# NTSB CEN23LA415: Piper PA-32-300, N4219T, Moberly, MO, September 11, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: September 10, 2023, 19:50 local (Sep 11, 2023, 00:50 UTC) - Place: Moberly, MO - Coordinates: 39.418369, -92.438237 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4184&lon=-92.4382&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 193115 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA415 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193115/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193115 - Page: https://openairdocs.org/ntsb/CEN23LA415 ## Probable cause The flight instructor’s inadequate fuel management that resulted in fuel starvation and a total loss of engine power during an approach for landing. ## 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-32-300, 9 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7103212), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Piper PA-32-300, 9 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7103212), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-32-300, 10 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=7103212), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Piper PA-32-300, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103212), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Approach: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-32-300, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7103212), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-32-300, 25 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103212), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32-300, 43 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor stated that prior to beginning the instructional flight, he visually confirmed there was fuel in each fuel tank. He did not use a fuel dip stick when he checked the fuel level and approximated the fuel level as 17 gallons. He said the flight would have required 8 gallons of fuel. About 10 miles from the destination airport, with the fuel selector positioned to the right main fuel tank, the engine began to run rough. He then selected the right auxiliary fuel tank, and the engine began to run smoothly again. About 4 miles from the destination airport and during the approach for landing, the engine began to run rough again. He then selected the left auxiliary fuel tank, but engine power was not restored. With the engine at idle power, he tried to restore engine power by cycling through the remaining fuel tanks but was unsuccessful. He then performed a forced landing to a field, during which the engine ceased to operate. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane revealed no leaks with the fuel system and no useable fuel was found in the left and right main fuel tanks. The flight instructor stated that after the accident, he checked the left auxiliary/tip tank and there was 7 gallon of fuel present. The examination revealed no failures or malfunctions with the airframe and engine that would have precluded normal airplane operation. ## Aircraft - Registration: [N4219T](https://openairdocs.org/aircraft/N4219T), registered now, S/N 32-7240037, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-32-300 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32-7240037 - Year built: 1971 - Engines: Lycoming IO-540-K1A5 300 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: 19t LLC - Airworthiness certificate: Standard, Normal - Departed: COU, Columbia, MO - Destination: Same as departure - Airport: MBY, Omar N Bradley Airport - Equipment: Auto-pilot, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 32; injuries: none; private, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review February 27, 2023; seat: left; restraint: 3-point; flight hours: 717 total, 15 in this make and model, 581 as pilot in command, 218 in the last 90 days, 64 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Lowest ceiling: none - Altimeter: 30.11 inHg - Observed at: MBY, 3 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 20230910021149A](https://openairdocs.org/incident/20230910021149A), Sep 10, 2023: Piper PA-32-300, Moberly, MO, Substantial damage. During the landing approach into the airport. Engine lost power and the pilot did his best to perform an emergency landing under challenging circumstances. The… ## Other investigations on N4219T (1) 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. - [NTSB ATL96LA024](https://openairdocs.org/ntsb/ATL96LA024), Dec 19, 1995: Piper PA-32-300 (N4219T), Monroe, NC, substantial damage. Probable cause: The pilot's inadequate planning and failure to follow operating procedures resulted in his descent below the decision height while on final approach. ## Docket (7 files) The files NTSB released with the investigation on March 21, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193115. 5.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 - flight instructor (item 1, PDF, 9 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749232&FileExtension=pdf&FileName=NTSB%20Form%206120.1%20-%2027Oct2023_Redacted-Rel.pdf - Statement - flight instructor (item 2, PDF, 1 page, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749083&FileExtension=pdf&FileName=NTSB%20Statement%20-%2027Oct2023-Rel.pdf - Record of conversation - flight instructor (item 3, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16750896&FileExtension=pdf&FileName=MOR%20Flight%20Instructor-Rel.pdf - Record of conversation follow up - flight instructor (item 4, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16752611&FileExtension=pdf&FileName=MOR%20Flight%20Instructor%20Second-Rel.pdf - Record of conversation - federal aviation administration inspector (item 5, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16752461&FileExtension=pdf&FileName=MOR%20Federal%20Aviation%20Adminstration-Rel.pdf - Aircraft track log of accident flight (item 6, PDF, 2 pages, 844 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16750685&FileExtension=pdf&FileName=Aircraft%20Track%20Log-Rel.pdf - Photos (item 7, PDF, 3 pages, 696 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749362&FileExtension=pdf&FileName=Photo%20Template-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.