# NTSB WPR21LA122: Cessna 172G, N4456L, Sisters, OR, March 4, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: March 3, 2021, 17:45 local (Mar 4, 2021, 01:45 UTC) - Place: Sisters, OR - Coordinates: 44.2984, -121.5445 - Nearby events: https://openairdocs.org/map.md?lat=44.2984&lon=-121.5445&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FSDO FAA, Textron Aviation - NTSB case key (mKey): 102704 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21LA122 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102704/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102704 - Page: https://openairdocs.org/ntsb/WPR21LA122 ## Probable cause A total loss of engine power due to fuel starvation and the pilot’s mismanagement of the available fuel. ## 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 level; cases with it: [Cessna 172G, 8 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072420), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172G, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2072420), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot; cases with it: [Cessna 172G, 6 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2072420), [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 go-around: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Cessna 172G, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=2072420), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Approach-VFR go-around: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 172G, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072420), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The pilot reported she took off with 16 to 17 gallons of fuel and returned to the departure airport following a 1 hour 15-minute flight that included four touch-and-go landings at two airports. During the final landing approach, the pilot performed a forward slip with the engine power at idle. The pilot reported the airplane’s airspeed was fast and the airplane bounced on the runway. She applied a “quick burst of throttle” to recover from the bounced landing but was unsuccessful, so she elected to perform an aborted landing. The pilot reported that she applied “almost” full power, removed carburetor heat, then applied the remaining power at which time the engine lost all power. The airplane was at an altitude of about 150 ft above ground level when the power loss occurred. The pilot attempted to restart the engine but did not switch fuel tanks. Unable to restart the engine, the pilot made a forced landing in an open field. The airplane came to rest in a nose-down attitude with substantial damage to the empennage, both wings, and the forward fuselage. An on-scene examination of the airplane revealed the right fuel tank was almost empty and the left fuel tank contained fuel. A small amount of fuel was present in the gascolator. The pilot reported the fuel selector was positioned on the right fuel tank during the landing. A postaccident examination of the engine did not reveal any mechanical anomalies that would have resulted in a loss of engine power. The pilot reported the mixture was leaned during the flight and landing. The Cessna Before Landing checklist states the mixture control should be positioned to the Rich position before landing. The checklist also states that the fuel selector should be positioned to the BOTH ON position. This procedure is also placarded on the fuel selector. Cessna issued a Pilot Safety and Warning Supplement that cautioned against the possibility of unporting the fuel supply outlet in the fuel tanks during uncoordinated flight, such as slips, with inadequate amounts of fuel in the fuel tanks. Given the small amount of fuel found in the right fuel tank, which was the tank selected, the loss of engine power likely occurred due to fuel starvation as a result of the pilot’s failure to ensure an adequate amount of fuel on board and the failure to have the fuel selector positioned to both fuel tanks during the landing. It is unknown what role the pilot’s decision to perform a forward slip during final approach or her failure to have the mixture control in the full rich position played in the loss of engine power. ## Factual narrative On March 3, 2021, about 1745 Pacific daylight time, a Cessna 172G, N4456L, was substantially damaged when it was involved in an accident near Sisters Eagle Air Airport (6K5) Sisters, Oregon. The pilot sustained a serious injury and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported she performed the airplane preflight and confirmed there was 16 to 17 gallons of fuel on board. The engine run-up was normal as was the flight to Bend Municipal Airport (BDN), Bend, Oregon, where she performed three touch-and-go landings. The flight then proceeded to Redmond Municipal Airport (RDM) where the pilot performed one touch and go landing before flying back to 6K5. The pilot reported that while on final approach to land at 6K5, she performed a forward slip with the engine power at idle and the flaps retracted. She stated the landing approach was fast and the airplane bounced on the runway. She applied a “quick burst of throttle” to recover from the bounced landing but was unsuccessful, so she elected to perform an aborted landing. The pilot reported that she applied “almost” full power, removed carburetor heat, then applied the remaining power at which time the engine lost all power. The airplane was at an altitude of about 150 ft above ground level when the power loss occurred. The pilot reported she attempted to restart the engine by increasing the mixture control to full rich, cycling the carburetor heat, and turning the magnetos. She then readjusted the mixture control and was not able to restart the engine. She did not switch the fuel tank selector during the attempts to restart the engine. Unable to regain engine power, the pilot initiated a forced landing to an open field. The airplane came to rest in a nose-down attitude with substantial damage to the empennage, both wings, and the forward fuselage. The pilot reported she leaned the mixture while en route to RDM and did not reposition the mixture control again until after the engine lost power. She also reported that she took off with the fuel selector in the BOTH position and switched to the left fuel tank upon reaching cruise altitude. She switched the selector to the right tank for the remainder of the flight after departing RDM. A Federal Aviation Administration inspector reported that following the accident the right-wing fuel tank was almost empty and the left-wing fuel tank had fuel remaining. The inspector also reported the gascolator contained very little fuel. A postaccident examination of the engine verified valve train continuity throughout the engine. Suction and compression were obtained on each cylinder when the propeller was rotated by hand. Both magnetos produced spark when tested. The spark plugs exhibited normal wear signatures. The carburetor was partially torn from its mount, but the carburetor itself was intact and clear of debris. The throttle cable and mixture linkage travelwere normal. The carburetor heat valve was closed. Fuel present in the carburetor was clean and tested free of water. No mechanical anomalies were identified during the engine examination that would have resulted in the loss of engine power. The Cessna 172 Owner’s Manual Before Landing checklist states the mixture control should be in the rich position for landing and the fuel selector should be in the BOTH ON position. In addition, the fuel selector was placarded BOTH TANKS ON FOR TAKEOFF & LANDING. The Cessna Pilot Safety and Warning Supplements publication contains a warning titled, “Flight Coordination Vs. Fuel Flow” which states: The shape of most airplane wing fuel tanks is such that, in certain flight maneuvers, the fuel may move away from the fuel tank supply outlet. If the outlet is uncovered, fuel flow to the engine may be interrupted and a temporary loss of power might result. Pilots can prevent inadvertent uncovering of the tank outlet by having adequate fuel in the tank selected and avoiding maneuvers such as prolonged uncoordinated flight or sideslips which move fuel away from the feed lines. ## Aircraft - Registration: [N4456L](https://openairdocs.org/deregistered/N4456L-2024-11-23), registration cancelled 2024-11-23, S/N 17254551, built 1966 (OpenAirDocs) - Reported make and model: CESSNA 172G - Registry model: [Cessna 172G](https://openairdocs.org/model/cessna-172g) (registry code 2072420) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17254551 - Year built: 1966 - Airframe hours: 2010.24 - Engines: Continental 0-300D 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Outlaw Aviation LLC - Registered owner: Outlaw Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, February 28, 2021, 17.54 hours before - Departed: KRDM, Redmond, OR - Destination: Same as departure - Airport: 6K5, Sisters Eagle Air - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 133 total, 98 in this make and model, 58 as pilot in command, 26 in the last 90 days, 16 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 14 °F - Altimeter: 26.69 inHg - Observed at: KRDM, 17 nm away - METAR: SA 04/03/2021 00:56-> METAR KRDM 040056Z 25003KT 10SM CLR 18/M10 A2969 RMK AO2 SLP053 T01781100= ## 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 20210303002699A](https://openairdocs.org/incident/20210303002699A), Mar 3, 2021: Cessna 172G, Sisters, OR, Substantial damage. The pilot of [privacy data omitted] had planned a one hour personal flight with a friend. [privacy data omitted] Is a rental aircraft and had just came back… ## Docket (11 files) The files NTSB released with the investigation on December 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102704. 22.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 580 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14838851&FileExtension=pdf&FileName=WPR21LA122%20Pilot%20Report-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 2 pages, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14813436&FileExtension=pdf&FileName=02%20-%20ROC%20Pilot%201-Rel.pdf - Memorandum for record a�� telephone interview, pilot no 2 (item 3, PDF, 1 page, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14828831&FileExtension=pdf&FileName=03%20-%20ROC%20Pilot%202%20Redacted-Rel.pdf - FAA email excerpt (item 4, PDF, 1 page, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14830887&FileExtension=pdf&FileName=FAA%20Email%20Statement-Rel.pdf - Engine examination report (item 5, PDF, 13 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14839145&FileExtension=pdf&FileName=Engine%20Exam%20Report-Rel.pdf - Cessna 172 fuel management procedures (item 6, PDF, 1 page, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14814612&FileExtension=pdf&FileName=05%20-%20Cessna%20172%20Modified%20Fuel%20Management%20Procedures-Rel.pdf - Cessna 172 operating checklist (item 7, PDF, 4 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14814133&FileExtension=pdf&FileName=06%20-%20Cessna%20172%20Operating%20Checklist-Rel.pdf - Flight coordination vs fuel flow (item 8, PDF, 4 pages, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14814622&FileExtension=pdf&FileName=07%20-%20Flight%20Coordination%20Vs.%20Fuel%20Flow-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 9 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14829307&FileExtension=pdf&FileName=WPR21LA122%20Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 8.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14838818&FileExtension=pdf&FileName=Wreckage%20Release%20Form%20signed-Rel.pdf - Aircraft photo (item 11, PDF, 1 page, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14905420&FileExtension=pdf&FileName=Aircraft%20Photo-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.