# NTSB ERA11LA393: Piper PA-28-161, N9202C, Ormond Beach, FL, July 10, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 10, 2011, 11:15 local (15:15 UTC) - Place: Ormond Beach, FL - Coordinates: 29.300277, -81.108055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.3003&lon=-81.1081&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report June 12, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA North Florida/Orlando FSDO - NTSB case key (mKey): 81057 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA393 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81057/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81057 - Page: https://openairdocs.org/ntsb/ERA11LA393 ## Probable cause The loss of engine power due to fuel starvation, which resulted from the flight instructor's inadequate in-flight fuel management. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-161, 12 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102803), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-161, 3 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7102803), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Piper PA-28-161, 11 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102803), [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. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-161, 22 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102803), [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-28-161, 19 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102803), [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-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During a 1.2-hour instructional flight, with the student pilot at the controls, the airplane lost engine power after takeoff. The airplane was climbing through 200 feet above ground level when the loss of power occurred, and the flight instructor maneuvered the airplane to a forced landing before it impacted trees beyond the departure end of the runway. Examination of the engine and airplane at the accident site did not reveal any preexisting mechanical anomalies that may have caused the loss of engine power. The flight instructor stated that each wing tank contained about 12 gallons of fuel before the flight. According to performance charts in the airplane's operating handbook, at best economy mixture settings, the engine would burn about 8.5 gallons per hour, which would result in about 1.4 hours of flight time for 12 gallons of fuel. The preflight ground checks of 0.2 hours and flight time of 1.2 hours would equate to about 12 gallons of fuel burn for the accident flight. Both the flight instructor and student pilot stated that the fuel selector was in the right tank position throughout the flight and was not switched to the left tank, even though the left tank had about 12 gallons of fuel. This resulted in fuel starvation to the engine when the right tank was depleted of fuel. ## Factual narrative On July 10, 2011, about 1115 eastern daylight time, a Piper PA-28-161, N9202C, registered to the Euro American School of Aviation Inc (EASA)., was substantially damaged during a forced landing after a loss of engine power shortly after takeoff from the Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida. The flight instructor and student pilot sustained serious injuries. The airplane was operated under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that originated at 1030 from OMN. The flight originated about 45 minutes prior to the accident from OMN, at which time the flight instructor and student pilot flew in the local area to practice flight maneuvers. The flight then returned to OMN to practice takeoffs and landings on runway 26. After the flight's second takeoff, the Ormond Beach Tower Control lost sight of the airplane. The airplane first collided with trees in a wooded area approximately 150 feet beyond the departure end of runway 26. The wreckage came to rest on the ground just south of the extended runway centerline with its nose perpendicular to the centerline. The airplane sustained substantial damage to the fuselage and wings. In a written statement, the flight instructor reported that the flight was his second of the day in N9202C. He stated that the student pilot was new to the flight school and this was his first flight in the USA. The student had about 26 hours of previous flight training in the United Kingdom. During the preflight, the instructor said that he verified the amount of fuel and talked about the differences between the airplanes the student had previously flown and the PA-28. The instructor reported that there was at least 12 gallons of 100LL fuel per tank equaling a total of 24 gallons. He stated that based on his experience with the aircraft, 24 gallons should have been sufficient for 3 hours of training flight at a fuel consumption of 8 gallons per hour. The instructor stated that since the flight was the student's first in the PA-28 and also his first in the USA, the startup process and taxi took longer than usual. He said that it took a minimum of 0.2 hours until they were ready to go through the power check checklist, which included switching fuel tanks. After takeoff, the airplane was flown to a local practice area to perform routine training maneuvers, then returned to the airport for touch and go practice landings and takeoffs. The instructor performed the first touch and go to show the student the procedures used at the flight school. On the second touch and go takeoff which was flown by the student, the engine lost power after climbing to about 200 feet AGL. The instructor took the flight controls and realized that the airplane was too low to reach a safe landing area. The instructor stated that about 40 minutes after the accident, a thunderstorm passed through thearea and contaminated the accident site. The NTSB did not travel to the accident site. On site examination of the airplane and engine was done by an FAA inspector, and his findings were relayed to the NTSB during a telephone interview. There was no indication or evidence that the propeller was being driven by power prior to impact. Both fuel tanks were found compromised and void of fuel. A visual inspection of the aircraft controls indicated that the primer knob was stowed and the throttle was in the full forward position. The fuel selector knob was found in the left tank position. The electric fuel pump was found in the “ON” position, and the fuel mixture knob was found in a normal range for flight. Inspection of the firewall mounted fuel filter screen revealed that it was clean and free of obstruction. About one table spoon of fuel was detected in the bottom of the fuel bowl. No fuel was found in the carburetor bowl and the throttle linkage to the carburetor showed no signs of damage. When the carburetor jet was activated, it operated normally. The main fuel line that extended from the fuel tanks to the mechanical fuel pump was void of fuel when it was disconnected from the pump at the fuel pump fitting. Activation of the mechanical fuel pump lever indicated that the diaphragm was intact and operational, with no signs of damage or binding. No fuel was detected in the fuel pump bowl. Removal of the valve covers, and rotation of the propeller forward and aft resulted in the intake and exhaust valves opened and closed respectively. The left magneto was removed from the engine and checked for a short to ground. The unit showed no evidence of damage or internal failures. The right magneto could not be removed for inspection. A review of EASA flight logs indicated that on the day of the accident, the airplane was flown on the first flight about 1.5 hours. The airplane crashed about 1.2 hours into the second flight. The log also indicated that the airplane was not refueled between flights. It was not possible to verify the aircraft fuel system quantity prior to the first flight on the day of the accident. However, a refueling slip for the airplane showed that the aircraft was last refueled on the day prior to the accident with about 26 gallons. According to the airplane's operating handbook, the total fuel capacity is 48 usable gallons (26 gallons per tank). Daily flight records for the airplane indicated that three different pilots flew the airplane for about 4.8 hours without evidence of refueling before it crashed. The instructor pilot stated that there was about 12 gallons of fuel in each wing tank prior to the accident flight. According to performance charts in the airplane's operating handbook, best economy mixture settings would burn about 8.5 gallons per gallons per hour (GPH) which translates to about 1.4 hours of flight time for 12 gallons. The preflight ground checks of 0.2 hours and flight time of 1.2 hours would equate to about 1.4 hoursof fuel burn for the accident flight. Both the instructor pilot and student pilot stated that the fuel selector was in the right tank position throughout the flight and was not switched to the left tank. ## Aircraft - Registration: [N9202C](https://openairdocs.org/deregistered/N9202C-2015-03-09), registration cancelled 2015-03-09, S/N 2841002, built 1988 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2841002 - Engines: LYCOMING O-320 SERIES 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Euro American School of Aviation Inc - Registered owner: Euro American School of Aviation Inc - Airworthiness certificate: Standard, Normal - Departed: OMN, Ormond Beach, FL - Destination: OMN, Ormond Beach, FL - Airport: OMN, Ormond Beach Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 32; injuries: serious; airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 6, 2011; seat: right; flight hours: 2,715 total, 1,909 in this make and model, 2,697 as pilot in command, 176 in the last 90 days, 29 in the last 30 days, 3 in the last 24 hours - Student pilot; age 17; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 26 total ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft broken - Temperature: 84 °F, dew point 77 °F - Altimeter: 30.06 inHg - Observed at: OMN ## 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 20110710013689A](https://openairdocs.org/incident/20110710013689A), Jul 10, 2011: Piper PA-28-161, Ormond Beach, FL, Destroyed. The aircraft was executing touch-and-go landings on runway 26 at the Ormond Beach airport (komd). On the second attempt just after takeoff, the engine stop… ## Docket (6 files) The files NTSB released with the investigation on April 23, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81057. 14.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389986&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Telephone Interview - FAA (item 2, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390508&FileExtension=.PDF&FileName=Record%20of%20Telephone%20Interview%20-%20FAA-Master.PDF - Flight Logs for N9202C (item 3, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390509&FileExtension=.PDF&FileName=Flight%20Logs%20for%20N9202C-Master.PDF - Refueling Documents for N9202C (item 4, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390510&FileExtension=.PDF&FileName=Refueling%20Documents%20for%20N9202C-Master.PDF - Excerps from Airplane Operating Manual and Performance Chart (item 5, .PDF, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390511&FileExtension=.PDF&FileName=Excerps%20from%20Airplane%20Operating%20Manual%20and%20Performance%20Chart-Master.PDF - Photo of Accident Site (item 6, .PDF, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40390513&FileExtension=.PDF&FileName=Photo%20of%20Accident%20Site-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.