CEN16LA079

NTSB accident investigation · Piper 28-140 · Republic, MO · December 31, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
December 30, 2015, 21:55 local (Dec 31, 2015, 03:55 UTC)
Place
Republic, MO
Injuries
1 serious, 1 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N4643RPiper 28-140
Defining event
Enroute-cruise: Fuel starvation
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 1, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration; MKC FSDO, Piper Aircraft, Inc, Lycoming Engines
FAA report
20151230023279A
Case key
92531

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's inadequate fuel management, which resulted in fuel starvation and a total loss of engine power during cruise flight.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelAll aircraft: 1,695 casesProbable cause
Object/animal/substanceEnvironmental issues › Physical environment · Not specifiedAll aircraft: 224 casesProbable cause
Equipment/furnishings: emergency equipmentAircraft › Aircraft systems · Not specifiedAll aircraft: 10 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot and a passenger were conducting a night cross-country flight. About 15 miles from the destination, the engine experienced a total loss of power. The pilot attempted to restart the engine but was only able to obtain momentary engine power each time he pumped the throttle. The pilot then performed a forced landing to a field, during which the airplane struck a tree and fence. A first responder to the accident stated that there was a smell of fuel and the ground was wet at the accident site. Postaccident examination of the airplane revealed the left wing fuel tank was breached and contained no fuel. The right wing fuel tank was intact. The right tank contained no usable fuel, and the fuel selector was selected to the right tank. The examination revealed no mechanical anomalies that would have precluded normal engine operation. It is likely that the pilot exhausted the fuel supply in the right tank and did not reposition the fuel selector to the left tank; thus, the engine experienced a loss of power due to fuel starvation.

Factual narrative

On December 30, 2015, at 2155 central standard time, a Piper PA-28-140, N4643R, experienced a loss of engine power and impacted trees and a fence during a forced landing on a high school practice field near Republic, Missouri. The private pilot sustained serious injuries and the passenger sustained minor injuries. The airplane was destroyed. The airplane was operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight that departed from Creve Coeur Airport (1H0), St Louis, Missouri, at 2030 and was destined to Jerry Sumners Sr. Aurora Municipal Airport (2H2), Aurora, Missouri. The pilot stated he performed a pre-flight inspection of the airplane and added 15-16 gallons of 100 low-lead fuel from a self-service pump prior to a direct flight from 1H0 to 2H2 [2H2 was approximately 184.4 nautical miles southwest of 1H0]. The pilot said that there was very little wind and the flight was "unremarkable." The cruise altitude was below a cloud ceiling of about 5,500 – 6,000 feet mean sea level and the cruise power setting was 2,400-2,450 rpm. The pilot stated that the engine was "running perfectly." About 15 miles from 2H2, the engine "abruptly quit" and it shut off without warning as if the magnetos had been shut off, but they were on. The pilot immediately applied carburetor hear, full throttle, mixture full rich, auxiliary fuel pump on, and switched fuel tanks back and forth. He said that the fuel pressure indicator "looked fine" and there was "plenty" of fuel on board in both fuel tanks. He tried to lean the mixture in the event of extreme carburetor icing, but there was no response, so he left it in the full rich position. The pilot stated that he tried "all known emergency procedures" but was unable regain engine power. The only response he obtained from the engine was when he rapidly pumped the throttle from idle to full power and the engine would then run "perfect" for about 1-1.5 seconds and then immediately die after each time he pumped the throttle. The pilot then performed a forced landing to a high school practice field. Prior to touching down on the field, the airplane "brushed" a tree, which felt unnoticeable and during landing rollout, the airplane struck a chain-link fence. When asked by the National Transportation Safety Board (NTSB) Investigator-In-Charge as to what the fuel quantity gauges were indicating at the time of engine power loss. The pilot stated that the gauges were unreliable. The right side gauge always indicated ¾ full and indicated that at the time of engine power loss. He said the left gauge, which was more accurate than the right gauge, indicated ¼-1/3 full. He said he used time to calculate fuel available. He said the he used a stick to determine a fuel quantity of 6-7 gallons before fuel was added for the flight. A first responder stated that upon arrival at the accident site, there was a "strong odor of gasoline around the areaalong with the surrounding area being wet." The airframe fuel gascolator and the fuel line to the carburetor were removed at the accident site by a Federal Aviation Administration (FAA) Inspector from the Kansas City Flight Standards District Office (FSDO). Upon removal there was fuel in the fuel line to the carburetor. Aircraft recovery personnel indicated they removed between 1 and 2 quarts of fuel from the right wing fuel tank. The airplane later underwent a post-accident examination under the supervision of a Federal Aviation Administration Airworthiness Inspector from the St Louis Flight Standards District Office with representatives from Piper Aircraft, Inc. and Textron Lycoming. N4643R was a 1966 Piper PA-28-140, serial number 28-21397, airplane that was equipped with a Lycoming O-320-E2AD, serial number L-16012-27A, engine. The airplane registration was cancelled as of December 16, 2014, in a letter from the FAA Flight Standards Service Aircraft Registration Branch to the an individual other than the pilot. A letter dated November 18, 2015, to the same individual stated that the documents concerning N4643R had been received and a certificate of registration may be issued upon completing the enclosed aircraft registration application to show the printed or typed name of the signer in the signature block. There were no subsequent documents in the FAA registry records for the airplane. During the post-accident examination, engine rotation and continuity was confirmed by rotating propeller with the top spark plugs removed. Thumb compression and suction was obtained from each cylinder. The engine oil screen was removed and found clean with very little carbon. The left and right magnetos were removed and rotated using a hand drill which resulted in an electrical spark from each magneto lead. The fuel pump was removed and verified to be operational. The carburetor was disassembled and there was no evidence of fuel consistent with fuel starvation. The fuel selector was selected to the right wing fuel tank which was not ruptured in the accident, and contained no useable fuel. There was no staining of the wing consistent with fuel leakage. The left fuel tank was broken open and contained no fuel. The aircraft manufacturer's front seat factory installed lap belts had been replaced by a lap and shoulder belt harness made by TANAKA. TANAKA belts are normally manufactured for automotive use and they did not display aircraft manufacturing data or STC approval tags. The left and right shoulder harness ends had been fastened with a single large bolt into the roof channel of the airframe at fuselage station 108.16. The material used for the fuselage frame was 0.40 inch 2024 aluminum. The attach bolts had been installed without any reinforcements or additional structure. This installation was consistent with an unapproved installation. Both shoulder harness bolts had pulled through the fuselage frame. Both ends of the lap belts had been fastened to theexisting airframe mounts and were secure. The pilot's logbook showed entries for flights between March 11, 2006, and July 18, 2014. The logbook showed a total flight time in Piper PA-28-140 airplanes of about 20 hours and a total flight time of about 108 hours. The pilot reported in his NTSB Form 6120 that he accumulated 60 hours in Piper PA-28-140 airplanes and a total flight time of 140 hours. During and prior to 2006, there were logbook entries for flight in Piper PA-28-140 airplanes. Following 2006, the next logbook entry for Piper PA-28-140 airplanes was dated November 1, 2015, which listed N4643R. The next three entries in the logbook were dated November 3, 2015, November 8, 2015, and November 8, 2015, all of which were for flights in N4643R. The total flight for these four entries was 5.1 hours. There were no subsequent logbook flight entries.

Aircraft

Registration
N4643R
Reported as
Piper 28-140
Category
Airplane
Serial number
28-21397
Built
1966
Airframe hours
2,455
Engine
Lycoming O-320-E2-A, 150 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Pilot
Registered owner
Pilot
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · July 20, 2015
Departed
1H0 · Creve Coeur, MO
Destination
2H2 · Aurora, MO
Equipment
Stall warning system

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3
Last flight review
July 19, 2014
Seat
Left
Restraint
3-point
Flight hours
140 total · 60 in this make and model · 140 as pilot in command · 28 in the last 90 days · 18 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
4,700 ft overcast
Temperature
39 °F, dew point 30 °F
Altimeter
30.14 inHg
Observed at
SGF, 18 nm away

Docket · 8

The files NTSB released with the investigation on March 23, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.