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On April 19, 2012, at 1600 eastern daylight time, a Cessna 172R, N28BC, operated by Eastern Kentucky University (EKU), was substantially damaged after impacting a tree during landing roll, after a forced landing in Richmond, Kentucky. The certificated flight instructor and student pilot were not injured. Visual meteorological conditions prevailed and no flight plan had been filed for the instructional flight, which was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91, between Hisle Field Airport (75KY), Winchester, Kentucky, and Madison Airport (I39), Richmond, Kentucky.
According to the flight instructor, earlier that day before departing I39 for 75KY he watched his student perform the preflight on airplane, and watched his student "dip" the fuel tanks with a "fuel stick" to visually check the fuel level in the fuel tanks.
Upon getting in the airplane for their one hour long training flight he asked the student how much fuel was in each tank. His student advised him that they had 21.5 gallons of fuel in one tank and 20 gallons in the other.
Once the airplane was started the flight instructor then verified the fuel level by looking at the fuel gauges. Both tanks were "registering" 20 gallons on the fuel gauges prior to departure.
After departing I39 they flew to 75KY which was located approximately 20 miles northeast of I39 to conduct a short field and soft field training lesson on the grass runway which was located there. After 30 or 45 minutes of training they departed 75KY for I39.
On the way back to I39, the flight instructor noticed that the fuel gauges were reading low. They continued however on a direct course to I39. When they were approximately 5 miles to the north of I39, the engine started to sputter, and the flight instructor took over control of the airplane. He then turned on the fuel pump and richened the mixture, and the engine started running normally again. At this point he decided to climb and get as much altitude as possible while maintaining a direct course for I39. Approximately 1 minute later, while climbing through 3,500 feet above mean sea level, the engine lost power. The flight instructor then performed the "emergency procedures" and attempted to restart the engine without result. He then realized that they would be unable to make the runway so he decided to make an off airport landing. He chose a field and then proceeded with an emergency landing. The emergency landing was uneventful and the airplane touched down in the grass covered field in slightly uphill terrain.
During the landing rollout as the airplane came to the crest of the hill he saw a tree immediately in front of them. He put in full control input to the left to try and miss the tree but, he could not get the airplane to turn to the left fast enough, and the right wing impacted the tree.
According to Federal Aviation Administration (FAA) and pilot records, the flight instructor held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. He also held a flight instructor certificate with a rating for airplane single engine. His most recent FAA first-class medical certificate was issued on July 21, 2011. He reported that he had accrued 453 total hours of flight experience, 351 hours of which were in the accident airplane make and model, 321 hours as pilot in command, and 157 hours as a flight instructor.
According to FAA and pilot records, the student pilot held a student pilot certificate. His most recent FAA first-class medical certificate was issued on January 13, 2012. He reported that he had accrued 17 total hours of flight experience.
The accident aircraft was a high wing, strut braced, four place, single engine airplane of conventional construction. It was powered by a 160 horsepower, four cylinder, fuel injected engine.
It was certificated for flight in instrument meteorological conditions and was equipped with analog instruments with all of the flight instruments contained in a single panel located in front of the pilot.
These instruments were designed around the basic "T" configuration. A fuel quantity indicator was located just to the left of the flight instruments and a multi-function annunciator was located above the altimeter. It provided caution and warning messages for fuel quantity, oil pressure, low vacuum, and low voltage situations.
According to FAA and airplane maintenance records, the airplane was manufactured in 2000 and was delivered to an owner in Canada, where it carried the Canadian registration of C-GGPN.
On September 27, 2002 it was removed from Canadian registry and imported into the United States after being purchased by a company headquartered in Texas. On July 9, 2003 it was sold to the owner who was in possession of the airplane at the time of the accident.
On April 30, 2007, it was involved in a previous accident in Livermore, California (SEA07CA120), when the airplane impacted a runway in a nose low attitude and incurred substantial damage to the firewall.
The airplane's most recent annual inspection was completed on March 20, 2012. At the time of the inspection, the airplane had accrued approximately 6,040 total hours of operation.
The reported weather at I39, at 1555, included: winds 060 degrees at 3 knots, 10 miles visibility, sky clear, temperature 22 degrees C, dew point 05 degrees C, and an altimeter setting of 30.01 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
Examination of the accident site revealed that during the emergency landing the airplane struck powerlines before touching down in a field of knee high grass. After touchdown, the airplane traveled approximately 510 feet on an approximate 180 degree magnetic heading before cresting a hill, impacting a tree with the right wing, pivoted 180 degrees, traveling backward down the hill and coming to rest 670 feet from where it touched down. Evidence of braking was visible for approximately the first 40 feet.
Examination of the wreckage by an FAA inspector revealed no evidence of any preimpact mechanical failures or malfunctions of the airplane or engine that would have precluded normal operation, and that the airplane was substantially damaged.
The right wing outboard of the right fuel tank was crumpled back and the leading edge was torn away. The right aileron was torn at the hinge point, the right inboard flap was jammed into the fuselage above the rear window, the window was broken, and the top of the fuselage was crumpled.
The right horizontal stabilizer was bent and the right elevator trim tab was bent down. The left horizontal stabilizer was bent and the left elevator was bent downward.
The right door was also jammed shut, and the right window had popped open and was unable to be closed.
Both fuel tank caps were closed. The fuel tanks were devoid of fuel, and neither was breached. There also was no fresh fuel staining above or below the wings, or on the belly of the airplane. With electrical power both off and selected on, the fuel quantity indicator read "0" for both fuel tanks. The fuel selector was in "BOTH" and the fuel shut off valve was open.
Fuel was present in the fuel strainer but, no fuel was found in the fuel line from the fuel strainer to the engine driven pump.
Both magnetos produced spark and 7 quarts of oil was present in the engine. After adding 5-gallons of 100LL aviation gasoline to the left wing tank, the electric fuel pump was turned on and the engine was started. Starting was normal and the engine was accelerated up to 1,800 rpm before the airplane began to slide on the long grass of the field. A magneto check was then performed and both magnetos dropped approximately 100 rpm. The fuel selector was then switched between the "LEFT" and "BOTH". During the engine run, no fuel leakage was observed.
On April 20, 2012 the airplane was moved to I39 where fuel staining was observed on the lower fuselage just aft of the firewall by EKU personnel. As a result, on April 25, 2012, a reexamination was conducted. During the reexamination, the fuel strainer was reexamined and no leakage or anomalies were noted. The floor and wings were also opened up and no evidence of leakage or staining was discovered. Examination of the fuel stains revealed that it was light in color indicating that it had been exposed to the elements and had been present for a considerable period of time.
Review of the airplane's discrepancy log also indicated that the staining may have occurred prior to March 21, 2012, when a fuel leak was discovered coming from the small drain valve on the bottom of the fuel strainer. The leak had been reported to EKU's maintenance provider at that time. The drain valve was removed, the small O-ring at the bottom of the fuel strainer was replaced, and the drain valve was reinstalled. The larger O-ring in the top of the bowl had been replaced the day before and the maintenance provider inspected it once again, found it to be serviceable, and reinstalled it. When the fuel selector was turned on, no leaks were detected and the airplane was released for service. No log book entry, however, was made indicating that this maintenance action had occurred.
TESTS AND RESEARCH
The airplane's fuel system consisted of two vented 28 gallon integral fuel tanks (one tank in each wing), a three-position fuel selector valve, auxiliary fuel pump, fuel shutoff valve, fuel strainer, engine driven fuel pump, fuel/air control unit, fuel distribution valve, and fuel injection nozzles.
Fuel would flow by gravity from the two wing tanks to a three position selector valve, labeled "BOTH", "RIGHT", and "LEFT" and on to the reservoir tank. Then from the reservoir tank, fuel flowed through the auxiliary fuel pump, past the fuel shutoff valve, then through the fuel strainer to the engine driven fuel pump.
From the engine driven fuel pump, fuel was delivered to the fuel/air control unit, where it was metered and directed to a fuel distribution valve (manifold) which distributed it to each cylinder. Fuel flow into each cylinder was continuous and flow rate was determined by the amount of air passing through the fuel/air control unit.
Fuel quantity was measured by two float type fuel quantity transmitters (one in each tank) and indicated by an electrically operated fuel quantity indicator on the left side of the instrument panel. The gauges were marked in gallons of fuel. An empty tank was indicated by a red line and the number "0". When an indicator showed an empty tank, approximately 1.5 gallons remained in each tank as unusable fuel. According to Cessna Aircraft, the indicators should not be relied upon for accurate readings during skids, slips, or unusual attitudes.
Each fuel tank also incorporated warning circuits which could detect low fuel conditions and erroneous transmitter messages. Anytime fuel in the tank would drop below approximately 5 gallons (and remained below this level for more than 60 seconds), the amber "LOW FUEL" message would flash on the annunciator panel for approximately 10 seconds and then remain steady amber. The annunciator could not be turned off by the pilot. If the left tank was low, the message would read "L LOW FUEL". If the right tank was low, the message would read "LOW FUEL R".
In addition to low fuel annunciation, the warning circuitry was designed to report failures with each transmitter caused by shorts, opens, or transmitter resistance. If the circuitry detected any one of these conditions, the fuel level indicator needle would go to the "OFF" position (below the "0" mark on the fuel indicator), and the amber annunciator would illuminate. If the left tank transmitter failed, the message would read "L LOW FUEL". If the right tank transmitter failed, the message would read "LOW FUEL R". If both tank transmitters failed, the message would read "L LOW FUEL R".
Fuel System Limitations
According to Cessna Aircraft, to ensure maximum fuel capacity and minimize cross-feeding when refueling, the airplane should be parked in a wings level, normal ground attitude, with the fuel selector in the "LEFT" or "RIGHT" position and warned that failure to operate the airplane in compliance with fuel limitations may further reduce the amount of fuel available in flight.
Additionally, they also advised that when securing the airplane, the fuel selector valve should be placed in the "LEFT" or "RIGHT" position to prevent cross feeding.
According to the student that had flown the airplane on the flight before the accident flight, during his preflight he noticed that the airplane only had 11 gallons of fuel onboard. However before they departed he had the airplane fueled up to "48 gallons". He and his instructor then taxied out and did 8 takeoffs and landings. During their flight they noted no abnormalities with the airplane.
Student Pilot Interviews
According to the student pilot who was on the accident flight, the flight instructor was physically present and watched him perform the preflight on the airplane, and watched him dip the fuel tanks with the fuel stick to visually check the fuel level. He stated that each tank had about 20 gallons. The fuel gauges also showed about the same. After departing I39, they flew to 75KY to practice soft field landings. After performing two landings at 75KY, on the third landing he noticed the fuel gauges were down to about 5 gallons each tank. Additionally, he commented to his instructor concerning the condition of the field, specifically that it was pretty rough. At that point the decision was made to return to I39. They looked out the windows but could not see any indication of fuel leaking from the airplane. He stated that about 5 miles out, the engine began to run rough and lose power. The instructor then took control and executed the forced landing.
After the forced landing, the student pilot stated that he exited the aircraft and got up on each wing. He stated that he could not see any fuel in either tank and that there was no indication of fuel on the dipstick. He stated that he thought that he had left one and possibly both fuel caps off while checking the fuel. When asked if he was talking about before the airplane departed I39 or after the forced landing, the student pilot stated that he meant after the forced landing. After being told that both fuel caps were found to be closed by the FAA when they arrived at the accident site, he was asked if he knew who had reinstalled them and he said he did not know. When asked if he remembered any low fuel annunciations from the annunciator panel he stated that he did not remember any.
When asked if the airplanes were parked with the fuel selector on "BOTH" he advised that they were.
Flight Instructor Interviews
The flight instructor was asked how he knew that there was 20 gallons of fuel in each tank. He stated that his student had stuck the tanks and had told him there was 20 gallons a side when he went out to the aircraft. He was then asked if he had verified the quantity. He said that when he got into the aircraft, he noticed that the fuel gauges read 20 in one and 15 in the other. He stated that he had performed a walk-around and then got in the aircraft. He also mentioned that he always watched his student do the entire preflight, which is how he knows his student stuck the tanks. He made a point to say that he always does this and doesn't do anything else when the student is preflighting the aircraft.
He was asked if he noticed if the fuel-flow gauge had showed an increase in flow. He said that it was reading normal, around 10gph, "That is where we lean it to." He was then asked if there was a fluctuation in the Exhaust Gas Temperature (EGT). He advised that no, the EGT was normal, and that they had leaned the aircraft out in cruise to the "needles" on the EGT.
When asked when he noticed that there was a problem. He said that on their way back to the airport, he noticed that the fuel gauges were lower than normal. About 5 to 6 miles north of the airport around 3000 feet above mean sea level (msl) the engine sputtered. He stated that he took control of the aircraft and turned the fuel pump on, enriched the mixture and the engine ran normally for about a minute. He climbed to an altitude of about 3500 feet msl, where the engine totally quit. The propeller continued to windmill. This occurred approximately 4 miles north of the airport. He pitched for best glide speed of 65 knots indicated airspeed and attempted the restart procedure, while turning directly towards the airport. He noticed around 700 feet above ground level that he wasn't going to make the runway, so he picked the field to make an emergency landing.
After discovering that a non-approved checklist for the airplane was in the cockpit, the flight instructor was asked what checklist he used for the engine failure. He then mentioned that "he always uses the pilot operating handbook (POH), as he doesn't trust anything but." However, when asked where the POH was located; he stated that it was in the back of the airplane.
He was asked if during the flight he had any smell of fuel. He said that there was no odor and he didn't notice any spray. He stated that during the preflight he had not noticed any abnormalities due to fuel leakage, and he had done a walk around. He was also asked if the student mentioned to him any abnormalities concerning fuel leakage. He stated that he was notified about any fuel issues noticed on the preflight.
Review of EKU fueling records revealed that no specific records were recorded by aircraft registration number making it impossible to determine exactly how many gallons were uploaded to a particular aircraft or to do trend analysis of fuel consumption on a per aircraft basis.
Security Camera Video
Review of security camera video from multiple cameras revealed that at 1304 the airplane was tugged from the maintenance hangar to the fuel facility where the airplane appeared to be refueled.
At 1309, the airplane was then tugged to a tiedown position on the parking ramp.
At 1316, the instructor from the previous flight was observed to walk out to the airplane where he was joined by his student.
At 1320, the airplane was seen to exit the ramp.
At 14:15, the airplane was seen to reenter the parking ramp where it was parked in its previous position. The student and instructor from the flight previous to the accident flight were observed to exit the airplane and walk back to the main hangar.
At 14:40, the student from the accident flight was observed walking from the main hangar to the airplane, where he then began his preflight inspection while his instructor was engaged in conversation with another student at the entrance to the Madison Terminal.
At 14:48:55, the student was observed climbing up on the right wing to examine the right fuel tank.
At 14:51, the student was observed climbing up on the left wing, to examine the left fuel tank.
At 1458, the instructor was observed to leave the main hangar, walk out to the airplane, and get in it.
At 15:02:07, the airplane's engine was observed to start.
At 15:04 the airplane was observed to exit the parking ramp turning south on taxiway "A".
Review of satellite imagery of the parking ramp at I39 revealed that the parking ramp at I39 was not level and that the pavement sloped downward towards the east. Further review revealed that the west end of the parking ramp was approximately 8 feet higher in elevation than the east end.
Review of satellite imagery of the fueling pad also revealed that it sloped downward towards the east and an approximate difference in elevation of 1 foot existed between the east side of the fueling pad and the west side of the fueling pad.
The fuel sticks used by EKU were purchased from a commercial manufacturer and were a combination of factory calibrated fuel sticks (19 gallons for the Cessna172Ps and 26.5 for all of the Cessna 172Rs), and universal fuel sticks for all of the Cessna 172RGs and the Piper Seneca.
During the investigation it was revealed that the fuel sticks did not have aircraft registration markings on them to determine if the correct fuel stick was onboard the correct aircraft, and it was discovered that one of the airplanes in the fleet with 20 gallon tanks had a 26.5 gallon fuel stick in the cockpit.
ORGANIZATIONAL AND MANAGEMENT INFORMATION
In 1984, EKU offered its first aviation courses, and in 1989, was granted approval for a minor in aviation. In 1991, EKU was approved to offer a baccalaureate degree program in aviation.
Students, who earn their degree in professional flight, also obtain a private pilot certificate, commercial pilot certificate, and an instrument rating. They also can earn a flight instructor certificate with ratings for airplane single engine, airplane instrument, and airplane multi-engine.
The flight program was administered by two associate professors, the director of aviation/chief pilot, and an assistant chief pilot, and all training was conducted in accordance with 14 CFR Part 141. Before graduation students would accrue approximately 250 to 300 flight hours.
Fueling operations were administered by the airport manager, and maintenance operations were administered by an aircraft maintenance manager/ instructor pilot.
In order to increase safety, Eastern Kentucky University (EKU) took the following actions:
1. On April 20, 2012, EKU's fixed base operation's fuel processes were modified to track fuel purchase by aircraft registration number allowing them to determine the actual amount of fuel uploaded to each individual aircraft.
2. The owner of the university's aircraft assured that the correct dipsticks, i.e., 19 gallon factory-calibrated dipsticks for all of their Cessna 172Ps, factory-calibrated 26.5 gallon dipsticks for all their Cessna 172Rs, and universal dipsticks for their C172RGs and their Piper Seneca were provided to EKU. They also assured that the universal dipsticks were calibrated using the factory-provided calibration cards and instructions. All of the dipsticks have also been marked with the corresponding registration number and placed in their respective aircraft.
3. The maintenance provider modified their standard operating procedures to require their maintenance personnel to track maintenance actions on both the aircraft's discrepancy log and the aircraft logbooks.
4. A comprehensive process for determining whether or not a soft field is safe for operations or too soft has been developed by EKU. Additionally, the EKU Aviation operations SOP will be modified to amplify soft field training. It will reinforce the requirement that all soft field maneuvers will be demonstrated and practiced on a hard surface before introducing actual soft field approaches, landings, and takeoffs to a soft field.
5. On April 19, 2012, EKU stood down from all flight operations. Before returning to an operational status, the EKU chief flight instructor conducted safety stand down meetings with both maintenance personnel and all flight instructors. Additionally, all instructors were directed to re-review emergency landing procedures with all of their students on their very next flight.
6. On May 18, 2012, EKU held an "all hands" safety stand down for students and instructors to discuss the accident.
7. The EKU chief flight instructor developed an emergency landing pattern (ELP) for EKU's Cessna 172s and Seneca III aircraft based on the U.S. Navy's Precautionary Emergency Landing (PEL) procedure. Altitudes to cross high key (perpendicular to the runway centerline) and low key (high abeam) have been developed, practiced, and taught as another method of dealing with rough running engine versus entering the airport pattern on a 45-degree angle or on the downwind leg of the traffic pattern.