# NTSB CHI06LA031: Piper PA-28-181, N2241P, Milwaukee, WI, November 13, 2005 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 12, 2005, 18:20 local (Nov 13, 2005, 00:20 UTC) - Place: Milwaukee, WI - Coordinates: 42.947223, -87.896385 - Nearby events: https://openairdocs.org/map.md?lat=42.9472&lon=-87.8964&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report October 3, 2006 - Report: Approved by Office Director - Parties: FAA-Milwaukee FSDO - NTSB case key (mKey): 62828 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI06LA031 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62828/pdf - Page: https://openairdocs.org/ntsb/CHI06LA031 ## Probable cause The loss of engine power due to fuel starvation as a result of the pilot's fuel mismanagement. Factors to the accident included the pilot's impairment due to alcohol, the FAA's inadequate oversight when it issued the pilot a second class medical certificate, the power lines, and night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - fuel management - not performed, pilot in command (cause) - impairment(alcohol), pilot in command (contributing factor) - fluid,fuel - starvation (cause) - inadequate certification/approval,airman, faa(organization) (contributing factor) - Forced landing, emergency descent/landing - In flight collision with object, emergency descent/landing - object - wire,transmission (contributing factor) - light condition - night (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane sustained substantial damage when it impacted power lines at night during an emergency descent after a loss of engine power. The pilot reported that he departed on the flight in order to keep current at night flying and to practice night takeoffs and landings. He reported that rain was forecast for later that night, but that the sky was clear and "bumpy" after departure. He ran into light rain and decided to return to the departure airport before the weather got any worse. He reported that the engine quit and he executed a forced landing to a "desolate street," but impacted wires. The airplane remained tangled in the power line wires, and emergency personnel removed the pilot from the suspended airplane about 2 hours later. The inspection of the airplane revealed that the left fuel tank contained no fuel, and that fuel "poured" out of the right fuel tank when it was drained of fuel. The fuel tanks were not compromised, and there were no fuel leaks from either tank. The fuel selector was selected to the left fuel tank. The flight duration was about 2.3 hours. The pilot's blood was tested for the presence of alcohols. The blood ethanol concentration was 0.286 grams per 100 milliliters. The FAA FAR Part 91.17 legal limit is 0.04. The pilot's FAA medical records revealed that the pilot had a history of alcohol-related traffic offenses since at least 20 years of age (17 years prior to the accident). The manager of the FAA Aerospace Medical Certification Division sent a letter to the pilot on June 26, 2002, which noted, "Our review of your medical records has established that you are eligible for a second-class medical certificate. ... Continued airman medical certification remains contingent upon your total abstinence from use of alcohol. ..." There is no indication of any additional requirement for evaluation or follow up. The pilot's most recent Application for 2nd Class Medical Certificate, dated April 21, 2005 indicated "no" in response to "HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING ... Alcohol dependence or abuse." The pilot held a current second class medical certificate dated April 21, 2005. ## Factual narrative On November 12, 2005, at 1820 central standard time, a Piper PA-28-181, N2241P, operated by the Westosha Flying Club, sustained substantial damage when it impacted power lines about five miles east of the General Mitchell International Airport (MKE), Milwaukee, Wisconsin, during an emergency descent after a loss of power. The private pilot received minor injuries. The 14 Code of Federal Regulations Part 91 personal flight departed Westosha Airport (5K6), Wilmont, Wisconsin, about 1615 on a local flight. Night visual meteorological conditions prevailed at the time of the accident. No flight plan was filed. The pilot reported that he departed on the flight in order to keep current at night flying and to practice night takeoffs and landings. He reported that rain was forecast for later that night, but that the sky was clear and "bumpy" after departure. He reported that he ran into light rain near Milwaukee and decided to return to 5K6 before the weather got any worse. He reported, "Engine quit on the way home over Milwaukee. I was about 2,000 feet. I think to stay out of MKE airspace and stay clear of clouds. I was having a problem with the radio and couldn't contact anyone. Had only 20 seconds to go through emergency procedures and find a landing spot." He reported that he executed a forced landing to a "desolate street," but impacted wires. The airplane remained tangled in the power line wires, and emergency personnel removed the pilot from the suspended airplane about 2 hours later. A Federal Aviation Administration (FAA) inspector examined the airplane at the site of the accident. He reported that the left fuel tank contained no fuel, and that fuel "poured" out of the right fuel tank when it was drained of fuel. The fuel tanks were not compromised, and there were no fuel leaks from either tank. The fuel selector was selected to the left fuel tank. The pilot's blood was tested for the presence of alcohols. The blood ethanol concentration was 0.286 grams per 100 milliliters. The FAA FAR Part 91.17 legal limit is 0.04. The National Transportation Safety Board's Medical Officer reviewed the pilot's medical records maintained by the FAA's Aeromedical Certification Division. The medical records revealed that the pilot had a history of alcohol-related traffic offenses since at least 20 years of age (17 years prior to the accident). His personal summary in 2002 of his alcohol-related offenses indicated at least 8 different offenses, beginning in 1988. He indicated that in 1989, he underwent required level II alcohol education in Colorado, but then had two DUIs in 1992; in that same year, his FAA medical certificate was revoked for failure to note multiple actions against his driver's license on his application for airman medical certificate. The pilot's 2002 summary omitted mention of his 1991 license revocation in Nevada, which was noted in his FAA order of revocation in 1992. The pilot noted that in November of 1992, he was admitted to an inpatient treatment center for two weeks. In an attempt to regain his medical certificate, he submitted multiple reports to the FAA in May, August, and December 1995 indicating that he was in treatment and had been sober since the 1992 inpatient treatment. He noted that he was convicted and jailed for an offense in January of 1996, following which he underwent outpatient treatment. He noted that he was charged with DUI in May 1996, January 1997, and April 1997. He indicated that he quit drinking completely in 1998 and submitted an evaluation from a Certified Alcohol and Drug Counselor noting that he underwent counseling in 2001, and indicating that he had claimed sobriety for 3 years at that time. The manager of the FAA Aerospace Medical Certification Division sent a letter to the pilot on June 26, 2002, which noted, "Our review of your medical records has established that you are eligible for a second-class medical certificate. ... Continued airman medical certification remains contingent upon your total abstinence from use of alcohol. ..." There is no indication of any additional requirement for evaluation or follow up. The pilot's most recent Application for 2nd Class Medical Certificate, dated April 21, 2005 indicated "no" in response to "HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING ... Alcohol dependence or abuse." The application noted "yes" in response to "History of ... any conviction (s) involving driving while intoxicated ...," and noted "see previous application." The application noted that the pilot was issued a medical certificate by the aviation medical examiner. The FAA records did not contain any additional material submitted by the pilot or the aviation medical examiner with this application, and there is no record that any was requested. The pilot held a private pilot's certificate with single engine land and instrument airplane ratings. He had logged about 516 hours of total flight time. The pilot held a second class medical certificate dated April 21, 2005. ## Aircraft - Registration: [N2241P](https://openairdocs.org/deregistered/N2241P-2009-09-09), registration cancelled 2009-09-09, S/N 28-7990294, built 1979 (OpenAirDocs) - Reported make and model: Piper PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (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: 28-7990294 - Airframe hours: 4631 - Engines: Lycoming O-360-A4M reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Westosha Flying Club - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2005, 230 hours before - Departed: 5K6, Westosha, WI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: none; flight instructor, private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2; last flight review May 1, 2005; seat: left; flight hours: 526 total, 100 in this make and model, 10 in the last 90 days ## Weather - Conditions: Visual (VMC), Night - Wind: 200° at 17 knots, gusting 24 - Visibility: 6 statute miles - Lowest ceiling: 3,900 ft overcast - Temperature: 57 °F, dew point 48 °F - Altimeter: 29.70 inHg - Observed at: MKE ## 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 20051112032079A](https://openairdocs.org/incident/20051112032079A), Nov 12, 2005: Piper PA28181, Milwaukee, WI, Destroyed. (-23) On November 12, 2005, at 1820 central standard time, a Piper PA-28-181, N2241P, operated by the westosha flying club, sustained substantial damage during… 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.