CEN16LA380

NTSB accident investigation · Piper PA 30 · Mineral Wells, TX · September 22, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
September 21, 2016, 19:20 local (Sep 22, 2016, 00:20 UTC)
Place
Mineral Wells, TX
Injuries
2 serious, 1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N7663YPiper PA 30
Defining event
Approach-VFR pattern final: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report May 1, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Piper Aircraft Inc, Federal Aviation Administration, Lycoming Engines
Case key
94052

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

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Probable cause

The pilot's fuel mismanagement, which resulted in fuel starvation to both engines and their subsequent loss of engine power.

Findings · 2

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-30: 14 casesAll aircraft: 1,695 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-30: 13 casesAll aircraft: 1,391 casesProbable cause

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 airline transport pilot reported that, before the flight preceding the accident flight, he added 19 gallons of fuel to the auxiliary and main fuel tanks. He added that he did not add fuel to the tip tanks and that he had used all the fuel in those tanks during the flight before the accident flight. The pilot then departed for the accident flight. He stated that, during the flight, he only used the auxiliary and main fuel tanks and that, while on final approach for landing, he switched from the auxiliary to the main fuel tanks for landing. Shortly thereafter, the right engine lost power and then the left engine lost power. The pilot subsequently conducted a forced landing to a road and a field, during which the fuselage and wings were crushed, the empennage was partially separated from the fuselage, and the pilot and one passenger sustained serious injuries. The examination of both engines, fuel tanks, and related fuel systems revealed no mechanical anomalies that would have precluded normal operation. One gallon of fuel was recovered from the right main tank fuel lines, and 3 gallons of fuel were recovered from the left auxiliary tank. Although no fuel was recovered from the tip fuel tanks, damage signatures on both tip fuel tanks were consistent with both tanks being full of fuel at the time of the accident. Given this evidence, it is likely that pilot did not use the tip fuel tanks during the previous flight despite believing that he had done so and instead used the main and auxiliary fuel tanks. The pilot's fuel mismanagement resulted in fuel starvation to both engines and their subsequent loss of engine power while on final approach to the airport.

Factual narrative

On September 21, 2016, about 1920 central daylight time, a Piper PA-30 airplane, N7663Y, was substantially damaged following a forced landing near Mineral Wells Airport (MWL), Mineral Wells, Texas. The airline transport certificated pilot and one passenger were seriously injured and one passenger was not injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight plan had been filed for the flight. The cross-country flight departed Marfa Municipal Airport (MRF), Marfa, Texas, at 1655 and was en route to MWL.According to the written statements provided by the pilot, he departed Draughon-Miller Central Texas Regional Airport (TPL), Temple, Texas, on the day of the accident, to fly to MRF to pick up two passengers. He wrote that when he departed TPL the main fuel tanks, the auxiliary fuel tanks, and the tip tanks were all full; a total of 114 gallons of useable fuel. After landing at MRF 19.38 gallons of fuel were added. The pilot did not recall how many gallons were added in each tank; he only recalled that he did not add fuel to the tip tanks as he had "burned those off on the way" from TPL to MRF. The pilot was assisted in fueling the airplane by an airport employee. In the written statements submitted by the pilot, he described using the "Shadin fuel flow [instrument] to lean each engine to 8.7 to 8.9 gallons per hour at level cruise." He also described using fuel out of the tip tanks by switching "the little silver switch" to burn fuel out of the tips." The pilot did not mention the position of the fuel selector valve handle or the illumination of the red fuel transfer light when the tip tanks were selected. During the flight from TPL to MRF, he estimated flying on the tip tanks for one hour and twenty minutes and then flying on the auxiliary fuel tanks for an additional hour and ten minutes. He used the main fuel tanks for takeoff and landing only. The pilot wrote that during the flight from MRF to MWL he only flew on the auxiliary tanks and the main tanks. As the flight passed San Angelo, Texas, he switched back to main tanks and remained in that position for the duration of the flight. While on approach to runway 13 at MWL, he advanced the mixtures to rich about 7 to 10 miles from the runway, at which time the right engine began to surge. He "turned on both electric fuel boost pumps" and established that the fuel gauges did not indicate anything abnormal. He elected not to shut down the right engine. As the pilot maneuvered the airplane for landing, the left engine started to "do the same thing" as the right engine. The airplane started to "loose [sic] airspeed" and the pilot maneuvered the airplane for a forced landing in the "clear", away from trees and obstacles. During the impact with the ground, the fuselage and wings were crushed and wrinkled and the empennage separated partially from thefuselage. The airplane was recovered to a hangar for examination under the auspices of the National Transportation Safety Board, assisted by a FAA inspector, and air safety investigators from Piper Aircraft and Lycoming Engines. The right wing fuel system included the tip tank (15 gallons useable), outboard or auxiliary tank (15 gallons useable), and the inboard or main tank (30 gallons total, 27 gallons usable). The right tip tank was impact damaged and compromised. No fuel was recovered from the tip tank. The damage to the tip tank was consistent with the fuel tank being full at the time of impact. The right auxiliary tank fuel cap was in place and the bladder was in place but was crushed up and wrinkled consistent with the impact damage to the wing. The auxiliary tank was borescoped and revealed no anomalies and no evidence of tearing or breach of the fuel tank bladder. The tank float was unremarkable. Evidence of fuel was documented at the finger screen and there was no evidence of a fuel leak on the upper or lower surface of the wing. The right main tank fuel cap and bladder were in place. The main tank was borescoped and revealed no anomalies and no evidence of tearing or breach of the fuel tank bladder. The tank float was unremarkable. One gallon of fuel was recovered from the right main tank fuel lines. The right side fuel filter was removed and exhibited trace fuel. There was no evidence of visible contamination in the fuel filter. The left wing fuel system included the tip tank (15 gallons useable), outboard or auxiliary tank (15 gallons useable), and the inboard or main tank (30 gallons total, 27 gallons useable). The left tip tank was impact damaged and compromised. No fuel was recovered from the tip tank. The damage to the tip tank was consistent with the fuel tank being full at the time of impact. The left auxiliary tank fuel cap and bladder were in place and the bladder was wet with a small amount of fuel on the bottom. The auxiliary tank was borescoped with no evidence of tearing or breach of the fuel tank bladder. The tank float was unremarkable. Evidence of fuel was documented at the finger screen and there was no evidence of a fuel leak on the upper or lower surface of the wing. Three gallons of fuel were drained from the left auxiliary tank. The left main tank fuel cap and bladder were in place. There was no evidence of fuel in bladder. The main tank was borescope with no evidence of tearing or breach of the fuel tank bladder. The tank float was unremarkable. The left side fuel filter was removed and exhibited trace fuel. There was no evidence of visible contamination in the fuel filter. The tip tank fuel lines for the left and right tanks contained several ounces of fuel. When the lines were opened and the solenoid activated the tip tank light illuminated. The forward fuel sump contained 3 ounces of fuel. The filter was free of visual contamination. The rear fuel sump contained 2 ounces fuel. The filter was free of visualcontamination. There were no mechanical anomalies with the airplane fuel system that would have precluded normal operation at the time of the accident. The left engine data plate identified the engine as a Lycoming IO 320 B1A. The upper bank of spark plugs were removed and illustrated signatures consistent with lean state. The internal exhaust tubing was white in color/residue consistent with a lean mixture. No evidence of fuel was found in the main fuel line between the fuel pump and manifold. Both magnetos were removed and driven with a power drill. Spark was observed on all leads. The engine was rotated through at the propeller. Tactile and audible detection of air movement was documented on all cylinders. Valve train and accessory case continuity was confirmed. The turbocharger spun freely when rotated by hand. The fuel pump was rotated through by hand without resistance or hesitation. The fuel screen was free of visual contaminants. The fuel injector nozzles were free of visible particulates. There was no evidence of fuel in the engine. There were no mechanical anomalies with the left engine that would have precluded normal operation at the time of the accident. The right engine data plate identified the engine as a Lycoming IO 320 B1A. The upper bank of spark plugs were removed and illustrated signatures consistent with lean state. The internal exhaust tubing was white in color/residue consistent with a lean mixture. No evidence of fuel was found in the main fuel line between the fuel pump and manifold. The magnetos were removed and driven with a power drill. Spark was observed on all leads. The engine was rotated through at the propeller. Tactile and audible detection of air movement was documented on all cylinders. Valve train and accessory case continuity was confirmed. The turbocharger spun freely when rotated by hand. The fuel pump rotated through by hand without resistance or hesitation. The fuel screen was free of visual contaminants. The fuel injector nozzles were free of visible particulates. Trace fuel was observed in the fuel servo. There were no mechanical anomalies with the right engine that would have precluded normal operation at the time of the accident. According to the Piper PA-30 Owners Handbook and the Piper PA-30 Turbo Twin Comanche (located in the accident airplane), the airplane as equipped had 114 gallons of useable fuel. The manual stated, "Fuel should be used from the main fuel cells during take-off, landing, climb, and descent. Auxiliary fuel and tip tank fuel is to be used in level flight only." The "Tip/Aux Fuel Management Instructions" placard in the airplane, just above the fuel selector valves, advised on the fuel selector valve handle and toggle switch placement to select fuel from each tank. Specifically for fuel use from the tip tank, the fuel selector valve handle should be selected in the aux position and the toggle switch selected to tip tanks.

Aircraft

Registration
N7663Y
Reported as
Piper PA 30
Category
Airplane
Serial number
30-741
Built
1965
Airframe hours
4,500
Engines
Lycoming IO 320 B1A, 160 horsepower, reciprocatingLycoming IO 320 B1A, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 1, 2016
Departed
KMRF · Marfa, TX
Destination
MWL · Mineral Wells, TX
Airport
MWL · Mineral Wells Airport
Equipment
Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
Serious
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 3, 2016
Seat
Left
Restraint
3-point
Flight hours
7,150 total · 24 in this make and model · 6,000 as pilot in command · 65 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 64 °F
Altimeter
29.97 inHg
Observed at
KMWL, 1 nm away

Docket · 8

The files NTSB released with the investigation on February 22, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 MB in all.