# NTSB WPR12LA023: Cessna 185, N520YH, Prineville, OR, October 28, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 28, 2011, 13:50 local (20:50 UTC) - Place: Prineville, OR - Coordinates: 44.145278, -120.973052 - Nearby events: https://openairdocs.org/map.md?lat=44.1453&lon=-120.9731&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report May 21, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 82196 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82196/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82196 - Page: https://openairdocs.org/ntsb/WPR12LA023 ## Probable cause A total loss of engine power due to fuel starvation, which resulted from the pilot inadvertently leaving the fuel selector set to the left tank. Contributing to the accident was the pilot’s deviation from his normal habit pattern and his failure to refer to the in-flight engine failure checklist after the engine power loss. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect use/operation (probable cause); cases with it: [Cessna A185F, 8 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072821), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna A185F, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072821), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna A185F, 5 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2072821), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna A185F, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=2072821), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna A185F, 8 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072821), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna A185F, 9 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072821), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna A185F, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072821), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis During the descent to the destination airport, when the airplane was about 10 miles out and descending through about 6,500 feet, the engine experienced a total loss of power. In response to the power loss, the pilot manipulated the throttle, mixture, and propeller controls, but the engine did not regain power. When the pilot recognized that the airplane would not be able to reach the destination airport, he conducted a forced landing on an unpaved road. During the landing roll at a groundspeed of about 10 mph, the airplane struck some vegetation, and it then nosed over onto its back. The pilot reported that, at the time of the engine power loss, the electronic fuel flow instrument indicated that 16 gallons of usable fuel was remaining, which he believed was sufficient fuel for about 1 more hour of flight and to reach the destination airport. During recovery, the fuel tanks were observed to contain about 16 gallons of total fuel, and the fuel selector handle was found set to the left tank. However, it was determined that some fuel had migrated from the fuller right tank to the nearly empty left tank via the tank vent line while the airplane was inverted. The pilot stated that his typical habit was to operate the airplane with the fuel selector set to the "both" position, but that, at some point during the flight, he had moved the fuel selector to the left tank to correct a fuel imbalance with the intention of resetting it to the "both" position once the imbalance had been corrected. The pilot reported that he realized that he had forgotten to reset the fuel selector to the "both" position and that this caused the power loss. The pilot reported that he did not manipulate the fuel selector handle after the power loss because he did not believe that he had a fuel problem and that he did not refer to any emergency checklists. The Pilot's Operating Handbook contained an engine failure during flight checklist, which included the step to place the fuel selector valve in the "both" position, which the pilot did not do. ## Factual narrative According to the pilot's written statement regarding the accident, just prior to the engine power loss, the fuel flow device indicated that 58 gallons had been consumed since the previous refueling, which left about 16 gallons of usable fuel remaining. At that time, the pilot estimated that the airplane was about 5 minutes from its destination, and therefore he had more than sufficient fuel to reach the destination. When the engine quit, the pilot was of the mindset that he "did not have a fuel problem." He did not refer to any emergency procedures checklists subsequent to the power loss. The third entry in the "Engine Failure During Flight" checklist in the Emergency Procedures section of the airplane manufacturer's Pilot's Operating Handbook was "Fuel Selector Valve – BOTH." The pilot stated that it was his habit pattern to operate the airplane with the fuel selector set to the BOTH position. When the airplane was righted the day after the accident, and the pilot saw that the fuel selector was set to the left tank, he recalled that at some point during the flight, he had moved the fuel selector from BOTH to LEFT in order to correct a fuel imbalance, with the intention of resetting it to BOTH once the imbalance had been corrected. The post-accident sight of the selector handle, coupled with the engine failure, prompted the pilot to realize that he had likely forgotten to reset the selector to the BOTH position, and that that was the likely cause for the power loss. According to FAA information, the airplane was manufactured in 2006, and was equipped with a Teledyne Continental Motors IO-550 series engine. Pilot-provided information indicated that as of its most recent annual inspection in November 2010, the airplane had accrued a total time in service of 8,131 hours. The pilot estimated that the engine had accumulated about 200 hours in service since it had been overhauled. The airplane was equipped with an electric fuel boost pump that was to be used for starting the engine, and was normally kept off for cruise flight. It was also equipped with a JPI-brand fuel flow indicator and JPI engine monitor. The engine monitor was extracted from the airplane, and was sent to the NTSB Recorders Laboratory in Washington, DC, for data download. The accident flight data was successfully downloaded, and review of the data did not indicate any operational abnormalities. Review of the data revealed that about 2 minutes and 10 seconds before the end of the data, the exhaust gas temperature (EGT) values rose temporarily, and then the EGT and cylinder head temperature values began rapid, smooth, and continuous decreases. The temporary EGT rise preceding the decrease was consistent with engine shutdown by fuel starvation. On October 28, 2011, about 1350 Pacific daylight time, a Cessna 185, N520YH, was substantially damaged during an off-airport forced landing near Prineville, Oregon, following a complete loss of engine power. The owner/pilot and the twopassengers were not injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight. According to the pilot, the flight originated from a private airstrip in central Idaho, and was destined for Bend Municipal Airport (BDN), Bend, Oregon. The pilot estimated that the departure fuel quantity was 57 gallons. The cruise portion of the flight was conducted at an altitude of 10,500 feet, in accordance with visual flight rules, without air traffic control services. About 2.5 hours after takeoff, the pilot began a cruise descent for BDN by reducing power to 20 inches of manifold pressure, and adjusting mixture as required to keep the engine temperature values within the desired ranges. When the airplane was approximately 10 miles from BDN, and descending through about 6,500 feet, the engine suddenly ceased developing power. At the time of the engine power loss, the electronic fuel flow instrument indicated that there was sufficient fuel for about one more hour of flight. In response to the power loss, the pilot manipulated the throttle, mixture, and propeller controls, but the engine did not resume developing power. The pilot did not manipulate the fuel selector handle, or activate the fuel boost pump. The pilot decided that he was committed to a forced landing off-airport, and selected an unpaved road in a wilderness area for the landing. The landing was uneventful until the airplane was nearly stopped. During the rollout, at a speed that the pilot estimated to be 10 mph, the airplane struck some vegetation, and it nosed over onto its back. The pilot shut down the airplane, and he and the two passengers exited through the pilot's door. The pilot telephoned for assistance using his mobile phone. The 1355 automated weather observation at an airport located about 10 miles west-southwest of the accident location included winds from 210 degrees at 9 knots; visibility 10 miles; clear skies; temperature 17 degrees C; dew point minus 12 degrees C; and an altimeter setting of 30.07 inches of mercury. The pilot held an airline transport pilot certificate with instrument airplane and single- and multi-engine land ratings. He reported a total flight experience of about 3,800 hours, including about 830 hours in the accident airplane make and model. His most recent FAA third-class medical certificate was issued in July 2008, and his most recent flight review was completed in October 2011. The airplane came to rest inverted on the unpaved two-track road that was used for the forced landing. The cowl, right wing strut, vertical stabilizer, and rudder were damaged by the nose-over. No fuel leaks were observed on site. The four-position (LEFT, RIGHT, BOTH, OFF) fuel selector handle was found set to the left tank. When the airplane was righted the day after the accident, the left fuel tank was found to contain about 6 gallons, and theright tank contained about 10 gallons. The two wing tanks were interconnected with a vent line located near the top of the tanks, which could permit fuel to migrate from the fuller tank to the other tank when the airplane was inverted. ## Aircraft - Registration: [N520YH](https://openairdocs.org/aircraft/N520YH), registered now, S/N 18503619, built 1978 (OpenAirDocs) - Reported make and model: CESSNA 185 - Registry model: [Cessna A185F](https://openairdocs.org/model/cessna-a185f) (registry code 2072821) (OpenAirDocs) - Registry engine: [Lycoming IO-520 series](https://openairdocs.org/engine/lycoming-io-520-series) (registry code 41584, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18503619 - Airframe hours: 8131 - Engines: Teledyne Continental IO-550 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 2, 2010 - Departed: Riggins, ID - Destination: BDN, Bend, OR - Airport: BDN, Bend Municipal Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: none; commercial, airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review October 14, 2011; seat: left; flight hours: 3,820 total, 838 in this make and model, 3,396 as pilot in command, 30 in the last 90 days, 10 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 10 °F - Altimeter: 30.05 inHg - Observed at: BDN, 10 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 20111028025799A](https://openairdocs.org/incident/20111028025799A), Oct 28, 2011: Cessna A185F, Bend, OR, Substantial damage. 10/30/2011 - Aircraft enroute from shepp airfield near salmon, id to Bend, OR lost power approximately 15 miles east of Bend, OR (S07). Pilot was was unable to… ## Docket (11 files) The files NTSB released with the investigation on April 24, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82196. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407763&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Sheriff Report Excerpts (item 2, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408591&FileExtension=.PDF&FileName=Sheriff%20Report%20Excerpts-Redacted.PDF - Record of Conversation - Pilot (item 3, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407765&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Record of Conversation - FAA inspector (item 4, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407766&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20inspector-Master.PDF - Recorder 17 - Specialist's Factual Report of investigation (item 5, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408627&FileExtension=.PDF&FileName=Recorder%2017%20-%20Specialist%27s%20Factual%20Report%20of%20investigation-Master.PDF - Recorder 17 - Attachment 1 Data to support Specialist's Factual Investigation (item 6, .CSV, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408628&FileExtension=.csv&FileName=Recorder%2017%20-%20Attachment%201%20Data%20to%20support%20Specialist%27s%20Factual%20Investigation-Master.csv - METARs (item 7, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408723&FileExtension=.PDF&FileName=METARs-Master.PDF - Photo 1. Road and Airplane (Crook County Sheriffs Office photo) (item 8, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407770&FileExtension=.PDF&FileName=Photo%201.%20Road%20and%20Airplane%20(Crook%20County%20Sheriffs%20Office%20photo)-Master.PDF - Photo 2. Front View (CCSO photo) (item 9, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407771&FileExtension=.PDF&FileName=Photo%202.%20Front%20View%20(CCSO%20photo)-Master.PDF - Photo 3. Aft View (CCSO photo) (item 10, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407772&FileExtension=.PDF&FileName=Photo%203.%20Aft%20View%20(CCSO%20photo)-Master.PDF - Photo 4. Lower Instrument Panel (Crook County Sheriff photo) (item 11, .PDF, 546 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407769&FileExtension=.PDF&FileName=Photo%204.%20Lower%20Instrument%20Panel%20(Crook%20County%20Sheriff%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.