Botched NTSB report

[dmspilot]

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1

The commercial pilot reported that he visually checked the fuel tanks before conducting the personal flight and verified that they were full with a total of 26 gallons (24.5 usable) before the personal flight departed; fuel receipts corroborated that the airplane was refueled before the flight. The pilot stated that, shortly after he descended the airplane from 5,500 ft mean sea level (msl) and then leveled off at 3,500 ft msl, about 3.5 hours into the flight, the engine began running roughly and then lost power. The pilot’s attempts to restart the engine were unsuccessful. The pilot subsequently executed a forced landing to a road, and the airplane collided with a pole.
The Pilot’s Operating Handbook stated that the airplane had about 3.1 hours of fuel endurance at cruise power. Responders to the accident site reported that there was no fuel in the fuel tanks. Further, after the accident, the pilot stated that the engine likely “ran out of gas.” Therefore, the engine lost power due to fuel exhaustion as a result of the pilot’s improper fuel planning.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The pilot’s improper fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.

A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

 

[eetrojan]

The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

It sure sounds like improper fuel planning.

Assuming for the sake of math that "about 3.5 hours into the flight" means exactly 3.5, as opposed to 3.6 or 3.7 etc., and ignoring fuel burn due to start, taxi and climb, the pilot flew 0.4 hrs into the 0.75 hr reserve referenced in the POH.

0.75 - 0.4 = 0.35

A calculated fuel reserve of 0.35 hrs doesn't comply with FAR 91.151 which requires enough for 0.5 hrs.

At minimum, he was right on the hairy edge.

 

[Rebel Lord]

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1


A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

View attachment 53014

Maybe he zoned out and flew right through his reserves. I don't think the NTSB likely going to be wrong, they have years of experience.

 

[dmspilot]

It sure sounds like improper fuel planning.

Assuming for the sake of math that "about 3.5 hours into the flight" means exactly 3.5, as opposed to 3.6 or 3.7 etc., and ignoring fuel burn due to start, taxi and climb, the pilot flew 0.4 hrs into the 0.75 hr reserve referenced in the POH.

0.75 - 0.4 = 0.35

A calculated fuel reserve of 0.35 hrs doesn't comply with FAR 91.151 which requires enough for 0.5 hrs.

At minimum, he was right on the hairy edge.

The report in combination with the ASF video made it sound like he had already pushed his luck by flying 0.4 hours beyond what was possible, and the report info is misleading for not mentioning that the POH includes a 45-minute reserve. But other than that I agree, just looking at his route and considering the 20-kt headwind he might have just barely made his destination before running the tanks dry if everything else was ideal--completely full tanks, mixture leaned properly, etc.

 

[dmspilot]

Maybe he zoned out and flew right through his reserves. I don't think the NTSB likely going to be wrong, they have years of experience.

Not likely to be wrong when you're talking about a major investigation, e.g. Part 121. Sometimes with nonfatal GA accidents they don't seem to try very hard.

 

[455 Bravo Uniform]

26 gal, 24.5 usable at 6 gph = 4 hrs 5 min

 

[mscard88]

Taught a ton of hours in C150/52s and ALWAYS taught my students, or anyone else who would listen, to be landing somewhere at the 3 hour point. Most listened, a couple did not. Those that did not were very fortunate they are still with us.

 

[MauleSkinner]

I don't think the NTSB likely going to be wrong, they have years of experience.

Did the NTSB investigate this directly, or did they compile info from the local FSDO inspectors? A lot can be lost in translation.

 

[dmspilot]

Taught a ton of hours in C150/52s and ALWAYS taught my students, or anyone else who would listen, to be landing somewhere at the 3 hour point. Most listened, a couple did not. Those that did not were very fortunate they are still with us.

The 3 hour point gives you a healthy reserve. You didn't expect them to be running the tanks dry at 3 (or 3.1) hours right?

 

[mscard88]

The 3 hour point gives you a healthy reserve. You didn't expect them to be running the tanks dry at 3 (or 3.1) hours right?

Should be obvious why I wanted them landing at the 3 hour point. Should be.

 

[flyingron]

The example in the book is also predicated on 8000 rather than 3500.

 

[SkyDog58]

Students typically burn more fuel per flight hour than they should. They tend not to lean, run at or near max power and do not trim well. These can lead to higher consumption rates which decreases range both as a function of distance and time. Setting a three hour max before refuel as Mark suggests is a great practice.

 

[MAKG1]

It sure sounds like improper fuel planning.

Assuming for the sake of math that "about 3.5 hours into the flight" means exactly 3.5, as opposed to 3.6 or 3.7 etc., and ignoring fuel burn due to start, taxi and climb, the pilot flew 0.4 hrs into the 0.75 hr reserve referenced in the POH.

0.75 - 0.4 = 0.35

A calculated fuel reserve of 0.35 hrs doesn't comply with FAR 91.151 which requires enough for 0.5 hrs.

At minimum, he was right on the hairy edge.

And it assumes the tanks were actually full. After asking for a top off, I've found everything from fuel all over the top of the wing, to 3-4 gal low in each tank. Visually, it's hard to see 3 gal low (but it's easier with a fuel stick unless you short-stick yourself). That's almost an hour of flight in a 152 if both tanks are that low.

 

[dmspilot]

Students typically

The pilot was a commercial pilot. It is literally the first three words of the report.

Literally every time I start a thread I end up being sorry I did. I can see why so many get frustrated when they post here.

 

[Fearless Tower]

Did you bother to read the whole thing???

The NTSB's conclusion was not based solely on their interpretation of the POH.

It was also based on responder reports that there was no fuel left in the tanks and the accident pilot's own statement that he likely ran out of fuel.

The NTSB has indeed been known to make mistakes.....but I don't think they are the ones that screwed the pooch here.

 

[dmspilot]

Did you bother to read the whole thing???

The NTSB's conclusion was not based solely on their interpretation of the POH.

It was also based on responder reports that there was no fuel left in the tanks and the accident pilot's own statement that he likely ran out of fuel.

The NTSB has indeed been known to make mistakes.....but I don't think they are the ones that screwed the pooch here.

Yes I read the whole thing. He ran out of fuel indeed. But the reporter thinks a Cessna 152 is predicted to run out of fuel after 3.1 hours. That's wrong.

 

[dmspilot]

Should be obvious why I wanted them landing at the 3 hour point. Should be.

I don't care what you want your students to do. You didn't answer the question so your reply is a waste of time.

 

[mscard88]

I don't care what you want your students to do. You didn't answer the question so your reply is a waste of time.

Well then, don't ****ing read it then Mr Expert.

 

[dmspilot]

Well then, don't ****ing read it then Mr Expert.

Would I have known that it didn't answer the question before I read it?

 

[mscard88]

Would I have known that it didn't answer the question before I read it?

Don't care man, just don't care.
Here, try some of this:

 

[Sundancer]

NTSB is all over the place on probable cause - truly spot on sometimes, other times they deliver a clearly biased guess, or a just not-so-logical conclusion. I imagine the more important investigations (for hire, or politically important) get a close review, but if a GA goes in, no other collateral damage, maybe not so intense a look.

 

[tawood]

And it assumes the tanks were actually full. After asking for a top off, I've found everything from fuel all over the top of the wing, to 3-4 gal low in each tank. Visually, it's hard to see 3 gal low (but it's easier with a fuel stick unless you short-stick yourself). That's almost an hour of flight in a 152 if both tanks are that low.

True, not to mention, older planes tend to have their fuel tanks capacity "shrink" a bit...such as small dents in the tank, un-level tanks, etc, which can add up to quite a bit less fuel too.

 

[SkyDog58]

The pilot was a commercial pilot. It is literally the first three words of the report.

Literally every time I start a thread I end up being sorry I did. I can see why so many get frustrated when they post here.

My post was more in response to Mark's comment about the instruction he provided his students which mirrored what my primary CFI taught me. Though I am no longer a student pilot, my personal minimums are to plan my flight so as to have about 1 hour of fuel remaining when I reach my destination. In my mind that provides an additional margin of safety incase winds are not as forecast, I do a slight detour to check out a site on the ground, or some other unforeseen circumstance.

My apologies if I caused you to suffer butt hurt.

 

[dmspilot]

My post was more in response to Mark's comment about the instruction he provided his students which mirrored what my primary CFI taught me. Though I am no longer a student pilot, my personal minimums are to plan my flight so as to have about 1 hour of fuel remaining when I reach my destination. In my mind that provides an additional margin of safety incase winds are not as forecast, I do a slight detour to check out a site on the ground, or some other unforeseen circumstance.

So in your experience after flying a C152 for 3 hours, you still had an hour of fuel remaining. This is exactly my point.

I can see that the accident pilot was foolish to attempt the flight that he did, yet I can also see that not everything in the report can be taken at face value because it doesn't add up. Something else was wrong...tanks not really fuel, or maybe even a leak. Plus it seems a fuel gauge was faulty, showing full when it was empty, but this was not investigated further either. The investigators phoned it in IMO...though I can't blame them entirely, they're probably working under a system in which they are understaffed/overworked.

 

[Clip4]

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1


A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

View attachment 53014

Yes, a 15

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1


A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

View attachment 53014

 

[Clip4]

He was flying at 100% power and ran out of gas.

 

[SbestCFII]

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1


A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

View attachment 53014

He was cruising at 5500, not 8000. Nor sure if he was leaning, or what the throttle setting was. Could have been full throttle, full rich. Also POH performance is difficult to replicate by the average pilot. It's OK to be wrong.

 

[nauga]

I can see that the accident pilot was foolish to attempt the flight that he did, yet I can also see that not everything in the report can be taken at face value because it doesn't add up. Something else was wrong...tanks not really fuel, or maybe even a leak. Plus it seems a fuel gauge was faulty, showing full when it was empty, but this was not investigated further either. The investigators phoned it in IMO...though I can't blame them entirely, they're probably working under a system in which they are understaffed/overworked.

Did you read the materials in the docket? Specifically the part in the pilot's writeup where he says "...or if I would have known if this particular plane had an excessive fuel burn - as stated by students @ Fl Flyers." There is no clarification but it sounds like he later found out that students had reported this airplane had a higher than normal fuel burn.

He also hand-wrote a fuel ladder in the report, estimating 21.26 gal used for his plan, of 24.5 useable, to cruise 266 nm in 3.8 hr with a 20 kt headwind.

Nauga,
referentially

 

[dmspilot]

I know he wasn't at 8,000. That proves my point that the report doesn't even bother to try to calculate the fuel burn with any accuracy whatsoever. However, at a constant power setting, altitude only affects range, not endurance.

 

[nauga]

I know he wasn't at 8,000. That proves my point that the report doesn't even bother to try to calculate the fuel burn with any accuracy whatsoever. However, at a constant power setting, altitude only affects range, not endurance.

I haven't flown a 150/2 since 1990. Is 5.2gal/hr for 90 knots true at 5.5K a reasonable estimate? Even his own estimate seemed to be cutting it close with book performance. Impossible to know if he was on the numbers but when you aim for optimal things can only get worse.

The report doesn't state a lot of stuff outright but that doesn't mean that (a) it wasn't considered, and (b) it needed to be included for the conclusion to be valid.

Nauga,
who doesn't need a weatherman to tell which way the wind blows

 

[Axtel4]

A recent AOPA ASF video highlighted the following accident:
https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20160118X02647&key=1


A Cessna 152 can fly a lot longer than 3.1 hours. The NTSB did not read the POH correctly. See attached image. The 3.1 hours includes an allowance for start/taxi/climb AND a 45-minute reserve.

View attachment 53014

Do you have a link to the ASF video?

 

[dmspilot]

"...if I would have known if this particular plane had an excessive fuel burn - as stated by students @ Fl Flyers." There is no clarification but it sounds like he later found out that students had reported this airplane had a higher than normal fuel burn.

No I did not view the full docket but now I did. Thank you for pointing it out. Interesting about the excessive fuel burn, I wonder how "excessive" it was exactly. This was not followed up on for reasons unknown, though it seems to me the investigator already made his/her mind up upon seeing the 3.1 hour number.

The pilot's fuel estimate is optimistic. It uses the book numbers, but the book calls for "recommended lean mixture" which requires leaning beyond peak RPM. I haven't seen anyone actually use that procedure in real life. At typical power and mixture settings, 6gph is more realistic. By my own "real world" estimation he would have landed at his destination with 15 minutes of fuel on board which exceeds legal reserve obviously. That's if everything was perfect. A fuel stop was called for.

 

[dmspilot]

Do you have a link to the ASF video?

Nothing interesting about this accident that hasn't already been discussed, it is just mentioned briefly. It's a good video though.

 

[Lindberg]

I know he wasn't at 8,000. That proves my point that the report doesn't even bother to try to calculate the fuel burn with any accuracy whatsoever. However, at a constant power setting, altitude only affects range, not endurance.

I'm not clear on what your complaint is, or how you think the NTSB "botched" this report. We can all agree the cause was fuel exhaustion, right? And the POH does say that there's a 3.1 hour cruise endurance, correct? So is your complaint just that the report doesn't mention the 45 minute reserve? It isn't like the report says, "The Pilot’s Operating Handbook stated that the airplane had about 3.1 hours of fuel endurance at cruise power, so we don't understand why the engine didn't die sooner...." It's just stating facts. This one appears to be correct, although not as precise as you would like. Does the NTSB need to rebuild the plane, fill the tanks, figure out exactly what settings and altitude the pilot used, stick the whole thing in a test chamber and see how long it runs? That seems like an awfully big waste of time when you have a live pilot who says, "I ran out of gas."

 

[Axtel4]

Did the NTSB investigate this directly, or did they compile info from the local FSDO inspectors? A lot can be lost in translation.

I believe the "LA" in the Report Identification (ERA16LA091) indicates it is classified as a Limited Aviation investigation (i.e Desk Investigation).

The only items in the docket are the Pilot's Interview, the FSDO Inspector Statement, a couple of photos of the accident, a page copied from the 152 POH, an excerpt out of the flight school fueling log, and the Pilot/Operators Accident/Incident report. The Pilot/Operator Aircraft Accident/Incident Report is a interesting read.

 

[Axtel4]

Nothing interesting about this accident that hasn't already been discussed, it is just mentioned briefly. It's a good video though.

Thanks.

 

[dmspilot]

And the POH does say that there's a 3.1 hour cruise endurance, correct? So is your complaint just that the report doesn't mention the 45 minute reserve?

Yes. That is my complaint. The endurance is not actually "3.1 hours" -- that's taken out of context. The actual endurance from takeoff until the tanks run dry under the book conditions (8,000 feet, 75% power, recommended lean) is 4.1 hours. I have the POH in front of me. Granted the pilot was not at 8,000 and the other caveats mentioned.

 

[MauleSkinner]

I think that finally one just has to accept the fact that NTSB reports, like just about anything, are going to be flawed.

In one case that I'm aware of, the NTSB blamed a broken linkage on one main gear that caused both mains to collapse together, even though the broken linkage physically separated the two main gear and the other main was still rigidly connected to the extension mechanism. Quite frankly, a physical impossibility.

We had an NTSB person speak to us at work once about some research they were doing regarding instrument scanning, and they noted that the airspeed indicator got much less attention than the rest of the flight instruments. They were attributing this to over-reliance on auto throttles. It seemed to me that my scan was very similar to what they noted, but it would be tough for me to over-rely on auto throttles since I've never used them.

I think that they, like all of us, get an idea in our heads and assemble facts that support that idea.

 

[eetrojan]

Hi dmspilot, we're probably dancing on the head of a pin here, but the POH defines endurance as "allowing for a 45 minute reserve at a specified cruise power." I don't see that any reference to an "actual" endurance that recaptures that 45 minutes reserve. Honestly, that doesn't seem like a good way to view endurance.

Pure speculation, but maybe that's how the accident pilot viewed endurance.

The only possible issue with the NTSB report is that it doesn't mention the 45 minute reserve that the accident pilot was knowing or unknowingly playing with.

 

[Let'sgoflying!]

I can't imagine on relying on the POH of light a/c for fuel burn.
If I get in a new-to-me airplane, I am taking off as fat as safely possible then landing well before what the book says it can do. Not going on a max range flight right off.
I determine the fuel burn in every airplane for myself.
If it later turns out to be what the book says, well that's interesting.