# NTSB DEN00LA145: Piper PA-22-108, N4689Z, Duchesne, UT, August 6, 2000 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 6, 2000, 17:00 local (23:00 UTC) - Place: Duchesne, UT - Coordinates: 40.100872, -110.490814 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.1009&lon=-110.4908&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 2, 2001 - Report: Approved by Office Director - ADs cited in the narratives: [AD 60-10-08](https://openairdocs.org/ad/60-10-08) (OpenAirDocs) - NTSB case key (mKey): 49909 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN00LA145 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/49909/pdf - Page: https://openairdocs.org/ntsb/DEN00LA145 ## Probable cause The pilot's use of excessive braking on soft terrain. Factors included fuel starvation, the fuel selector valve not engaging properly, the pilot's incorrect positioning of the fuel selector valve, and the soft terrain on which the forced landing was made. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, cruise - normal - fluid,fuel - starvation (contributing factor) - fuel system,selector/valve - not engaged (contributing factor) - fuel tank selector position - incorrect, pilot in command (contributing factor) - Forced landing, emergency descent/landing - Nose over, landing - roll - terrain condition - soft (contributing factor) - brakes(normal) - excessive, pilot in command (cause) ## Analysis Shortly after takeoff, the pilot switched the fuel selector from the left tank to the right tank and within a few moments the engine lost power. He switched the fuel selector back to the left tank, but could not restart the engine. He made a forced landing on a beach at an approach speed that was a 'little fast.' When he applied brakes, the airplane nosed over. The pilot said he 'may have shut the fuel off,' and later said the fuel selector handle and indicator pointer were not aligned with each other. In 1960, FAA issued A.D. 60-10-08 requiring the inspection of the fuel selector valve to assure proper alignment of the handle and pointer. According to the airplane maintenance records, A.D. 60-10-08 had been complied with. An FAA airworthiness inspector who examined the airplane said the fuel selector operated correctly. ## Factual narrative On August 6, 2000, approximately 1700 mountain daylight time, a Piper PA-22-108 (converted to a PA-20), N4689Z, was substantially damaged when it nosed over during a forced landing at Starvation Reservoir, near Duchesne, Utah. The airline transport certificated pilot, the sole occupant aboard, was not injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the personal flight being conducted under Title 14 CFR Part 91. The flight originated at Duchesne minutes before the accident. The following is based on the pilot's accident report and information he supplied during a telephone conversation. He departed Duchesne Municipal Airport, and was en route to Salt Lake City Municipal 2 Airport. After leaving the aircraft traffic pattern, he switched the fuel selector from the left tank to the right tank and within a few moments the engine lost power. He switched the fuel selector back to the left tank, but could not restart the engine. He made a forced landing on a beach at Starvation Reservoir at an approach speed that was a "little fast." When he applied brakes, the airplane nosed over. A witness at the scene stated that the pilot said, "I may have shut the fuel off." The pilot later said the fuel selector handle and indicator pointer were not aligned with each other. According to the Piper Aircraft Corporation, the fuel selector valve handle and pointer are both installed on the fuel selector valve shaft via a key-way, and that both must reference the same detent for positive engagement in all four detent positions. As a result, FAA issued Airworthiness Directive (A.D.) 60-10-08, effective May 13, 1960, requiring the inspection of the fuel selector valve to assure proper alignment of the handle and pointer. The A.D. is repetitive every 100 hours time-in-service. According to the airplane maintenance records, all airworthiness directives, including A.D. 60-10-08, were in compliance. An FAA airworthiness inspector from the Salt Lake City Flight Standards District Office examined the airplane and found that the fuel selector operated correctly. Both wing ribs, left engine mount, left strut, vertical stabilizer and rudder were damaged. ## Aircraft - Registration: [N4689Z](https://openairdocs.org/aircraft/N4689Z), registered now, S/N 22-8227, built 1961 (OpenAirDocs) - Reported make and model: Piper PA-22-108 - Registry model: [Piper PA-22-108](https://openairdocs.org/model/piper-pa-22-108) (registry code 7102204) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-8227 - Airframe hours: 2602 - Engines: Lycoming O-320-A2B 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: David F. Edgerly - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 22, 2000, 35 hours before - Departed: U69, DUCHESNE, UT - Destination: U42, SALT LAKE 2, UT ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 15,787 total, 25 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 37 °F - Altimeter: 30.00 inHg - Observed at: VEL, 60 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 20000806010169A](https://openairdocs.org/incident/20000806010169A), Aug 6, 2000: Piper PA22108, Duchesne, UT, No damage. (-23) Mr. David edgerly was pilot in command of a Piper PA-22, N4689Z, on a VFR flight from Duchesne, Utah, (U69) to saltlake city. Shortly after takeoff from… ## Other investigations on N4689Z (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 FTW75DQG39](https://openairdocs.org/ntsb/FTW75DQG39), Jan 3, 1975: Piper PA-22 (N4689Z), Dalhart, TX, substantial damage 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.