WPR22LA308

NTSB accident investigation · Cessna 195 · El Cajon, CA · August 18, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 18, 2022, 10:35 local (17:35 UTC)
Place
El Cajon, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1097DCessna 195
Defining event
Approach: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20220818014739A
Case key
105761

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 failure to verify the fuel quantity prior to departure, which led to a loss of engine power due to fuel exhaustion.

Findings · 5

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 · Inadequate inspectionCessna 195: 3 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 195: 3 casesAll aircraft: 1,695 casesProbable cause
Planning/preparation: fuel planningPersonnel issues › Task performance · PilotCessna 195: 2 casesAll aircraft: 719 casesProbable cause
Action: incomplete actionPersonnel issues › Action/decision · PilotCessna 195: 1 caseAll aircraft: 105 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Not inspectedCessna 195: 3 casesAll aircraft: 1,695 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 airplane had recently undergone maintenance, during which time the mechanic removed the fuel from the wings. The pilot stated that after completing the maintenance, the mechanic told him that he added the fuel back in the wings, so the pilot did not add any additional fuel. The pilot checked the quantity on the fuel gauges, but they were erroneous. He did not verify the quantity by doing a visual check of the actual fluid onboard. After departure, the engine stopped producing power due to fuel exhaustion. The pilot made an off-airport landing on a freeway and the airplane came to rest adjacent to an onramp, about three miles short of the runway.

Factual narrative

On August 18, 2022, at 1035 Pacific daylight time, a Cessna 195, N1097D, sustained substantial damage when it was involved in an accident near El Cajon, California. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane had recently undergone maintenance. The mechanic performing the maintenance stated that he removed the right wing as part of a repair. He additionally drained all the fuel from both wings to enable him to re-seal both wings’ fuel sending units. The pilot further stated that after completing the maintenance, the mechanic told him that he added the fuel back in the wings, adding about seven gallons in each tank. The pilot did not add any additional fuel. The pilot added that the accident flight was the first flight after the maintenance. He intended to depart Gillespie Field, San Diego, California, and stay in the traffic pattern. At 1023, the airplane departed from runway 27R. At 1033 the pilot declared an emergency to air traffic control stating he had experienced a full electrical failure. He maneuvered the airplane back toward the runway and the engine suddenly stopped producing power. He attempted to restart the engine to no avail. He made an off-airport landing on a freeway and the airplane came to rest adjacent to an onramp, about three-miles short of the runway. The recovery personnel stated that they recovered about 3-3.5 gallons of fuel at the accident site. The Federal Aviation Administration inspector stated that there was no fuel leakage at the accident site. The pilot stated that although he checked the quantity on the fuel gauges, they were erroneous. He did not verify the quantity by doing a visual check of the actual fuel on board. He reported that the mechanic had stolen the fuel and didn’t add it back to the wing tanks. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.

Aircraft

Registration
N1097D
Reported as
Cessna 195
Category
Airplane
Serial number
7721
Built
1951
Engine
Jacobs R755A, 300 hp, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · October 24, 2021 · 0 hours before
Destination
Same as departure
Airport
SEE · Gillespie Fld, runway 27R, 5,342 × 100 ft, asphalt
Equipment
None

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
65
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
BasicMed, Without waivers/limitations
Last flight review
June 10, 2022
Seat
Left
Restraint
4-point
Flight hours
1,850 total · 60 in this make and model · 1,850 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Temperature
84 °F, dew point 64 °F
Altimeter
29.93 inHg
Observed at
3 nm away

Docket · 3

The files NTSB released with the investigation on April 25, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.4 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.