WPR19LA243

NTSB accident investigation · Mooney M20C · Reno, NV · August 26, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 26, 2019, 16:44 local (23:44 UTC)
Place
Reno, NV
Injuries
2 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N78988Mooney M20C
Defining event
Approach-VFR pattern final: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Mooney International, Lycoming Engines
FAA report
20190826015789A
Case key
100145

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 improper inflight fuel management, which resulted in fuel starvation and a total loss of engine power.

Findings · 3

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 managementMooney M20C: 16 casesAll aircraft: 1,695 casesProbable cause
Fuel system: fuel indication systemAircraft › Aircraft systems · Not specifiedMooney M20C: 1 caseAll aircraft: 30 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotMooney M20C: 7 casesAll aircraft: 719 casesProbable cause

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

The pilot and two passengers departed on a cross-country flight. As they approached the destination airport, shortly after the pilot switched the fuel tank selector from the left tank to the right tank, the engine lost total power. During the subsequent forced landing, the airplane impacted a fence and then the ground, resulting in substantial damage to the left wing. Examination of the airplane revealed no preimpact anomalies with the engine, which ran continuously and displayed no anomalies. Fuel computations based on a photo of the airplane’s fuel gauges before departure indicated that the airplane should have contained enough fuel to complete the flight; however, the left fuel gauge and sender may have erroneously indicated that the left fuel tank contained a greater fuel quantity than it actually did. Testing of the fuel gauge and sender was inconclusive due the unknown condition of the units at the time of the accident. The pilot did not have a means to visually confirm fuel quantities other than full and regularly computed his fuel remaining by calculating the total fuel consumption for each flight, using the fuel quantity gauges as a secondary indicator. During flight, he balanced his fuel levels by switching tanks every 30 minutes; however, the pilot stated that during the flight before the accident, he may have become task saturated and forgot to switch tanks, which would have created a fuel imbalance and rendered his fuel computation incorrect for the accident flight. It is likely that the fuel quantity in the right tank was several gallons less than what the pilot calculated, which resulted in a total loss of engine power due to fuel starvation.

Factual narrative

On August 26, 2019, about 1644 Pacific daylight time, a Mooney M20C airplane, N78988, was substantially damaged when it was involved in an accident near Reno, Nevada. Both passengers were seriously injured, and the pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before departure, he sumped the fuel tanks, added oil, and subsequently departed on the accident flight with the fuel tanks about half full. He determined the fuel level by computing the total time the engine had been running since it was last refueled. The pilot reported that he did not have a dipstick for the fuel tanks nor was there one manufactured for his airplane. As he approached the destination airport, he descended below traffic pattern altitude, turned on the electric fuel boost pump, and switched to the right fuel tank just before entering the right base leg of the traffic pattern. Immediately after turning off the fuel pump after switching tanks, while turning onto final approach, the engine sputtered and then lost all power. The pilot switched the fuel selector back to the left tank and turned on the fuel boost pump again. He then pitched the airplane for its best glide speed and configured the airplane for a forced landing. The pilot stated that he was focused on the airspeed indicator during the landing and was not looking outside the airplane when the airplane impacted a fence and then the ground, resulting in substantial damage to the left wing. GPS data from a third-party commercial application used by the passenger during the accident flight showed that the airplane departed and reached its maximum altitude about 20 minutes after departure. The total duration of the flight was about 35 minutes. A Federal Aviation Administration (FAA) inspector arrived at the accident site about 30 minutes after the accident and did not smell any fuel around the wing fuel tanks, both of which had ruptured during impact. The airplane was equipped with two 26-gallon integral sealed fuel tanks located at the wing root of each wing. During normal operation, fuel is fed through aluminum fuel lines that carry it to the engine through a fuel selector valve and an electric boost pump. The system description states: The electric boost pump is turned on for take-off and landing to provide fuel pressure if the engine driven pump malfunctions. The pilot reported that he departed with 21.6 gallons of fuel onboard; about 9.6 gallons in the left wing, and 12 gallons in the right wing. Both propeller blades remained attached to the engine at the propeller hub. One blade exhibited blade tip curling and several gouges. The other blade displayed a slight bend. The engine was mostly intact, with the exception of the airbox and exhaust, which exhibited minor damage. About 1 gallon of 100 low-lead aviation fuel was plumbed directly into the engine-driven fuel pump. The propeller was not replaced before the enginerun. The engine started successfully and was advanced to 1,700 rpm before it was further advanced to the full throttle position and 2,700 rpm. Engine operation was smooth and continuous during the engine run. The pilot reported that he regularly used the fuel quantity gauges on the instrument panel to verify fuel levels. Postaccident examination revealed that both fuel tank gauges indicated erroneous fuel quantities. Tests completed with and without power showed that the right fuel tank indicated a fuel level near empty with the fuel sender at its lowest position. The fuel gauge indicated 6 lbs of fuel without power and 36 lbs of fuel with power for the left tank, with the fuel sender at its lowest position. The fuel senders and fuel gauge cluster were submitted to their manufacturers for further examination; however, tests were inconclusive due to the unknown condition of the fuel senders at the time of the accident. The pilot reported that, before the accident, he had flown from Wyoming, where he last refueled the airplane. The pilot stated that he assumed a fuel consumption rate of 10 gallons per hour and switched tanks every 30 minutes. He further remarked that the accident was likely the result of fuel exhaustion, as he calculated that he had 1 total hour of fuel remaining at the time of the accident. Additionally, he reported that he may have become task saturated during the flight from Wyoming due to turbulence and forgot to switch tanks within the prescribed time period. The pilot stated that the fuel indicators had always reported accurate indications consistent with his total run time computations. A photograph taken by the rear seat passenger of the instrument panel before departure on the accident flight showed that the left fuel tank contained about 9 gallons and the right fuel tank contained about 12 gallons. Fuel computations were completed using the takeoff and climb and cruise data charts from the pilot's operating handbook. Based on these charts, the airplane would have consumed fuel at a rate of 13 gph for the first 9 minutes, 12 gph for 6.5 minutes, 11 gph for 6.5 minutes and finally 10 gph for the remaining 13 minutes of flight. Based on the pilot's statement of fuel load prior to takeoff, the fuel computations indicated that the airplane had approximately 8.7 gallons of fuel in the right fuel tank and 6.2 gallons in the left fuel tank at the time of the power loss. If the pilot left the fuel selector on either tank for 30 minutes longer than planned during his previous flight, the quantity in that tank would have been reduced by about 5-6 gallons. The FAA Pilots Handbook of Aeronautical Knowledge contained the following guidance regarding cockpit fuel gauges: Aircraft certification rules require accuracy in fuel gauges only when they read "empty." Any reading other than "empty" should be verified. Do not depend solely on the accuracy of the fuel quantity gauges. Always visually check the fuel level in each tank during thepreflight inspection, and then compare it with the corresponding fuel quantity indication.

Aircraft

Registration
N78988
Reported as
Mooney M20C (No Series)
Category
Airplane
Serial number
2022
Built
1962
Airframe hours
3,916
Engine
Lycoming O-360-A1D, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 20, 2019 · 98 hours before
Departed
88NV · Gerlach, NV
Destination
RTS · Reno, NV
Flight plan
VFR
Airport
RTS · Reno/Stead
Equipment
Video recording device, Electronic flight bag or handheld device, Handheld GPS, Satellite tracking device

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
33
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
August 6, 2019
Seat
Left
Restraint
Lap only
Flight hours
127 total · 91 in this make and model · 49 as pilot in command · 54 in the last 90 days · 13 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 34 °F
Altimeter
30.12 inHg

Docket · 13

The files NTSB released with the investigation on May 24, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.6 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.