ERA15CA120

NTSB accident investigation · Piper PA 18-150 · Brookneal, VA · February 4, 2015

Accident · Minor injuriesData collectionFinal report
Date
February 4, 2015, 16:46 local (21:46 UTC)
Place
Brookneal, VA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N619GBPiper PA 18-150
Defining event
Maneuvering-low-alt flying: Fuel exhaustion
Weather
Visual (VMC) · Day
Status
Completed · report August 12, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Federal Aviation Administration
FAA report
20150204000819A
Case key
90691

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor and pilot-rated student's inadequate preflight inspection, which resulted in a total loss of engine power due to fuel exhaustion.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotAll aircraft: 792 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Student/instructed pilotAll aircraft: 792 casesProbable cause
Fuel system: fuel quantity indicatorAircraft › Aircraft systems · Incorrect use/operationAll aircraft: 35 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Not inspectedAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

According to the flight instructor and the pilot-rated student, both believed the airplane had been fueled at the time it was pulled out of the hanger by line personnel, and they had observed a fuel truck parked near the airplane prior to the flight. The student had performed the preflight inspection, during which he interpreted the fuel sight gauges as indicating full fuel; however, he did not visually check the fuel in the tanks. When the instructor arrived at the airplane, he asked the student how much fuel was on board and the student said the tanks were full. The flight departed from Lynchburg, Virginia and made several takeoffs and landings at a nearby airport. About 1 hour into the flight as the airplane was 1,000 feet above ground level, the engine lost all power. As the instructor began a turn toward a nearby pasture, the engine started producing power again and the instructor chose to continue the turn, heading toward the nearest airport. The engine then lost all power again. No longer able to glide to the nearby pasture, the instructor flew the airplane straight ahead and let it settle into the trees. The airplane struck the trees and terrain and came to rest inverted. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the wings and fuselage. The inspector recovered about 1 pint of fuel from each fuel tank. Additionally, neither pilot reported any mechanical malfunctions or anomalies that would have precluded normal operation of the airframe or engine. After the accident, the flight school held safety briefings with its instructors, faculty, and students. These briefings included discussion of the circumstances of the accident, and the implementation of policy changes related to pre and post flight responsibilities of students and instructors, new fuel level measuring procedures, and dispatch records of fuel status. These changes were applied to all airplane types and operations at the school, and were subsequently written in the Flight Operations Manual.

Factual narrative

According to the flight instructor and the pilot-rated student, both believed the airplane had been fueled at the time it was pulled out of the hanger by line personnel, and they had observed a fuel truck parked near the airplane prior to the flight. The student had performed the preflight inspection, during which he interpreted the fuel sight gauges as indicating full fuel; however, he did not visually check the fuel in the tanks. When the instructor arrived at the airplane, he asked the student how much fuel was on board and the student said the tanks were full. The flight departed from Lynchburg, Virginia and made several take and landings at a nearby airport. About 1 hour into the flight as the airplane was 1,000 feet above ground level, the engine lost all power. As the instructor began a turn toward a nearby pasture, the engine started producing power again and the instructor chose to continue the turn, heading toward the nearest airport. The engine then lost all power again. No longer able to glide to the nearby pasture, the instructor flew the airplane straight ahead and let it settle into the trees. The airplane struck the trees and terrain and came to rest inverted. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the wings and fuselage. The inspector recovered about 1 pint of fuel from each fuel tank. Additionally, neither pilot reported any mechanical malfunctions or anomalies that would have precluded normal operation of the airframe or engine. After the accident, the flight school held safety briefings with its instructors, faculty, and students. These briefings included discussion of the circumstances of the accident, and the implementation of policy changes related to pre and post flight responsibilities of students and instructors, new fuel level measuring procedures, and dispatch records of fuel status. These changes were applied to all airplane types and operations at the school, and were subsequently written in the Flight Operations Manual.

Aircraft

Registration
N619GB
Reported as
Piper PA 18-150
Category
Airplane
Serial number
18-8425
Built
1966
Airframe hours
6,288.5
Engine
Lycoming O-320-A2B, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Liberty University School Of Aeronautics
Registered owner
Liberty University School Of Aeronautics
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 12, 2014 · 50 hours before
Departed
0V4 · Brookneal, VA
Destination
LYH · Lynchburg, VA
Airport
0V4 · Brookneal/Campbell County

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
52
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
August 1, 2014
Seat
Rear
Restraint
4-point
Flight hours
5,130 total · 100 in this make and model · 5,018 as pilot in command · 50 in the last 90 days · 14 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
22
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 30, 2014
Seat
Front
Flight hours
230 total · 12 in this make and model · 130 as pilot in command · 50 in the last 90 days · 10 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 21 °F
Altimeter
30.04 inHg
Observed at
LYH, 14 nm away

Docket · 7

The files NTSB released with the investigation on August 4, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.