CEN18LA038

NTSB accident investigation · Piper / Laudeman J3C 65 · Palmyra, WI · November 26, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
November 26, 2017, 14:30 local (20:30 UTC)
Place
Palmyra, WI
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N11188Piper / Laudeman J3C 65
Defining event
Approach-VFR pattern downwind: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report July 23, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards DIstrict Office
FAA report
20171126018089A
Case key
96366

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 inadvertent pulling of the fuel shutoff valve, which resulted in a total loss of engine power and a subsequent forced landing into trees. Contributing to the pilot’s inadvertent pulling of the fuel shutoff valve were habit patterns he had developed from operating an airplane with different flight controls.

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.

Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect use/operationPiper / Laudeman J3C-65: 1 caseAll aircraft: 497 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotPiper / Laudeman J3C-65: 1 caseAll aircraft: 397 casesProbable cause
Personnel issuesPersonnel issues › Psychological · PilotPiper / Laudeman J3C-65: 1 caseAll aircraft: 5 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomePiper / Laudeman J3C-65: 1 caseAll aircraft: 933 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

Two airline transport-rated pilots departed on a personal, local flight to practice maneuvers. While returning to the departure airport and on the downwind leg, the rear seat pilot inadvertently pulled the fuel shutoff valve, which resulted in a total loss of engine power. The front seat pilot attempted to push the fuel shutoff valve back in but was unable to do so. The rear seat pilot then conducted a forced landing, during which the airplane impacted a tree about 2,000 ft short of the runway threshold, which resulted in substantial damage to both wings. Earlier in the year before the accident, both pilots frequently flew an airplane with a carburetor heat control that was in a similar position as the accident airplane's fuel shutoff valve. The rear pilot stated that he may have inadvertently pulled the fuel shutoff lever instead of the carburetor heat control. Therefore, it is likely that habit patterns developed from operating an airplane with different flight controls contributed to the rear seat pilot inadvertently pulling the fuel shutoff valve.

Factual narrative

On November 26, 2017, about 1430 central standard time, a Piper J3C-65 airplane, N11188, was substantially damaged during a forced landing at Palmyra Municipal Airport (88C), Palmyra, Wisconsin. Both airline transport pilots were seriously injured. The airplane was registered to and operated by Flying Hawks Inc. under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the local flight, which departed without a flight plan about 1400. The rear seat pilot stated that he performed a normal takeoff from the rear seat and flew to a nearby area to practice maneuvers. After completing these maneuvers and returning to 88C, the pilots noticed a loss of engine power while on downwind to runway 27. The pilots attempted unsuccessfully to restore engine power and the rear seat pilot turned the airplane toward runway 27. During the forced landing, the airplane struck a tree about 2000 ft short of the runway threshold and nosed over, damaging both wings. Examination of the airplane at the accident site by a Federal Aviation Administration (FAA) inspector revealed the fuel shut off valve was in the off position. The front seat pilot stated the fuel shut off valve had been inadvertently pulled off by the rear seat pilot. The front seat pilot attempted to push the fuel shut off valve back in but was unable to do so. The rear pilot stated he may have inadvertently pulled the fuel shut off lever instead of the carburetor heat control lever. Earlier in the year, both pilots frequently flew an airplane with a carburetor heat control lever that was in a similar position as the accident airplane's fuel shutoff valve. According to an Aviation, Space, and Environmental Medicine article, "Negative transfer is the transfer from one cockpit to another--of different design or configuration--of habits or responses which were appropriate in the former but are inappropriate in the latter, thereby posing a threat to flying safety. This danger has been demonstrated not only experimentally but also in a number of aircraft accident investigation reports."

Aircraft

Registration
N11188
Reported as
Piper / Laudeman J3C 65
Category
Airplane
Serial number
9400L
Built
1945
Airframe hours
1,205
Engine
Cont Motor C-85-12, 65 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Flying Hawks Inc
Registered owner
Flying Hawks Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 10, 2017 · 106 hours before
Departed
88C · Palmyra, WI
Destination
88C · Palmyra, WI
Airport
88C · Palmyra Muni, runway 27, 2,800 × 200 ft, grass/turf
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
76
Injuries
Serious
Certificates
Sport Pilot, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
September 16, 2015
Seat
Rear
Restraint
Lap only
Flight hours
10,000 total · 1 in this make and model
Role
Pilot
Age
75
Injuries
Serious
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
August 20, 2017
Seat
Front
Restraint
Lap only
Flight hours
20,000 total · 5 in this make and model · 70 in the last 90 days · 30 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 36 °F
Altimeter
30.03 inHg
Observed at
KBUU, 17 nm away

Docket · 5

The files NTSB released with the investigation on December 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.7 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.