damage to the buckle end of the right front seatbelt.

Aircraft

Registration
N65654
Reported as
Cessna 172P
Category
Airplane
Serial number
17275800
Airframe hours
1,645
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Davis Brian W
Registered owner
Davis Brian W
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 13, 2010 · 153 hours before
Departed
43U · Mount Pleasant, UT
Destination
43U · Mount Pleasant, UT

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
57
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
April 20, 2010
Seat
Left
Flight hours
543 total · 539 in this make and model · 529 as pilot in command · 2 in the last 90 days · 2 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F

Docket · 9

The files NTSB released with the investigation on October 5, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.7 MB in all.

FAA reports on this event · 1

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