# NTSB CEN18LA075: Piper PA 28-236, N4345K, Tishomingo, OK, January 13, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: January 13, 2018, 11:30 local (17:30 UTC) - Place: Tishomingo, OK - Coordinates: 34.198612, -96.674446 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1986&lon=-96.6744&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report November 15, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 96611 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96611/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96611 - Page: https://openairdocs.org/ntsb/CEN18LA075 ## Probable cause The pilot’s inadequate preflight fuel planning and in-flight fuel monitoring and his decision to take off with an unverified amount of fuel, which resulted in fuel exhaustion and a subsequent impact with trees during an attempted forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-236, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102815), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-236, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102815), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: expectation/assumption](https://openairdocs.org/ntsb-findings/02041525): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-236, 1 case](https://openairdocs.org/ntsb-findings/02041525/cases.md?model=7102815), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/02041525/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-236, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7102815), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Piper PA-28-236, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102815), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-236, 2 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102815), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Piper PA-28-236, 2 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7102815), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-236, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102815), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-236, 13 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102815), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot departed on a cross-country flight; he reported that 35 to 40 gallons of fuel were in the airplane's fuel tanks for a flight that he thought would require 20 gallons of fuel. As the airplane was nearing the destination, the pilot was concerned about the fuel level in the left tank because the fuel gauge indicated that the tank was between one-quarter full and empty and no fuel remained in the right tank, which the pilot had intentionally run dry. The pilot elected to divert to ensure that the airplane would have adequate fuel to complete the flight to the destination. Upon landing at the diversion airpark, the pilot learned that the airpark had no fuel. The pilot subsequently took off from the airpark, and the airplane reached an altitude of about 1,500 ft above ground level when the engine "sputtered." The pilot attempted to return to the airpark, but the airplane could not clear the trees in the area. The pilot attempted a forced landing, but the airplane impacted the trees and subsequently impacted terrain. The airplane was in an inverted position at the time of impact. The pilot reported that the left tank "apparently goes empty somewhere prior to the E [empty] on the fuel gauge." However, the pilot did not mention whether he visually checked the amount of fuel before leaving the diversion airpark. Thus, the pilot likely departed without sufficient fuel on board to complete the flight to another diversion airpark. Further, the fuel amount was lower than the pilot expected during the flight, which was consistent with poor preflight fuel planning and in-flight fuel monitoring. ## Factual narrative On January 13, 2018, about 1130 central standard time, a Piper PA 28-236 airplane, N4345K, impacted terrain during a forced landing following an inflight loss of engine power near Tishomingo, Oklahoma. The pilot was seriously injured. The airplane sustained substantial fuselage damage. The airplane was registered to Piper-Dakota LLC and operated by the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed in the area about the time of the accident, and the flight was operated not operated on a flight plan. The flight originated about 1000 from the Memorial Field Airport (HOT), near Hot Springs, Arkansas, and was destined for the Ardmore Downtown Executive Airport, near Ardmore, Oklahoma.According to the pilot, he departed from HOT with about 35 to 40 gallons of fuel between the left and right fuel tanks. The pilot estimated that the flight would require 20 gallons of fuel. As he was nearing the destination the pilot was concerned about the fuel level in the left tank as it indicated between 1/4 full and empty. There was also no fuel remaining in the right tank as he intentionally ran it dry. The pilot elected to divert to the Tishomingo Airpark (0F9), near Tishomingo, Oklahoma, to ensure the airplane had adequate fuel to complete the flight to Ardmore. The pilot said that upon landing he found out that there was no fuel at 0F9 and that it had not had any fuel for many months. An airpark attendant advised that there was no place nearby to obtain fuel and that the pilot should try the next available airport. The pilot subsequently took off from 0F9. When the airplane reached an altitude of about 1,500 ft above ground level, the engine "sputtered" as if out of fuel. The pilot immediately turned back to the airport. However, the airplane was at an altitude where it could not clear the trees in area. The airplane impacted the trees and subsequently impacted terrain inverted. The pilot did not indicate in his accident report that he visually checked the fuel level before departing 0F9. However, he stated that the "left tank apparently goes empty somewhere prior to the "E" on the fuel gauge" and that the gauges were inaccurate. Federal Aviation Regulation Part 23.1337, Powerplant Instruments Installation, in part stated, "Each fuel quantity indicator must be calibrated to read ''zero'' during level flight when the quantity of fuel remaining in the tank is equal to the unusable fuel supply." ## Aircraft - Registration: [N4345K](https://openairdocs.org/aircraft/N4345K), registered now, S/N 28-8411012, built 1984 (OpenAirDocs) - Reported make and model: PIPER PA 28-236 - Registry model: [Piper PA-28-236](https://openairdocs.org/model/piper-pa-28-236) (registry code 7102815) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8411012 - Year built: 1984 - Airframe hours: 2128 - Engines: LYCOMING O-540-J3A5D 235 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 2, 2017 - Departed: HOT, HOT SPRINGS, AR - Destination: 1F0, ARDMORE, OK - Equipment: Stall warning system, Auto-pilot, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review January 1, 2017; seat: left; restraint: 3-point; flight hours: 634 total, 522 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 34 °F, dew point 12 °F - Altimeter: 30.64 inHg - Observed at: KADM, 18 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 20180113000779A](https://openairdocs.org/incident/20180113000779A), Jan 13, 2018: Piper PA-28-236, Tishomingo, OK, Substantial damage. Pilot departed from the memorial field airport, near hot springs, Arkansas, about 0940, and was intending to go to ardmore municipal airport, near ardmore,… ## Docket (2 files) The files NTSB released with the investigation on March 19, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96611. 4.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460981&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Miscellaneous Information - Part 23 Excerpt (item 2, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460982&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20Part%2023%20Excerpt-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.