# NTSB ERA12LA165: Piper PA-31-310, N30DC, Palm Beach, FL, January 28, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 28, 2012, 14:30 local (19:30 UTC) - Place: Palm Beach, FL - Coordinates: 26.770555, -80.035278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.7706&lon=-80.0353&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 24, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 82776 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82776/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82776 - Page: https://openairdocs.org/ntsb/ERA12LA165 ## Probable cause The pilot’s in-flight misjudgment of fuel remaining resulting in fuel exhaustion and a total loss of engine power. Contributing to the accident was an inadequate fuel quantity for the flight for reasons that could not be determined during postaccident investigation. ## 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 level (probable cause); cases with it: [Piper PA-31-310, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7103102), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-31-310, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7103102), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-31-310, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7103102), [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-31-310, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103102), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-31-310, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis On the morning of the accident, the pilot had the airplane topped off with 22 gallons of fuel, which he visually confirmed. The pilot flew the airplane to an offshore island that did not have fuel, deplaned passengers, and was returning to the mainland. The pilot planned for 4.6 hours of round trip operation and had previously flown similar flights to the same destination with durations of 4.6 to 5.1 hours. The outbound leg was completed without any anomalies noted; the pilot reported that the preflight inspection, start, taxi, runup and takeoff checks for the returning accident flight were "normal." Throughout the climb after takeoff, the pilot noted less manifold pressure on the left engine, and, by the time the airplane reached a cruising altitude of 10,500 feet, the engine was unable to maintain more than 55 percent power at 2,200 rpm and 26 inches of manifold pressure. The pilot matched the right engine power setting to the left and switched from the main fuel tanks to the outboard tanks at the top of the climb. He consulted the pilot operating handbook, which indicated a 4 gallon-per-hour reduction in fuel consumption at that power setting. En route, the left outboard tank emptied about 15 minutes before the right tank, which the pilot later reported was unusual because both engines normally burned evenly. About 60 nautical miles (nm) from the destination, the pilot initiated a descent, and about 55 nm from the destination, the left engine began surging. According to the pilot, the fuel gauges at the time indicated just below 1/4 full on the left main fuel tank and above 1/4 full on the right main fuel tank. The pilot turned on the emergency boost pump and selected fuel crossflow, which restored power to the left engine. The pilot then turned the airplane toward the nearest mainland airport, about 32 nm away, and contacted approach control. Shortly thereafter, the left engine surged, then lost power, followed closely by the right engine. The pilot turned on the emergency boost pumps, switched to the outboard and inboard fuel tanks sequentially (separately and with cross flow) but was unable to restore engine power. With the airplane descending through about 7,500 feet, the pilot completed the feathering procedure for both engines and established a best glide attitude, eventually landing the airplane on a beach. On-scene examination of the airplane did not reveal the presence of fuel, and no evidence of fuel leakage. The investigation did not reveal any mechanical malfunctions or failures that would have precluded normal operation, and the pilot did not note any preexisting anomalies with the fuel quantity indicators. Insufficient and contradictory information precluded a determination as to why the airplane ran out of fuel. The pilot had previously flown the same route with ample fuel remaining, but couldn't for this flight. The left engine would not produce normal power, so the pilot reduced right engine power, which should have resultedin more en route flight time, but didn't. Lower power settings should have resulted in a longer time to destination, yet based on provided flight times, it didn't. The left outboard fuel tank ran out of fuel sooner than normal, indicating that either the left engine was utilizing an excessive amount of fuel, or the fuel tank had not been filled completely or fuel was drained from it at the intermediate stop. Also, when the left engine stopped the first time, the fuel gauge, which had not been previously been noted as inaccurate, reportedly still indicated the presence of fuel at just under 1/4 tank. A direct line plot from the departure airport for the accident flight to the intended destination indicated the airplane overflew an island airport with fuel facilities about 105 nm from the destination and about 50 nm before the left engine began to surge. It is unknown if the pilot had sufficient information at that point to properly judge whether he should bypass an available en route fuel stop. However, with the information he did have, he judged that he had adequate fuel to complete his flight, which ultimately proved to be incorrect. ## Factual narrative Radar data was requested from the FAA for the accident flight. However, the only data provided was from about the time that the pilot contacted Palm Beach Approach Control. A commercial flight tracking web site, FlightAware, revealed outbound radar tracking from PBI to MYSM, with a takeoff time of 0957, and a landing time of 1206. However, there was no data available for the return flight. A direct line plot from MYSM to FPR indicated that the airplane would have passed over Grand Bahama International Airport (MYGF), Freeport, The Bahamas. At the time the pilot called Palm Beach Approach Control, the airplane was about 50 nm beyond MYGF, 55 nm from FPR, and 32 nm northeast of PBI. MYSM did not have fuel. According to multiple sources, MYGF had 100 LL fuel. In a written statement, the pilot stated that he took off from MYSM at 1240. On the NTSB Pilot/Operator Report, he stated that he took off at 1220. A request to Bahamian authorities for an official takeoff time was unsuccessful. The pilot also stated in the Pilot/Operator Report that the airplane took off from MYSM with 120 gallons of fuel onboard. The pilot provided a copy of his flight planning calculations. According to his flight planning, start, taxi and run-up fuel usage was 12.0 gallons, two climbs combined for 15.6 gallons, 65 percent power cruise PBI to MYSM was 52.8 gallons, and MYSM to FPR 66.7 gallons for a total time of 4.6 hours and 147.1 gallons used. The pilot also provided previous U.S. to/from The Bahamas fuel usage and noted that he had successfully flown the airplane round trip to MYSM on numerous previous occasions, with varying routes, with hours of operation ranging from 4.6 to 5.1 hours. According to the Piper Navajo Service Manual, "The fuel system is contained in two independent systems that allow each engine to have its own fuel supply. The systems are connected by a cross feed valve that allows fuel to be drawn from one set of fuel cells to the engine on the opposite side, in the event of an emergency. The fuel cells are of the bladder type. The inboard cells (main) and the outboard cells (auxiliary) are installed in cavities in the wings. Each inboard cell has a capacity of 56 U.S. gallons and each outboard has a capacity of 40 U.S. gallons. Fuel is taken from each cell through a screen located in the cell outlet fitting and then onto the shutoff selector valve. From the selector valve, fuel is drawn in a series configuration through the fuel filter, electric fuel pump, emergency shutoff valve and onto the engine-driven pump. These units, except for the engine driven pump, are accessible through a panel located between the underside of each wing and the fuselage. The fuel filter, and electric and engine pumps incorporate a bypass that will open in the event of fuel stoppage through the normal passage. Drains are provided for each fuel cell, filter bowl and the cross feed line. The cell drains are visible on the underside of each wing at the inboard end of thecells. The filter bowl drains are accessible through an access door on the panel that is located between the underside of each wing and the fuselage. The cross feed is located on the left panel, aft of the filter bowl access door. The fuel valves are operated through controls located in a panel just ahead of the main spar, between the pilot seats. Fuel gauges will indicate the quantity of fuel in each cell that fuel is being drawn from." On January 28, 2012, about 1430 eastern standard time, a Piper PA-31-310, N30DC, was substantially damaged during a forced landing to a beach in Palm Beach, Florida, following a loss of engine power in both engines. The airline transport pilot was not injured. The airplane was registered to and operated by Secure Aviation, Inc., under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and a visual flight rules fight plan was filed for the personal flight, which originated at San Salvador International Airport (MYSM), San Salvador, The Bahamas, around 1220. The intended destination was St. Lucie County International Airport (FPR), Fort Pierce, Florida. According to the pilot, the accident occurred on the inbound leg to the United States, with the airplane having flown an outbound leg the same day. Flight planning was completed on the day before the flights, with 2.0 hours planned outbound and 2.5 hours inbound. Planned fuel consumption was for 150 to 160 gallons used with 26 to 36 useable remaining. On the morning of the accident, the pilot flew the airplane first to Palm Beach International Airport (PBI), West Palm Beach, Florida, where one of the owners and two guests boarded the airplane. The pilot had the airplane topped off with fuel and visually confirmed a top-off of 22 gallons. Preflight inspection, start, taxi, run-up and takeoff checks were normal, and the airplane departed PBI about 1015. The pilot climbed the airplane to 9,500 feet and landed at MYSM 2 hours later. Ground speeds were 184 to190 knots. Fuel tanks were switched inboard to outboard at the top of the climb and back to inboard prior to landing. Cruise power setting was 65 percent, 2,400 RPM and 27 inches of manifold pressure. Descent was a coupled, 400 fpm constant power down to 1,000 feet. After unloading and clearing customs, the airplane took off for FPR about 1240. Pre-flight, start, taxi, run-up and pre-takeoff checks were "normal." The pilot noted a slight split in manifold pressure throughout the climb. By the time the airplane reached a cruising altitude of 10,500 feet, the left engine was unable to maintain more than 55 per cent power, 2,200 rpm and 26 inches of manifold pressure. The pilot matched the right engine power to that setting. Fuel tanks were switched at the top of the climb. The pilot consulted the Pilot Operating Handbook which indicated a 4 gallon-per-hour reduction in fuel consumption. Ground speeds were 152 to160 knots. Estimated time en route per the GPS was 2.6 hours of total time.The pilot utilized the outboard fuel tank fuel after reaching cruise altitude. The left outboard tank emptied about 15 minutes before the right tank, which was unusual as both engines burned evenly, and would [normally] lose power within 5 minutes of each other. About 60 nm from FPR, the pilot started a coupled, 400-feet-per-minute (fpm) rate of descent. About 40 nm south of FPR, the left engine began surging. Fuel gauges indicated just below 1/4 full on the left main fuel tank and above 1/4 full on the right main fuel tank. The pilot turned on the emergency boost pump, then selected fuel cross flow which restored power to the left engine. Using the "nearest airport" GPS function, he determined that PBI was the closest airport, 14 nm closer than FPR. The airplane was slightly north of PBI at that point, so the pilot slowed the descent rate, turned the airplane toward PBI, contacted Palm Beach Approach Control and continued the descent. PBI was landing runways 10R, 10L, and 14. The controller advised the pilot to cross the Palm Beach Inlet at 2,000 feet for runway 14. Shortly thereafter, the left engine surged, then lost power, followed closely by the right engine. The pilot turned on the emergency boost pumps, switched to the outboard fuel tanks and inboard tanks sequentially, both separately and with cross flow, but was unable to restore engine power. The pilot then completed the feathering procedure for both engines and established a best glide attitude. The airplane was about 7,500 feet at the time, with a descent rate of about 500 fpm. The pilot considered his landing options, which included requesting runways 28R or 28L. He elected to remain on the heading for the inlet as it was doubtful that the airplane would make it all the way to the airport. Once past the beach, the flight path direct to the airport was over a densely populated area. As the airplane got closer, the options became the beach north of the inlet, the beach south of the inlet, or the water just offshore. There was a long, wide, clear spot on the southern beach adjacent to the inlet with no people on it. The pilot advised the controller that a landing was assured on the beach south of the inlet. He established a high base turn over the inlet, completed the landing checks, selected full flaps and turned onto a final approach. Pumping the landing gear down was not an option, and the airplane touched down in a nose high attitude, decelerated rapidly, and spun counter-clockwise about 450 degrees. According to a responding FAA inspector, the right engine firewall was substantially damaged, there was no fuel observed onboard, and there was no evidence of fuel leakage. There were also no apparent preexisting mechanical anomalies noted with the airplane other than the left engine turbocharger, which revealed evidence of oil seepage between the turbine and compressor sections. FAA personnel were not present when the airplane was removed from the beach; however, the insuranceadjuster who was present also did not note any evidence of fuel leakage on the underside of the airplane once it was lifted. Photographs confirmed no fuel streaks underneath. A follow-on examination of the left engine turbocharger under FAA oversight did not reveal any defects with the unit. The pilot did not note any preexisting anomalies with the fuel quantity indicators. ## Aircraft - Registration: [N30DC](https://openairdocs.org/deregistered/N30DC-2012-04-27), registration cancelled 2012-04-27, S/N 31-7401267, built 1974 (OpenAirDocs) - Reported make and model: PIPER PA-31-310 - Registry model: [Piper PA-31-310](https://openairdocs.org/model/piper-pa-31-310) (registry code 7103102) (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: 31-7401267 - Airframe hours: 5045 - Engines: LYCOMING TI0-540 SER 310 horsepower reciprocating; LYCOMING TI0-540 SER 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Secure Aviation Inc - Registered owner: Secure Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2011 - Departed: MYSM, San Salvador, AOBF - Destination: FPR, Fort Pierce, FL - Flight plan: VFR - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: none; flight instructor, airline transport, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review August 31, 2011; seat: left; flight hours: 8,740 total, 2,100 in this make and model, 8,050 as pilot in command, 115 in the last 90 days, 47 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 4,300 ft broken - Temperature: 81 °F, dew point 61 °F - Altimeter: 30.06 inHg - Observed at: PBI, 5 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 20120128001589A](https://openairdocs.org/incident/20120128001589A), Jan 28, 2012: Piper PA-31-310, Palm Beach, FL, Destroyed. Pilot states route of flight was fpr-pbi-mysm-pbi. Aircraft was fueled several days prior to departure at fpr by owner, and pilot took on 22 gallons upon… ## Docket (15 files) The files NTSB released with the investigation on February 3, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82776. 11.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375259&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375265&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Straight-Line Estimated Track with Divert Radar Track (item 3, .PDF, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398917&FileExtension=.PDF&FileName=Straight-Line%20Estimated%20Track%20with%20Divert%20Radar%20Track-Master.PDF - Closer Straight-Line Estimated Track with Divert Radar Track and Nearby Airports (item 4, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398918&FileExtension=.PDF&FileName=Closer%20Straight-Line%20Estimated%20Track%20with%20Divert%20Radar%20Track%20and%20Nearby%20Airports-Master.PDF - Final Radar Track to Forced Landing (item 5, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398919&FileExtension=.PDF&FileName=Final%20Radar%20Track%20to%20Forced%20Landing-Master.PDF - Pilot-Provided Fuel Usage/Flight Time History (item 6, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389262&FileExtension=.PDF&FileName=Pilot-Provided%20Fuel%20Usage%2FFlight%20Time%20History-Master.PDF - Excerpts, FAA Air Traffic Control Accident Package (item 7, .PDF, 533 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373806&FileExtension=.PDF&FileName=Excerpts,%20FAA%20Air%20Traffic%20Control%20Accident%20Package-Redacted.PDF - Most Recent Maintenance Inspections (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375260&FileExtension=.PDF&FileName=Most%20Recent%20Maintenance%20Inspections-Redacted.PDF - PBI Weather Observations (item 9, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375261&FileExtension=.PDF&FileName=PBI%20Weather%20Observations-Master.PDF - Turbocharger Examination Report (item 10, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375262&FileExtension=.PDF&FileName=Turbocharger%20Examination%20Report-Redacted.PDF - Memorandum of Record: FAA Statement (item 11, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375263&FileExtension=.PDF&FileName=Memorandum%20of%20Record%3A%20FAA%20Statement-Master.PDF - Memorandum of Record: Fuel Observations (item 12, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407180&FileExtension=.PDF&FileName=Memorandum%20of%20Record%3A%20Fuel%20Observations-Master.PDF - Photo 1: Front View of Airplane (Courtesy of FAA) (item 13, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384206&FileExtension=.PDF&FileName=Photo%201%3A%20Front%20View%20of%20Airplane%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2: Front view of left engine (Courtesy of FAA) (item 14, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384207&FileExtension=.PDF&FileName=Photo%202%3A%20Front%20view%20of%20left%20engine%20(Courtesy%20of%20FAA)-Master.PDF - Photo 3: Front view of right engine (Courtesy of FAA) (item 15, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384209&FileExtension=.PDF&FileName=Photo%203%3A%20Front%20view%20of%20right%20engine%20(Courtesy%20of%20FAA)-Master.PDF From the NTSB's public API. 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