ERA12LA294

A total loss of engine power due to fuel exhaustion. Contributing to the accident was the flight instructor’s failure to supervise the student’s preflight inspection, his inadequate fuel management and preflight and in-flight fuel planning, and the operator’s inadequate fueling policies and procedures.

The flight instructor reported that, after getting in the airplane, he asked the student pilot how much fuel was in each tank. The student pilot replied that 21.5 gallons of fuel were in one tank and 20 gallons of fuel were in the other tank. The student pilot reported dipping a "fuel stick" into the fuel tanks during the preflight to check the fuel levels. Although the flight instructor noticed that the fuel quantity indicators showed that 20 gallons of fuel were in one tank and 15 gallons of fuel were in the other tank, he did not question the fuel discrepancy. A review of security camera video revealed that the flight instructor did not supervise the student pilot's preflight inspection nor conduct a walk-around inspection. After departure, the student pilot flew the airplane to another airport for a short- and soft-field training lesson. After 45 minutes of training, they departed for their home airport. Although the flight instructor noticed that the fuel gauges were reading low, he chose to continue the flight. Five miles north of the airport, the engine began sputtering, and the flight instructor took control of the airplane. He turned on the fuel pump and richened the fuel mixture, and the engine started running normally. He then decided to climb to get as much altitude as possible while continuing to fly to the airport. One minute later, the engine lost power. The flight instructor then unsuccessfully attempted to restart the engine. When he realized that the airplane would not make the runway, he decided to land in a field. During the approach and landing roll, the airplane struck power lines, and the right wing struck a tree and was substantially damaged. Examination of the fuel tanks revealed that they were empty and that neither of them was breached. No evidence of fresh fuel staining or leakage was found above or below the wings or on the belly of the airplane. After adding 5 gallons of fuel to the left wing tank, the engine was started, and it ran normally. Examination of the fuel sticks used by the operator revealed that they did not have aircraft registration markings on them to verify if the correct fuel stick was onboard the correct aircraft and that one of the airplanes in the fleet with 20-gallon tanks had a 26.5-gallon fuel stick in the cockpit. It could not be determined whether the student pilot used the proper fuel stick during the preflight inspection. Examination of the operator's fueling pad and parking ramp revealed that they were significantly sloped. Examination of its fueling and parking procedures also revealed that the airplanes were being parked and serviced with the fuel selector valves in the "both" position. According to the airplane manufacturer, the airplane should be parked in a wings-level, normal ground attitude with the fuel selector in the "left" or "right" position to ensure maximum fuel capacity and minimize cross-feeding when refueling.

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. Fuel System 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 Indicating 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. Fueling Information 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 t