CEN19LA252

NTSB accident investigation · Piper PA28 · Miami, FL · August 5, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 5, 2019, 09:40 local (13:40 UTC)
Place
Miami, FL
Injuries
2 serious, 1 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N5915UPiper PA28
Defining event
Takeoff: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20190805013389A
Case key
100007

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

On this page

Probable cause

The flight instructor's and student pilot's inadequate preflight inspection of the fuel system for water contamination, which resulted in a loss of engine power during takeoff and subsequent forced landing.

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.

Inspection: preflight inspectionPersonnel issues › Task performance · Instructor/check pilotPiper PA-28-140: 5 casesAll aircraft: 551 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · Student/instructed pilotPiper PA-28-140: 5 casesAll aircraft: 551 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionPiper PA-28-140: 32 casesAll aircraft: 1,695 casesProbable cause
Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-28-140: 3 casesAll aircraft: 442 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 flight instructor and student pilot conducted a preflight inspection of the airplane before the local flight. All the indications were "normal" during the run up. At 150-200 ft above ground level, the engine had a partial loss of power. The instructor subsequently took over the controls; he reported that "everything" was good. During a turn to land the airplane on a parallel runway, the engine lost all power and the instructor decided to conduct a forced landing on a corn field between runways, where the airplane sustained substantial damage. An examination of the airplane revealed that the left wing fuel tank contained 16 oz of water. The gascolator bowl and carburetor contained a liquid consistent with water and fuel. It is likely that the flight instructor and student pilot did not conduct a thorough preflight inspection and did not detect and remove the water in the fuel system, which led to the loss of engine power.

Factual narrative

On August 5, 2019, about 0940 eastern daylight time, a Piper PA28 140 airplane, N5915U, impacted vegetation and terrain during a forced landing following a loss of engine power after takeoff from the Miami Executive Airport (TMB), near Miami, Florida. The flight instructor received minor injuries and the student and passenger reported receiving serious injuries. The airplane sustained substantial wing and fuselage damage during the forced landing. The airplane was registered to and operated by Osorio Aviation Corp. 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 was originating from TMB at the time of the accident. According to the flight instructor, a preflight inspection of the airplane was conducted. Some oil was added to the engine and a check of the fuel revealed about 30-40 gallons was present. The passenger, student pilot, and flight instructor boarded the airplane and followed the checklist to start the airplane engine, which they describe as a "normal" start. They copied the automated terminal information service details, which indicated calm wind and that runways 27R/27L were in use. After that, they contacted clearance and ground controllers, and subsequently taxied via taxiway alpha for runway 27R. The instructor added that the engine run up was conducted using the checklist. The magneto check produced about a 50 RPM drop for each magneto. The carburetor heat test indicated about a 50 RPM drop. The fuel pump was on, all gauges were indicating in the green arc, and all the indications were "normal." The tower controller subsequently issued a clearance for takeoff and the student conducted the takeoff that was a normal takeoff with no flaps. The student rotated the airplane about 75 kts. At 150-200 ft above ground level, the engine RPMs dropped about 200-300 RPMs like a partial loss of power. The instructor subsequently took over the controls. The instructor checked if all the switches were on and if the throttle was full forward. "Everything" was good. The instructor elected to keep climbing at 70-75 kts, which is the best glide speed. He advised the tower that he was going to land the airplane on 9R. During the turn the engine completely lost power and the instructor decided to do a force landing on a corn field between runway 9R and 9L. After the landing, the instructor assessed the occupants and advised the tower of their location and need for immediate medical assistance. He secured the airplane and they evacuated the airplane. At 0907, the recorded weather at TMB was: Wind calm; visibility 10 statute miles; sky condition few clouds at 800 ft, few clouds at 1,400 ft; temperature 28° c; dew point 26° C; altimeter 30.03 inches of mercury. At 0953, the recorded weather at TMB was: Wind calm; visibility 10 statute miles; sky condition clear; temperature30° C; dew point 26° C; altimeter 30.04 inches of mercury. The temperature and dew point spread present about the time of the accident was in the light carburetor icing range at cruise or descent power. A Federal Aviation Administration inspector examined the airplane. During sampling the left-wing fuel tank sump, 16 oz of water was removed. The airplane was recovered on a on flatbed truck. Another sample was taken where contamination consistent with fuel and water was found. The gascolator bowl was broken. However, it contained a liquid consistent with water and fuel. The carburetor sampling also found the same contamination. Pilot's Handbook of Aeronautical Knowledge, FAA-H-8083-25B, Aircraft Systems, in part, stated: Fuel Contamination Accidents attributed to powerplant failure from fuel contamination have often been traced to: - Inadequate preflight inspection by the pilot - Servicing aircraft with improperly filtered fuel from small tanks or drums - Storing aircraft with partially filled fuel tanks - Lack of proper maintenance Fuel should be drained from the fuel strainer quick drain and from each fuel tank sump into a transparent container and then checked for dirt and water. When the fuel strainer is being drained, water in the tank may not appear until all the fuel has been drained from the lines leading to the tank. This indicates that water remains in the tank and is not forcing the fuel out of the fuel lines leading to the fuel strainer. Therefore, drain enough fuel from the fuel strainer to be certain that fuel is being drained from the tank. The amount depends on the length of fuel line from the tank to the drain. If water or other contaminants are found in the first sample, drain further samples until no trace appears. Water may also remain in the fuel tanks after the drainage from the fuel strainer has ceased to show any trace of water. This residual water can be removed only by draining the fuel tank sump drains. Water is the principal fuel contaminant. Suspended water droplets in the fuel can be identified by a cloudy appearance of the fuel, or by the clear separation of water from the colored fuel, which occurs after the water has settled to the bottom of the tank. As a safety measure, the fuel sumps should be drained before every flight during the preflight inspection.

Aircraft

Registration
N5915U
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-26897
Built
1970
Airframe hours
9,800
Engine
Lycoming O-320, 140 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Osorio Aviation Corp
Registered owner
Osorio Aviation Corp
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Unknown · June 24, 2019
Departed
TMB · Miami, FL
Destination
TMB · Miami, FL
Airport
TMB · Miami Executive
Equipment
Stall warning system

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
Flight instructor
Age
22
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 11, 2019
Seat
Right
Restraint
Lap only
Flight hours
1,539 total · 4.3 in this make and model · 1,399 as pilot in command · 56 in the last 90 days · 50 in the last 30 days · 2.7 in the last 24 hours
Role
Student pilot
Age
18
Injuries
Serious
Certificates
Private, Foreign
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
April 27, 2019
Seat
Left
Restraint
Lap only
Flight hours
99.6 total · 7.5 in this make and model · 66 as pilot in command · 50 in the last 90 days · 31 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
82 °F, dew point 79 °F
Altimeter
30.03 inHg
Observed at
KTMB

Docket · 9

The files NTSB released with the investigation on September 11, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 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.