# NTSB WPR19LA243: Mooney M20C, N78988, Reno, NV, August 26, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: August 26, 2019, 16:44 local (23:44 UTC) - Place: Reno, NV - Coordinates: 39.656944, -119.857498 - Nearby events: https://openairdocs.org/map.md?lat=39.6569&lon=-119.8575&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 2 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Mooney International, Lycoming Engines - NTSB case key (mKey): 100145 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA243 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100145/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100145 - Page: https://openairdocs.org/ntsb/WPR19LA243 ## Probable cause The pilot's improper inflight fuel management, which resulted in fuel starvation and a total loss of engine power. ## 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 · Fluid management (probable cause); cases with it: [Mooney M20C, 16 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=5870208), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel indication system](https://openairdocs.org/ntsb-findings/01022840): Aircraft › Aircraft systems · Not specified (probable cause); cases with it: [Mooney M20C, 1 case](https://openairdocs.org/ntsb-findings/01022840/cases.md?model=5870208), [All aircraft, 30 cases](https://openairdocs.org/ntsb-findings/01022840/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mooney M20C, 7 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=5870208), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Mooney M20C, 8 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=5870208), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach-VFR pattern final: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mooney M20C, 39 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5870208), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N78988-2022-11-28), registration cancelled 2022-11-28, S/N 2022 (OpenAirDocs) - Reported make and model: Mooney M20C (No Series) - Registry model: [Mooney M20C](https://openairdocs.org/model/mooney-m20c) (registry code 5870208) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2022 - Year built: 1962 - Airframe hours: 3916 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: minor; 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 ## 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 20190826015789A](https://openairdocs.org/incident/20190826015789A), Aug 26, 2019: Mooney M20C, Reno, NV, Substantial damage. Crashed during approach to rts engine stopped and could not be restarted by pilot as stated to Reno police at the scene and pilot elected to land on the… ## Docket (13 files) The files NTSB released with the investigation on May 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100145. 24.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13917112&FileExtension=pdf&FileName=CompletedNTSB6120_Redacted-Rel%20(1)-Rel.pdf - Record of conversation (item 2, PDF, 2 pages, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986722&FileExtension=pdf&FileName=Record%20of%20Conversation-Rel.pdf - Federal aviation administration inspector statements (item 3, PDF, 3 pages, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986108&FileExtension=pdf&FileName=FAA%20statements-Rel.pdf - NTSB examination report (item 4, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986458&FileExtension=pdf&FileName=NTSB%20examination%20report-Rel.pdf - Correspondence with fuel cluster manufacturer (item 5, PDF, 7 pages, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9987077&FileExtension=pdf&FileName=Fuel%20cluster%20exam%20corrspondence_Redacted-Rel.pdf - Foreflight track data excerpt from accident flight (item 6, PDF, 20 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9959093&FileExtension=pdf&FileName=N78988%20tracklog-Rel.pdf - Fuel performance computations (item 7, PDF, 1 page, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986033&FileExtension=pdf&FileName=fuel%20performance%20computations-Rel.pdf - Excerpt from aircraft logbooks (item 8, PDF, 2 pages, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986601&FileExtension=pdf&FileName=Excerpt%20from%20aircraft%20logs_Redacted-Rel.pdf - Fuel system description from pilot's operating handbook (item 9, PDF, 1 page, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9987068&FileExtension=pdf&FileName=fuel%20system%20description-Rel.pdf - Performance charts from pilot's operating handbook (item 10, PDF, 6 pages, 552 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9986680&FileExtension=pdf&FileName=Excerpt%20from%20POH-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 2 pages, 8.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10076965&FileExtension=pdf&FileName=party%20forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 2 pages, 895 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13917240&FileExtension=pdf&FileName=Signed%20Release%20of%20Wreckage%20N78988_Redacted-Rel%20(1)-Rel.pdf - Accident photographs (item 13, PDF, 2 pages, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9987095&FileExtension=pdf&FileName=Accident%20Photographs-Rel.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.