# NTSB CEN15CA033: Piper PA-23-250, N62791, Quincy, IL, October 26, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 26, 2014, 14:20 local (19:20 UTC) - Place: Quincy, IL - Coordinates: 39.943054, -91.194442 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.9431&lon=-91.1944&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report February 11, 2015 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - Springfield FSDO - NTSB case key (mKey): 90330 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15CA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90330/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90330 - Page: https://openairdocs.org/ntsb/CEN15CA033 ## Probable cause The pilot's improper fuel management, which resulted in the total loss of power to both engines due to fuel exhaustion and the subsequent forced landing in a field. Also causal to the accident was the pilot's decision to use the slower emergency hand-pump to extend the landing gear instead of the available carbon-dioxide blowdown system, which resulted in a landing without the landing gear fully extended. ## 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 · Fluid management (probable cause); cases with it: [Piper PA-23-250, 3 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102308), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Capability exceeded (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=7102308), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23-250, 3 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102308), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Landing gear system: gear extension and retract sys](https://openairdocs.org/ntsb-findings/01023230): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-23-250, 2 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md?model=7102308), [All aircraft, 416 cases](https://openairdocs.org/ntsb-findings/01023230/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-23-250, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102308), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Piper PA-23-250, 5 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7102308), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-23-250, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102308), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-23-250, 7 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102308), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Landing gear not configured](https://openairdocs.org/ntsb-events/095); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-events/095/sequence.md?model=7102308), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md) - [Landing-flare/touchdown: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA-23-250, 8 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=7102308), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Landing-landing roll: Dragged wing/rotor/float/other](https://openairdocs.org/ntsb-events/093); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-events/093/sequence.md?model=7102308), [All aircraft, 319 cases](https://openairdocs.org/ntsb-events/093/sequence.md) ## Analysis The pilot reported that the airplane departed with 122 gallons of fuel for the cross-country flight from Destin, Florida, to Quincy, Illinois. The airplane's two inboard wing fuel tanks, each having a 36 gallon capacity, were completely full before departure; however, in order to keep the airplane below its maximum gross weight at departure, the two outboard wing fuel tanks were each partially fueled with 25 gallons. The pilot reported that the inboard fuel tanks were used for engine startup, taxi, takeoff, and climb to the initial cruise altitude assigned by air traffic control. After reaching the initial cruise altitude, he switched to the outboard fuel tanks and leaned the mixture setting for optimal fuel consumption. About 2 hours into the flight, the pilot switched back to the inboard fuel tanks after the engines had consumed the useable fuel in the two outboard fuel tanks. The pilot reported that when the flight was about 7 miles from the destination airport, descending through 3,500 feet mean sea level, the right engine lost total power. The pilot feathered the right propeller, secured the right engine, and continued toward the planned destination. Shortly thereafter, the left engine lost total power and the pilot feathered the propeller and secured the engine. The pilot reported that he delayed extending the landing gear until the airplane cleared a row of trees that bordered the harvested soybean field that he selected for the forced landing. After clearing the trees, the pilot attempted to extend the landing gear by moving the landing gear selector handle to the down position; however, because the left engine was inoperative, a normal landing gear extension with the engine driven hydraulic pump was not possible. The pilot immediately attempted to extend the landing gear using the emergency hand-pump, but the airplane impacted terrain before the landing gear was fully extended. Upon contact with the terrain, the nose and left main landing gear collapsed. The left wing and fuselage sustained substantial damage during the forced landing. A postaccident examination of the airplane established that the inboard and outboard fuel tanks were void of any useable fuel. The pilot reported that the accident flight was about 4 hours 20 minutes in duration and that fuel exhaustion was the reason that both engines had lost total power. Before departing on the accident flight, he estimated that the flight would require about 118 gallons of fuel, and as such, there would be about 4 gallons of fuel remaining at the completion of the flight. However, after the accident, the pilot acknowledged that he failed to account for the 6.8 gallons of unusable fuel within the fuel system. Additionally, the airplane was equipped with an emergency carbon-dioxide blowdown system that the pilot could have used to rapidly extend the landing gear instead of the more laborious and time consuming emergency hand-pump. The pilot did not offer an explanation on why he choseto use the emergency hand-pump instead of the carbon-dioxide blowdown system. Had the landing gear been fully extended before landing, it is likely that the landing gear would not have collapsed. ## Factual narrative The pilot reported that the airplane departed with 122 gallons of fuel for the cross-country flight from Destin, Florida, to Quincy, Illinois. The airplane's two inboard wing fuel tanks, each having a 36 gallon capacity, were completely full before departure; however, in order to keep the airplane below its maximum gross weight at departure, the two outboard wing fuel tanks were each partially fueled with 25 gallons. The pilot reported that the inboard fuel tanks were used for engine startup, taxi, takeoff, and climb to the initial cruise altitude assigned by air traffic control. After reaching the initial cruise altitude, he switched to the outboard fuel tanks and leaned the mixture setting for optimal fuel consumption. About 2 hours into the flight, the pilot switched back to the inboard fuel tanks after the engines had consumed the useable fuel in the two outboard fuel tanks. The pilot reported that when the flight was about 7 miles from the destination airport, descending through 3,500 feet mean sea level, the right engine lost total power. The pilot feathered the right propeller, secured the right engine, and continued toward the planned destination. Shortly thereafter, the left engine lost total power and the pilot feathered the propeller and secured the engine. The pilot reported that he delayed extending the landing gear until the airplane cleared a row of trees that bordered the harvested soybean field that he selected for the forced landing. After clearing the trees, the pilot attempted to extend the landing gear by moving the landing gear selector handle to the down position; however, because the left engine was inoperative, a normal landing gear extension with the engine driven hydraulic pump was not possible. The pilot immediately attempted to extend the landing gear using the emergency hand-pump, but the airplane impacted terrain before the landing gear was fully extended. Upon contact with the terrain, the nose and left main landing gear collapsed. The left wing and fuselage sustained substantial damage during the forced landing.A postaccident examination of the airplane established that the inboard and outboard fuel tanks were void of any useable fuel. The pilot reported that the accident flight was about 4 hours 20 minutes in duration and that fuel exhaustion was the reason that both engines had lost total power. Before departing on the accident flight, he estimated that the flight would require about 118 gallons of fuel, and as such, there would be about 4 gallons of fuel remaining at the completion of the flight. However, after the accident, the pilot acknowledged that he failed to account for the 6.8 gallons of unusable fuel within the fuel system. Additionally, the airplane was equipped with an emergency carbon-dioxide blowdown system that the pilot could have used to rapidly extend the landing gear instead of the more laborious and time consuming emergency hand-pump. The pilot did not offer an explanation on why he chose touse the emergency hand-pump instead of the carbon-dioxide blowdown system. ## Aircraft - Registration: [N62791](https://openairdocs.org/deregistered/N62791-2018-03-12), registration cancelled 2018-03-12, S/N 27-7754028 (OpenAirDocs) - Reported make and model: PIPER PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Category: Airplane - Serial number: 27-7754028 - Year built: 1976 - Airframe hours: 3693.4 - Engines: Lycoming IO-540-C4B5 250 horsepower reciprocating; Lycoming IO-540-C4B5 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Great River Aviation, LLC - Registered owner: Great River Aviation, LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 27, 2014 - Departed: DTS, Destin, FL - Destination: UIN, Quincy, IL - Flight plan: IFR - Airport: UIN, Quincy Regional Airport - Equipment: Stall warning system, Auto-pilot, Electronic multifunction display, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review October 11, 2014; seat: left; restraint: 3-point; flight hours: 1,499 total, 54 in this make and model, 1,325 as pilot in command, 15 in the last 90 days, 13 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 43 °F - Altimeter: 29.85 inHg - Observed at: UIN, 2 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 20141026018969A](https://openairdocs.org/incident/20141026018969A), Oct 26, 2014: Piper PA-23-250, Quincy, IL, Substantial damage. Pilot reports fuel exhaustion approximately 2.2 miles west of Quincy Illinois airport (kuin). Aircraft landed in a farm field while on approach to runway 31… ## Docket (3 files) The files NTSB released with the investigation on January 29, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90330. 2.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421814&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector Statement (Douglas Wilson) (item 2, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421815&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20(Douglas%20Wilson)-Redacted.PDF - Photo 1 - Accident Site (item 3, .PDF, 982 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40421816&FileExtension=.PDF&FileName=Photo%201%20-%20Accident%20Site-Master.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.