# NTSB WPR22LA308: Cessna 195, N1097D, El Cajon, CA, August 18, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: August 18, 2022, 10:35 local (17:35 UTC) - Place: El Cajon, CA - Coordinates: 32.811779, -116.91732 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8118&lon=-116.9173&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 105761 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22LA308 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105761/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105761 - Page: https://openairdocs.org/ntsb/WPR22LA308 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Inadequate inspection (probable cause); cases with it: [Cessna 195, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073102), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 195, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073102), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 195, 2 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073102), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 195, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=2073102), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not inspected (probable cause); cases with it: [Cessna 195, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073102), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna 195, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073102), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) ## 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](https://openairdocs.org/deregistered/N1097D-2024-01-20), registration cancelled 2024-01-20, S/N 7721, built 1951 (OpenAirDocs) - Reported make and model: CESSNA 195 - Registry model: [Cessna 195](https://openairdocs.org/model/cessna-195) (registry code 2073102) (OpenAirDocs) - Registry engine: [Jacobs R755A series](https://openairdocs.org/engine/jacobs-r755a-series) (registry code 35006, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7721 - Year built: 1951 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; 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 ## 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 20220818014739A](https://openairdocs.org/incident/20220818014739A), Aug 18, 2022: Cessna 195, El Cajon, CA, Substantial damage. At 10:23 PDT the Cessna 195 departed gillespie field in El Cajon, CA. Requesting extended right traffic. 10 minutes after departure the pilot declared… ## Docket (3 files) The files NTSB released with the investigation on April 25, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105761. 25.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 7 pages, 24.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16456828&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Records of conversation (item 2, PDF, 2 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16456082&FileExtension=pdf&FileName=Z%20-%20Attachment%2002%20-%20Record%20of%20Conversations-Rel.pdf - Photographs (provided by FAA) (item 3, PDF, 1 page, 542 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16456638&FileExtension=pdf&FileName=C-Form%20Photos-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.