# NTSB CEN19FA093: Piper PA28, N7369W, Summersville, MO, March 6, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: March 5, 2019, 22:04 local (Mar 6, 2019, 04:04 UTC) - Place: Summersville, MO - Coordinates: 37.195926, -91.70314 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.1959&lon=-91.7031&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA St. Louis FSDO, Piper Aircraft, Lycoming Engines - NTSB case key (mKey): 99061 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99061/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99061 - Page: https://openairdocs.org/ntsb/CEN19FA093 ## Probable cause The total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot’s inadequate preflight fuel planning and in-flight fuel monitoring. ## 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 level (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) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 17 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102808), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Piper PA-28-180, 16 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=7102808), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: 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 pilot was conducting a multileg cross-country flight and had last refueled the airplane with 26.98 gallons of fuel about 375 miles from the accident location and about 450 miles from the destination airport. After departure from the last fuel stop, the pilot continued on the final leg of the flight in dark night conditions. Radar data consistent with the accident flight showed the airplane on course about 5,000 ft mean sea level for about 4 hours. Just before the end of the radar track, the airplane began descending, then turned north and then southeast. The airplane impacted trees and terrain. The right wing separated and the fuselage was buckled. The wreckage of the airplane was found on wooded, hilly terrain the next morning by a motorist on a nearby road. The airplane impacted the trees and terrain in an attitude, consistent with a forced landing. The dark night conditions likely would have made it difficult for the pilot to see the trees during the landing. Postaccident examination of the airplane revealed that the two fuel tanks were not compromised; the left fuel tank was empty, and the right fuel tank contained only a minimal amount of fuel. Only a trace amount of fuel was found in the fuel lines and fuel pump. The damage to the propeller blades was consistent with little or no engine power at the time of impact. No preimpact mechanical malfunctions or failures with the airframe or engine were noted during the examination, although the emergency locator transmitter was found to be inoperable. The airplane averaged about 94 knots ground speed during the flight, and the entire flight from the fuel stop to the destination airport should have taken about 4 hours 48 minutes at that speed. Although the extent of the pilot’s preflight fuel planning and in-flight fuel monitoring could not be determined, with a fuel burn rate of 10 gallons per hour, there was not enough fuel to complete the planned flight with the required 45-minute night flight fuel reserve. Thus, the pilot’s preflight fuel planning was likely inadequate, and the engine lost power due to fuel exhaustion. Although the emergency locator transmitter did not activate, there was insufficient information from which to determine whether or how this affected survivability in this accident. ## Factual narrative A placard mounted on the airplane wing adjacent the fuel cap indicated a maximum fuel capacity of 25 gallons. According to the Piper Cherokee PA-28-180 Owner’s Handbook, the engine would burn about 10 gallons per hour at 75% horsepower. The fuel capacity was 50 gallons total: 25 gallons in each wing fuel tank, with 1 gallon per side that was unusable. According to a fuel receipt from LOZ, the pilot purchased 26.98 gallons of fuel at a self-service pump. Investigators were unable to determine if this amount filled both fuel tanks to capacity. On March 5, 2019, about 2204 central standard time, a Piper PA 28-180 airplane, N7369W, was substantially damaged when it was involved in an accident near Summersville, Missouri. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the owner of the airplane and a family member of the pilot, the pilot traveled to Virginia on commercial airline flights the morning of the accident to pick up the airplane for the owner and return to Missouri. The pilot departed New River Valley Airport (PSK), Dublin, Virginia, at an unknown time and was en route to Downtown Airport (3DW), Springfield, Missouri. Investigators established that the pilot stopped at London (Corbin) Magee Airport (LOZ), London, Kentucky, for fuel about 1731 and departed about 1801. The pilot did not receive, nor was he required to receive, air traffic control services. The accident airplane squawked a nondiscreet beacon code of 1200, and positive radar identification could not be made. However, radar data depicted a flight track consistent with the airplane’s reported departure time from LOZ. According to the radar data, the airplane was westbound at an altitude of 5,000 ft mean sea level. Just before the radar data ended, the altitude started to decrease, and the airplane turned towards the north followed by about a 180° course reversal toward the southeast. The wreckage was located the next morning by the driver of a vehicle on a nearby road. The flight track ended about 2204, about 1.8 nautical miles northwest of the accident location. The wreckage was found the next morning by a motorist on a nearby road. Southwest Missouri Forensics performed an autopsy of the pilot; on March 7, 2019. The cause of death was multiple blunt force injuries with environmental hypothermia contributing to the death. The Federal Aviation Administration’s Forensic Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Results were negative for carbon monoxide and ethanol. Atorvastatin (a medication used to treat high cholesterol) and cetirizine (a sedating antihistamine) were detected in the urine. About 48.3 ng/mL ceterizine was detected in the blood The accident site had deciduous walnut trees and hilly terrain covered in short grass (see figure 1). The airplane came to rest on a measured heading of 99° at anelevation of 1,310 ft. The initial impact point was located at the top of a 45-ft-tall tree, characterized by broken branches. The main wreckage came to rest about 76 ft east of the initial impact point. A section of the right wing, broken branches, and paint chips were scattered on the ground between the initial impact point and a second tree. The second tree was about 45 ft tall and exhibited broken branches near the top and witness marks consistent with impact from the airplane. Additional branches, plexiglass, paint chips, torn metal from the wing, torn fiberglass, the baggage door, and a fragmented red lens cover were scattered over 45 ft between the second tree and the main wreckage. Figure 1. Accident Site The main wreckage included the fuselage, empennage, left wing, and engine and propeller assembly. The right wing came to rest about 14 ft north of the main wreckage. The right wing included the right aileron, right flap, right fuel tank, and the right main landing gear. The right fuel tank was not compromised and contained less than 1 cup of fuel. The left wing remained attached to the fuselage at the wing spar and included the left flap, left aileron, left fuel tank, and left main landing gear. The left fuel tank was not compromised and contained no fuel. The engine remained attached to the fuselage; the engine mounts were intact, and the tubing was bent down. The two-blade propeller remained attached at the flange. One propeller blade was extended in the air and exhibited chordwise scratches along the entire chambered face of the blade. The second blade was bent and embedded in the ground. The blade was bent aft slightly, exhibited chordwise scratches on the cambered face of the blade, and had several leading-edge nicks. The engine-driven fuel pump and electrical fuel pump line contained a trace amount of fuel; the carburetor contained liquid consistent with fuel. The examination of the engine and airframe revealed no mechanical anomalies that would have precluded normal operation before the accident. The emergency locator transmitter was examined and was found to be nonfunctional. Investigators were not able to determine if this was impact related or if the condition existed before the accident flight. ## Aircraft - Registration: [N7369W](https://openairdocs.org/deregistered/N7369W-2020-01-03), registration cancelled 2020-01-03, S/N 28-1251, built 1963 (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: 28-1251 - Year built: 1963 - Airframe hours: 4925.6 - Engines: Lycoming Engines O-360-A3A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 25, 2018, 20 hours before - Departed: PSK, London, KY - Destination: 3DW, Springfield, MO - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review June 17, 2017; seat: left; restraint: 3-point; toxicology performed; flight hours: 690.8 total, 5 in this make and model ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 310° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 21 °F, dew point 10 °F - Altimeter: 30.43 inHg - Observed at: KUNO, 40 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 20190305000899A](https://openairdocs.org/incident/20190305000899A), Mar 5, 2019: Piper PA-28-180, Summersville, MO, Substantial damage, 1 fatal. On March 05, 2019 at approximately 1630 eastern daylight time (EDT) / 2030Z (zulu), N7369W, Piper PA-28-180 departed dublin, VA, new river valley airport ?… ## Docket (13 files) The files NTSB released with the investigation on May 4, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99061. 26.9 MB in all. - Radar data plot (item 1, PDF, 1 page, 446 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11628102&FileExtension=pdf&FileName=Radar%20Data%20Plot-Rel.pdf - Fuel stop documentation (item 2, PDF, 3 pages, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12214973&FileExtension=pdf&FileName=N7369W%20fuel%20Stop_Redacted-Rel.pdf - Weather reports (item 3, PDF, 2 pages, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12216392&FileExtension=pdf&FileName=Weather%20Metar-Rel.pdf - Records of conversation (item 4, PDF, 2 pages, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12215219&FileExtension=pdf&FileName=Records%20of%20Conversation%20-%20CEN19FA093-Rel.pdf - Examination summary statement (item 5, PDF, 4 pages, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10121455&FileExtension=pdf&FileName=On-Scene%20Examination%20Summary%20--%20CEN19FA093-Rel.pdf - Examiation summary statement - ELT (item 6, PDF, 1 page, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12215589&FileExtension=pdf&FileName=Examination%20Summary%20Notes%20-%20ELT-Rel.pdf - Piper PA28-180 POH fuel excerpts (item 7, PDF, 2 pages, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12215740&FileExtension=pdf&FileName=Piper%20PA%2028-180%20POH%20Excerpts-Rel.pdf - Pilot logbook excerpts (item 8, PDF, 6 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11628233&FileExtension=pdf&FileName=Pilot%20logbook%20excerpts_RedactedSmall-Rel.pdf - N7369W - maintenance records excerpts (item 9, PDF, 8 pages, 21.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12215550&FileExtension=pdf&FileName=Maintenance%20Logbook%20Excerpts%20-%207369W_Redacted-Rel.pdf - Toxicological report (item 10, PDF, 1 page, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7877216&FileExtension=pdf&FileName=Toxicology%20-%20CEN19FA093_Redacted-Rel.pdf - Medical officer factual report (item 11, PDF, 4 pages, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11584913&FileExtension=pdf&FileName=CEN19FA093_Medical%20Factual%20Report_rev-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 1 page, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12215839&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release%20-%20N7369W_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 2 pages, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10122109&FileExtension=pdf&FileName=Signed%20party%20forms_Redacted-Rel.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.