# NTSB CEN18LA381: Piper PA28, N8003W, Pagosa Springs, CO, September 19, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 19, 2018, 10:00 local (16:00 UTC) - Place: Pagosa Springs, CO - Coordinates: 37.230278, -106.967224 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.2303&lon=-106.9672&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 98322 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA381 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98322/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98322 - Page: https://openairdocs.org/ntsb/CEN18LA381 ## Probable cause The student pilot's mismanagement of the fuel selector valve during the simulated forced landing demonstration and the flight instructor's inadequate supervision to ensure the fuel selector was properly set, which resulted in a loss of engine power and subsequent forced landing on unsuitable terrain. ## 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-28-180, 32 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102808), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-180, 16 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102808), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-180, 6 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7102808), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-180, 6 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=7102808), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7102808), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28-180, 17 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102808), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-180, 40 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102808), [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-28-180, 96 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102808), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airline transport pilot rated flight instructor was introducing engine failure emergency procedures to the student pilot. Emergency procedures were reviewed inflight. The flight instructor then reduced the engine power to idle to simulate a loss of engine power. The student pilot conducted the emergency procedures on the left side of the cockpit that included switching the fuel tank selector position from right to left. The engine sputtered when the flight instructor subsequently added power to go around about 600 ft above the ground. The engine sputtered. Emergency procedures were reviewed again and the fuel pressure indication was zero. The flight instructor subsequently performed a forced landing where the airplane impacted fencing and ditches and came to rest in a field. Following the accident, the flight instructor noticed the fuel selector valve was about 1.5 to 2 inches between the left detent and off positions. No preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation were reported by the flight instructor and the engine was operational during a subsequent examination of the accident airplane at the accident site. It is likely the student pilot, while conducting the emergency procedure, mismanaged the positioning of the fuel selector valve. While the student pilot was conducting the emergency procedure, the flight instructor did not adequately supervise the student pilot to ensure the fuel selector valve was properly set to the correct position. ## Factual narrative On September 19, 2018, about 1000 mountain daylight time, a Piper PA28 180 airplane, N8003W, impacted fencing and terrain during a forced landing near Pagosa Springs, Colorado, following an inflight loss of engine power. The airline transport pilot rated flight instructor and the student pilot were uninjured. The airplane sustained substantial damage during the impact with fencing. The airplane was registered to and operated by San Juan Flyers Inc. as a Title 14 Code of Federal Regulations Part 91 instructional flight. Day visual meteorological conditions prevailed in the area about the time of the accident, and the flight was not operated on a flight plan. The local flight originated from the Stevens Field Airport, near Pagosa Springs, Colorado, about 0900.According to the flight instructor's accident report, the flight instructor was introducing engine failure emergency procedures to the student pilot. Emergency procedures were reviewed inflight, the instructor located a landing spot, and pulled the throttle to idle to simulate a loss of engine power. The student pilot conducted the emergency procedures on the left side of the cockpit that included switching the fuel tank selector position from right to left, verifying the primer was in and locked, turning on the fuel pump, checking magneto operation, and turning the carburetor heat on. The flight instructor subsequently added power to go around about 600 ft above the ground. The engine sputtered. Emergency procedures were reviewed again and the flight instructor noticed that the fuel pressure indication was zero. The flight instructor did not check the fuel selector nor could the selector be seen due to its location. The flight instructor subsequently performed a forced landing during which the airplane impacted fencing and ditches before coming to rest in a field. Following the accident, the flight instructor observed the fuel selector valve was about 1.5 to 2 inches between the left detent and off positions. Subsequent to the accident, a Federal Aviation Administration inspector examined the accident airplane at the accident site. The airplane's engine was started, and the engine was operational. The flight instructor reported no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation and had a safety recommendation to double check the fuel selector valve position during the forced landing demonstration. ## Aircraft - Registration: [N8003W](https://openairdocs.org/aircraft/N8003W), registered now, S/N 28-2063, built 1964 (OpenAirDocs) - Reported make and model: Piper PA28 (180) - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-2063 - Year built: 1964 - Airframe hours: 5125 - Engines: Lycoming O-360-A4A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: San Juan Flyers Inc - Registered owner: San Juan Flyers Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 18, 2018 - Departed: PSO, Pagosa Springs, CO - Destination: PSO, Pagosa Springs, CO - Airport: PSO, Stevens Field - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: right; restraint: lap only; flight hours: 10,000 total, 500 in this make and model, 9,800 as pilot in command, 54 in the last 90 days, 11 in the last 30 days, 1 in the last 24 hours - Student pilot; age 62; injuries: none; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 3.4 total, 3.4 in this make and model, 3.4 in the last 90 days, 3.4 in the last 30 days, 0.6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 6 knots - Visibility: 10 statute miles - Temperature: 70 °F, dew point 32 °F - Altimeter: 30.21 inHg - Observed at: KPSO, 5 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 20180919013859A](https://openairdocs.org/incident/20180919013859A), Sep 19, 2018: Piper PA-28-180, Pagosa Springs, CO, Substantial damage. While conducting part 61 flight instruction near Pagosa Springs, CO, N8003W experienced a loss of engine power and landed in a field 6.2 miles nw of stevens… ## Docket (3 files) The files NTSB released with the investigation on October 18, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98322. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467495&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record – Inspector B. Proud Ran -- Engine Ran (item 2, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467496&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Inspector%20B.%20Proud%20Ran%20--%20Engine%20Ran-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467497&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.