# NTSB ERA10LA410: Piper PA-44-180, N730FT, Eastman, GA, August 10, 2010 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: August 10, 2010, 01:55 local (05:55 UTC) - Place: Eastman, GA - Coordinates: 32.198055, -83.134445 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1981&lon=-83.1344&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed, report December 19, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper Aircraft Corporation, FAA/FSDO, Lycoming Engines - NTSB case key (mKey): 76910 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA410 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76910/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76910 - Page: https://openairdocs.org/ntsb/ERA10LA410 ## Probable cause Both pilots’ failure to use emergency checklist procedures for restarting the engine after the loss of engine power due to fuel starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Piper PA-44-180, 4 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7104402), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Unintentional use/operation; cases with it: [Piper PA-44-180, 2 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7104402), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Piper PA-44-180, 6 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7104402), [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-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-44-180, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7104402), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-44-180, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7104402), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-44-180, 11 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104402), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The certified flight instructor (CFI) stated that the fuel tanks were approximately full prior to the instructional cross-country flight. During the descent, the left engine and then the right engine lost total engine power. The CFI assumed control of the airplane and initiated an engine restart, which was unsuccessful. The airplane struck several trees and came to rest inverted. According to the airplane’s pilot operating handbook, in order to begin restoring power, the fuel selector must be in the "ON" position. Examination of the wreckage indicated that the fuel selector valves were in the "OFF" positions; further, no malfunctions or anomalies were found to prevent the engines from operating normally. According to both pilots, neither could recall turning the fuel selector valves to the "OFF" positions. In a written statement provided by the flight school's assistant chief flight instructor, a rear seat passenger would be able to inadvertently retard both fuel selector valves to the "OFF" position. Although it is probable that the inadvertent retarding of the selector valves caused the initial engine failures, there was no evidence to indicate that the engines could not have been restarted had the air start or the engine securing procedure checklists been accomplished and the fuel selector valves been placed in the "ON" position. ## Factual narrative On August 10, 2010, at 0155 eastern daylight time, a Piper PA-44-180, N730FT, registered to Jules Aircraft Company, and operated by Orlando Flight Academy, doing business as Space Coast Aviation, was substantially damaged when it collided with terrain while maneuvering for landing at the Heart of Georgia Regional Airport (EZM), Eastman, Georgia. Night visual meteorological conditions prevailed and no flight plan was filed for the 14 Code of Federal Regulations Part 91 instructional flight. The certificated flight instructor (CFI), private pilot receiving instruction, and pilot rated passenger reported minor injuries. The flight originated from St. Augustine Airport (SGJ,) St. Augustine, Florida, about 0000. The pilot receiving instruction stated he was on final approach to runway 2 at EZM. The precision approach path indicator (PAPI) indicated the airplane was low on the approach. He added power, lowered the landing gear and added "a notch of flaps." About four miles from the airport the PAPI indicated the airplane was again low on glide path. He added power, and the left engine failed. The pilot initiated the engine failure emergency checklist. The right engine started losing power and the CFI took control of the airplane. The pilot verified that the fuel pumps were on and that the fuel selector was in the "ON" position. However, after the accident he did not turn "OFF" the fuel selector valve. The CFI stated the fuel tanks were filled to "within an inch of the filler neck," before departing SGJ. The flight climbed to their cruising altitude of 6,500 mean sea levels (msl) which was uneventful. The pilot initiated a "powered descent" through 3,000 feet msl. The mixture was increased to full rich and the fuel pumps were selected "ON." The CFI noticed the pilot performing the engine failure checklist and immediately took control of the airplane. He initiated an engine restart which was unsuccessful. The airplane struck several trees and came to rest inverted at the edge of a swamp. After impact he ordered the student to secure the airplane and verify that the fuel was off. According to the pilots and Federal Aviation Administration (FAA) records, the CFI, age 27, held a commercial pilot and flight instructor certificate each with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent application for an FAA first-class medical certificate was issued on October 22, 2007. He reported a total flight experience of 968 hours; 90 total hours of flight experience in airplane multiengine, of which 35 hours were in the accident airplane make and model. The student pilot, age 23, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA first-class medical certificate was issued on November 9, 2009. He reported a total flight experience of 230 hours, of which 9 total hours of flight experience was in the accident airplane make and model. According tothe CFI and FAA records, the airplane was manufactured in 1978 as a four-seat, low-wing airplane with retractable landing gear and was powered by a Lycoming LO-360-E1AED, 180-horsepower engine on the right side. The left side engine was an O-360-E1AED, 180-horsepower engine. The airplane's most recent 100-hour inspection was conducted on August 3, 2010. At the time of the accident the airplane had 6,742 total hours in service. Both engines had been inspected 31 flight hours prior to the accident. The left engine had 1,631 total hours since overhaul and the right engine had 2,605 total hours since overhaul. According to an FAA inspector that responded to the accident location, the right wing was damaged and the right fuel tank had been breached. The left fuel tank remained attached, and according to a written statement provided by the salvage company 20 gallons of fuel was extracted from the left wing fuel tank. The airplane was examined at a salvage facility near Griffin, Georgia, on August 13, 2010, by representatives from the airframe manufacturer, engine manufacturer, and the FAA. According to information provided by the FAA, flight control continuity was confirmed to all control surfaces. The fuel selector valves were both in the "OFF" position. The engine gas temperature (EGT) gauge was placarded "INOP." The engines were examined and rotated by hand, the compression was verified on all cylinders, the two magnetos on both engines produced spark at all leads. The spark plugs were removed and normal in appearance. The right engine plugs were noted as lighter in color than the left engine plugs. Approximately 1 to 2 ounces of blue fluid consistent with 100 LL aviation fuel was observed in both carburetors. The engine driven and electrical fuel pumps were tested and operated normally. According to a signed written statement provided by the flight school's assistant Chief Flight Instructor, the rear seat passenger/observer was placed in the backseat of another flight school's PA-44 and was requested to sit in the exact position that she could recall. The passenger could not recall the exact location of her feet; however, did report that she had just awoken prior to the dual engine failure. A scenario was simulated having her place her legs in front of her between the two front seats. While wearing the exact shoes as she had worn on the accident flight, "…she pulled her foot out [and] she was able to turn both fuel selectors off without purposely trying to do so." According to the PA-44-180 Seminole Pilots Operating Handbook, Chapter 3, Emergency Procedures, "ENGINE SECURING PROCEDURE" and "AIR START (UNFEATHERING PROCEDURE)" the fuel selector was to be in the "ON" position. ## Aircraft - Registration: [N730FT](https://openairdocs.org/deregistered/N730FT-2011-05-16), registration cancelled 2011-05-16, S/N 447995190 (OpenAirDocs) - Reported make and model: PIPER PA-44-180 - Registry model: [Piper PA-44-180](https://openairdocs.org/model/piper-pa-44-180) (registry code 7104402) (OpenAirDocs) - Registry engine: [Lycoming LO-360-E1A6DA](https://openairdocs.org/engine/lycoming-lo-360-e1a6da) (registry code 42310, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 44-7995190 - Airframe hours: 6742 - Engines: LYCOMING LO-360-E1A6DA 180 horsepower reciprocating; LYCOMING LO-360-E1A6DA 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Orlando Flight Academy, doing business as Space Coast Aviation - Registered owner: Jules Aircraft Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, August 3, 2010 - Departed: SGJ, St. Augustine, FL - Destination: EZM, Eastman, GA - Airport: EZM, Heart of Georgia Regional Air, runway 02, 6,506 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 27; injuries: minor; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 26, 2010; seat: right; flight hours: 968 total, 35 in this make and model, 916 as pilot in command, 163 in the last 90 days, 67 in the last 30 days, 4 in the last 24 hours - Student pilot; age 23; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 24, 2010; seat: left; flight hours: 230 total, 9 in this make and model, 135 as pilot in command, 136 in the last 90 days, 54 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 73 °F - Altimeter: 29.98 inHg - Observed at: DBN, 22 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 20100810048299A](https://openairdocs.org/incident/20100810048299A), Aug 10, 2010: Piper PA-44-180, Eastman, GA, Substantial damage. N730FT, enroute from ksgj to kezm, during flight instruction, lost power to both engines on final approach to runway 2. N730FT crashed at approximately 0155… ## Other investigations on N730FT (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 NYC08CA190](https://openairdocs.org/ntsb/NYC08CA190), Mar 21, 2008: Piper PA-44-180 (N730FT), Inverness, FL, substantial damage. Probable cause: The student pilot's improper landing flare and the flight examiner's inadequate remedial action. ## Docket (10 files) The files NTSB released with the investigation on October 14, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76910. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335186&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilots Written Statement to the FAA (item 2, .PDF, 759 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335212&FileExtension=.PDF&FileName=Pilots%20Written%20Statement%20to%20the%20FAA-Redacted.PDF - Written Statement from Chief Flight Instructor (item 3, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349229&FileExtension=.PDF&FileName=Written%20Statement%20from%20Chief%20Flight%20Instructor-Redacted.PDF - Memorandum For Record Dublin Georgia Weather (item 4, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353232&FileExtension=.PDF&FileName=Memorandum%20For%20Record%20Dublin%20Georgia%20Weather-Master.PDF - Fuel Receipt (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335187&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Salvage Statement on Fuel (item 6, .PDF, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353243&FileExtension=.PDF&FileName=Salvage%20Statement%20on%20Fuel-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349230&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 997 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349231&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1: Airplane At Rest (Coourtesy of the FAA) (item 9, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353236&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20At%20Rest%20(Coourtesy%20of%20the%20FAA)-Master.PDF - Photo 2: Airplane Cockpit (Courtesy of the FAA) (item 10, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353237&FileExtension=.PDF&FileName=Photo%202%3A%20Airplane%20Cockpit%20(Courtesy%20of%20the%20FAA)-Master.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.