Fuel Exhaustion & Starvation · NTSB CEN11FA358

ROCKWELL 112 — Bryan, TX

2 fatal
DateMay 29, 2011
LocationBryan, TX
AircraftROCKWELL 112
Purpose of flightPersonal
ConditionsDusk · Visual Meteorological Cond
Phase / occurrencePrior to flight Aircraft servicing event
Pilot age57
Pilot total time460 hrs · Building experience
Time in type259 hrs
Fatalities2

Probable cause

The pilot's inadequate fuel planning, which resulted in a loss of engine power due to fuel exhaustion, and his improper control inputs following the loss of engine power, which resulted in an aerodynamic stall and subsequent loss of control. Contributing to the accident was the pilot's impaired judgment, which led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.

NTSB findings

  • Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid management - C
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
  • Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - F
  • Personnel issues-Task performance-Planning/preparation-Fuel planning-Pilot - C

What happened

A review of the pilot's logbooks revealed that he had flown two flights in the airplane several days before the accident flight for a total of 2.8 flight hours. The airplane was not refueled after those flights. About 1.4 hours after takeoff on the accident flight, the pilot reported that he was "running out of fuel," and the airplane subsequently started descending. A witness reported seeing the airplane at a low altitude and then suddenly turn and depart controlled flight, indicating than an aerodynamic stall had occurred. The airplane impacted terrain in the parking lot of an apartment complex in a congested urban area. Engine data monitor information for the accident flight showed that, for most of the flight, the airplane had an average fuel flow of about 14.7 gallons per hour. The airplane had a total useful fuel capacity of 62 gallons. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot improperly planned how much fuel he would need for the accident flight and that the airplane ran out of fuel, which resulted in a loss of engine power due to fuel exhaustion.

The pilot's medical records revealed a diagnosis of major depression, and toxicology testing found medications in the pilot's body consistent with the treatment of this condition. The pilot's depression had been documented and treated since 1989, but the treatment and medications were inadequately reported to the Federal Aviation Administration on the pilot's recent airman medical applications and would have disqualified him from obtaining an airman's medical certificate. The pilot's depression and the medications he was taking would have significantly degraded his cognitive abilities, including executive functioning and judgment, and likely led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →