# NTSB CEN20LA252: Piper PA28R, N811MS, Denver, CO, June 28, 2020 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: June 27, 2020, 21:00 local (Jun 28, 2020, 03:00 UTC) - Place: Denver, CO - Coordinates: 39.749023, -105.00098 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7490&lon=-105.0010&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Minor injuries - Injuries: 1 minor, 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 101506 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA252 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101506/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101506 - Page: https://openairdocs.org/ntsb/CEN20LA252 ## Probable cause The total loss of engine power during climbout due to fuel starvation. Contributing to the accident was the pilot’s inadequate fuel planning. ## 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-28R-201, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102816), [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-28R-201, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=7102816), [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-28R-201, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102816), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102816), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102816), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28R-201, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102816), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis During climbout after a touch-and-go landing maneuver, the pilot reported that the engine hesitated. Suspecting a fuel issue, the pilot attempted to switch fuel tanks, but was unable to reach the fuel selector because the shoulder harness would not release. He abandoned attempts to switch fuel tanks and turned toward flat terrain for a forced landing. The airplane landed in a field adjacent to a tree line, resulting in substantial damage to the left wing. Examination of the engine, throttle and mixture controls, and fuel distribution system did not reveal any pre-impact anomalies. About 4.25 total gallons of fuel were drained from the fuel tanks; 4 gallons from the left tank and .25 gallons from the right tank. The airplane flight manual stated that unusable fuel for the airplane is 5 total gallons, 2.5 gallons in each tank for critical flight conditions. It is likely that the reported engine hesitation after takeoff was due to fuel starvation. ## Factual narrative On June 26, 2020, about 2100 central daylight time, a Piper PA28R-201, N811MS, was substantially damaged when it was involved in an accident at Rocky Mountain Metropolitan Airport (BJC), Broomfield, Colorado. One passenger sustained minor injuries, and the private pilot and two passengers were not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot departed BJC, flew to a nearby airport, and was returning to BJC when the accident occurred. He reported that his shoulder harness inertial reel locked up while preparing for the outbound and return flights for no apparent reason, but he was able to free up the harness in both cases. The pilot reported that he arrived back at BJC with about 15 gallons of fuel left in the airplane (10 gallons in the right tank and 5 gallons in the left tank). The pilot requested clearance to perform a touch-and-go maneuver at BJC. Shortly before the turn from base to final, the pilot’s shoulder harness locked up once again. He leaned back to release the belt, but it took out the slack without releasing. After touchdown, the pilot performed the touch-and-go, with the shoulder harness still locked. During the climb, the engine hesitated and the pilot pitched the airplane forward. Suspecting a fuel issue, the pilot attempted to switch fuel tanks. The pilot stated that it was difficult to reach the fuel selector lever because of the shoulder harness not releasing. The pilot abandoned further attempts to switch fuel tanks and initiated a left turn toward flat terrain for a forced landing. The airplane landed in a field about 350-feet beyond the departure end of runway. The airplane came to rest upright adjacent to a tree line, resulting in substantial damage to the left wing. A postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuel distribution system was intact and appeared normal. Cockpit throttle and mixture controls were rigged properly and appeared normal. The cockpit fuel selector valve was found in the left tank position. A total of about 4.25 gallons of fuel was removed from the left and right fuel tanks; 4 gallons from the left tank, and .25 gallons from the right tank. The tanks were not compromised. The cockpit fuel gauges appeared to function normally When examined, the pilot’s inertial reel on the shoulder harness did not function properly as the pilot reported. The airplane flight manual states that the unusable fuel for the airplane is 5 total gallons, 2.5 gallons in each fuel tank for critical flight conditions. ## Aircraft - Registration: [N811MS](https://openairdocs.org/deregistered/N811MS-2022-02-24), registration cancelled 2022-02-24, S/N 2837042, built 1989 (OpenAirDocs) - Reported make and model: Piper PA28R (201) - Registry model: [Piper PA-28R-201](https://openairdocs.org/model/piper-pa-28r-201) (registry code 7102816) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2837042 - Year built: 1989 - Airframe hours: 15144 - Engines: Lycoming IO-360 230 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Rocky Mountain Flight School - Registered owner: G & M Aircraft Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 5, 2020 - Departed: FMM, Fort Morgan, CO - Destination: Same as departure - Airport: BJC, Rocky Mountain Metro, runway 30R, 9,000 × 100 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review February 4, 2019; seat: left; restraint: 4-point; flight hours: 428 total, 19 in this make and model, 24 in the last 90 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dusk - Wind: 260° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 32 °F - Altimeter: 29.86 inHg - Observed at: BJC ## 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 20200627015549A](https://openairdocs.org/incident/20200627015549A), Jun 27, 2020: Piper PA-28R-201, Broomfield, CO, Substantial damage. On June 27th, 2020, at 2100 MST at rocky mountain metropolitan airport (kbjc), in Broomfield Colorado, airplane N811MS, a Piper PA-28R-201, experienced loss of… ## Docket (5 files) The files NTSB released with the investigation on June 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101506. 8.2 MB in all. - NTSB form 6120 pilot operator report CEN20LA252 (item 1, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14004915&FileExtension=pdf&FileName=NTSB%20Form%206120%20Pilot%20Operator%20Report%20CEN20LA252_Redacted-Rel.pdf - Airport security video of accident CEN20LA252 (item 2, AVI, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14004950&FileExtension=avi&FileName=Airport%20Security%20Video%20of%20Accident%20CEN20LA252-Rel.avi - Memorandum for the record engine and fuel system examination findings CEN20LA252 (item 3, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14004793&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Engine%20and%20Fuel%20System%20Examination%20Findings%20CEN20LA252_Redacted-Rel.pdf - Piper PA28 AFM fuel limitation excerpt CEN20LA252 (item 4, PDF, 1 page, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14004499&FileExtension=pdf&FileName=Piper%20PA28%20AFM%20Fuel%20Limitation%20Excerpt%20CEN20LA252-Rel.pdf - Photo array CEN20LA252 (item 5, PDF, 2 pages, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14005048&FileExtension=pdf&FileName=Photo%20Array%20CEN20LA252-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.