# NTSB WPR22LA231: James C Geyman RV-9A, N12VV, Missoula, MT, June 27, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: June 27, 2022, 10:02 local (16:02 UTC) - Place: Missoula, MT · On Airport - Coordinates: 46.916306, -114.09055 - Nearby events: https://openairdocs.org/map.md?lat=46.9163&lon=-114.0905&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Lycoming Engines, Federal Aviation Administration - NTSB case key (mKey): 105366 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22LA231 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105366/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105366 - Page: https://openairdocs.org/ntsb/WPR22LA231 ## Probable cause The pilot’s improper fuel management, which resulted in fuel starvation and a loss of engine power. Contributing to the accident was the pilot’s failure to activate the auxiliary fuel boost pump, which inhibited a successful engine restart. ## 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) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot - [Fuel system: fuel pumps](https://openairdocs.org/ntsb-findings/01022822): Aircraft › Aircraft systems · Not used/operated (probable cause) ## Analysis The pilot reported that he was performing flight testing after accumulating 9 hours of flight time on the recently constructed airplane. He departed with 16 gallons of fuel in the right tank and 8 gallons in the left tank. The pilot then flew for about 70 minutes with the fuel selector on the right tank. As the airplane approached the airport to land, a total loss of engine power occurred, and the pilot switched the fuel selector to the left fuel tank but did not activate the auxiliary fuel pump and his attempt to restart the engine was unsuccessful. The flight characteristics in the airplane’s final moments suggest the airplane entered an aerodynamic stall when it began a steep left turn and rapidly descended into the ground. Postaccident examination of the wreckage did not reveal any preimpact mechanical anomalies with the engine or airframe that would have precluded normal operation. The pilot departed with about 15 gallons of usable fuel in the selected tank, and then flew for about 70 minutes. The engine was likely consuming fuel at a rate of about 12 gallons per hour (gph), which would have yielded a total fuel consumption of about 14 gallons during this flight. Fuel flow data indicated that the engine-driven fuel pump likely cavitated just before the engine lost power, which was likely caused by an unporting of the right fuel tank pickup due to insufficient fuel in the selected fuel tank. It is likely that the pilot’s improper fuel management resulted in fuel starvation and a loss of engine power. Further, the pilot’s failure to activate the auxiliary fuel boost pump likely inhibited the engine restart. ## Factual narrative On June 27, 2022, about 1002 mountain daylight time, an experimental amateur-built Van’s RV-9A airplane, N12VV, was substantially damaged when it was involved in an accident near Missoula, Montana. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot (and builder of the accident airplane), he was performing flight tests on his airplane to break in the engine. The pilot reported that he completed one test flight on the morning of the accident and landed about 0800 to refuel the airplane. He then departed with the fuel selector positioned on the right fuel tank. The right fuel tank contained16 gallons of fuel; 8 gallons of fuel were in the left tank. Data retrieved from an onboard recording device showed that the airplane departed runway 29 at 0850. The pilot flew the airplane in a racetrack style pattern from the southeast to northwest in an area about 2 nautical miles (nm) west of his departure airport for about 1 hour 15 minutes. According to the parametric data, at 1000:10 the fuel flow became increasingly erratic with two spikes indicating a fuel consumption of about 42 gph. During this time, the engine speed, exhaust gas temperatures, and cylinder head temperatures decreased over time. The pilot contacted air traffic control to inform them that his engine was “surging” and was “probably about to quit.” The controller then cleared the pilot to land on runway 8. After the engine quit the pilot switched fuel tanks from the right tank to the left tank and the engine restarted for about 2 seconds before it quit again. An airport surveillance video showed the airplane descending from a low altitude as it approached the airport from the northwest. While passing near the approach end of runway 8, the airplane made a steep left turn from an estimated altitude of about 30 ft above ground level and descended rapidly towards the ground and impacted terrain, which resulted in substantial damage to the left wing. The airport manager stated that the wreckage came to rest between runway 12/30 and taxiway alpha between midfield and the approach end of runway 30. The wreckage was located about 0.5 nm east of the approach end of runway 8. Wreckage examination Postaccident examination of the airplane and engine did not reveal any preimpact mechanical anomalies. The fuel system was traced from each wing tank to the carburetor at the engine through the fuel selector, which rotated normally and was unobstructed. The fuel lines that had not been damaged from impact or removed to transport the airplane were secure. Mechanical continuity was established throughout the rotating group, valvetrain, and accessory section as the crankshaft was manually rotated at the propeller by hand. Thumb compression was achieved at all four cylinders and the valves displayed normal lift when the crankshaft was rotated. Examination of the cylinders’ combustion chamber interior componentsusing a lighted borescope revealed normal piston face and valve signatures and no indications of catastrophic engine failure. The engine-driven fuel pump functioned normally when tested by hand. Fuel Consumption Data retrieved from a Garmin G3X onboard recording unit displayed the fuel quantities as 18 gallons in the right tank and 18 gallons in the left tank (totaling 36 gallons) from 0837 to 0849. At 0849, about when the engine was advanced to full power, the fuel quantities changed to 2 gallons in the left fuel tank and 13 gallons in the right fuel tank. These quantities were displayed for the remainder of the flight. The fuel flow advanced to about 10 gph during takeoff and remained between 10-14 gph until about 1000, at which time the fuel flow became erratic showing a minimum of 2 gph and a maximum of 42 gph at 1001:19. One second later, the engine speed began to reduce from 2,240 rpm to idle power and then 100 rpm. According to the engine manual for an O-360-A1A, which is comparable to the engine that was installed on the accident airplane and had the same compression ratio, the fuel consumption is 9.5 gph at 65% power, 10.5 gph at 75% power, and 14.9 gph at 100% power. Using the recorded engine data, an average fuel consumption of 12 gph would have resulted in a total fuel burn of about 14 gallons. The pilot reported that he was using 10.5 gph to determine the engine’s fuel consumption for the flight and added that he did not activate the electric fuel pump after the engine quit. At 10.5 gph, the engine would have consumed a total of about 12.25 gallons in the airplane’s 70 minutes of flight. According to the pilot, he had not yet determined the airplane’s unusable fuel quantity, but assumed it was about 1 gallon. The pilot also noted that he was operating at higher power settings to break in the engine during the accident flight. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event) - [Emergency descent: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) ## Aircraft - Registration: [N12VV](https://openairdocs.org/deregistered/N12VV-2023-09-20), registration cancelled 2023-09-20, S/N 93267, built 2022 (OpenAirDocs) - Reported make and model: JAMES C GEYMAN RV-9A - Registry model: [James C Geyman RV-9A](https://openairdocs.org/model/james-c-geyman-rv-9a) (registry code 056400B) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1A](https://openairdocs.org/engine/lycoming-o-360-a1a) (registry code 41594, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 93267 - Airframe hours: 9 - Engines: Lycoming YO-360-EXP278 180 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 7, 2022, 8 hours before - Departed: MSO, Missoula, MT - Destination: Same as departure - Airport: MSO, Missoula Intl, runway 30/12, 9,501 × 150 ft, asphalt - Equipment: Handheld GPS, Onboard weather, ADS-B, Auto-pilot, Data recorder, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review June 20, 2022; seat: left; restraint: 4-point; flight hours: 1,350 total, 800 in this make and model, 1,300 as pilot in command, 37 in the last 90 days, 27 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 45 °F - Altimeter: 30.23 inHg - Observed at: KMSO - METAR: KMSO 271553Z 00000KT 10SM CLR 19/07 A3023 RMK AO2 SLP220 T01890067 ## 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 20220627012239A](https://openairdocs.org/incident/20220627012239A), Jun 27, 2022: James C. Geyman RV-9A, Missoula, MT, Substantial damage. On July 27, 2022, at 1002 MDT, a vans RV-9A, N12VV, [privacy data omitted], crashed on approach to runway 30 on the Missoula, MT airport (mso). Visual… ## Docket (12 files) The files NTSB released with the investigation on April 18, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105366. 25.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15787980&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Accident photographs (item 2, PDF, 2 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15787699&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf - Air traffic control tower audio - mso (item 3, MP3, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749387&FileExtension=mp3&FileName=KMSO-Jun-27-2022-1530Z-Rel.mp3 - Global positioning system devices - specialist's factual report (item 4, PDF, 14 pages, 8 photos, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15103540&FileExtension=pdf&FileName=FINAL_WPR22LA231_report-Rel.pdf - Global positioning system devices - attachment 1 (csv data for accident flight) (item 5, ZIP, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15103190&FileExtension=zip&FileName=WPR22LA231_data_all-Rel.zip - Email correspondence with pilot (item 6, PDF, 5 pages, 518 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15748876&FileExtension=pdf&FileName=email%20correspondence%20with%20pilot%20fuel%20consumption_Redacted-Rel.pdf - Maintenance logbooks (item 7, PDF, 6 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749196&FileExtension=pdf&FileName=mx%20log_Redacted-Rel.pdf - Northstar fuel records (item 8, PDF, 3 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749832&FileExtension=pdf&FileName=northstar%20records_Redacted-Rel.pdf - Examination report, federal aviation administration (item 9, PDF, 2 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749842&FileExtension=pdf&FileName=N12VV%20investigaton%20report.-Rel.pdf - Fuel consumption computations (item 10, PDF, 1 page, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749622&FileExtension=pdf&FileName=Fuel%20burn-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 2 pages, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749503&FileExtension=pdf&FileName=N12VV%20NTSB%20Wreckage%20Release%20Form%20Signed%2002%2010%2023_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 1 page, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15749450&FileExtension=pdf&FileName=party%20form%20pilot_Redacted-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.