# NTSB ERA15CA120: Piper PA 18-150, N619GB, Brookneal, VA, February 4, 2015 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: February 4, 2015, 16:46 local (21:46 UTC) - Place: Brookneal, VA - Coordinates: 37.141666, -78.969444 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.1417&lon=-78.9694&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report August 12, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Federal Aviation Administration - NTSB case key (mKey): 90691 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15CA120 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90691/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90691 - Page: https://openairdocs.org/ntsb/ERA15CA120 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Fuel system: fuel quantity indicator](https://openairdocs.org/ntsb-findings/01022841): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01022841/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not inspected (probable cause); cases with it: [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. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Maneuvering-low-alt flying: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [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: [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: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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 (not matched to a registry record) - Reported make and model: PIPER PA 18-150 - Category: Airplane - Serial number: 18-8425 - Year built: 1966 - Airframe hours: 6288.5 - Engines: 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 As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 52; injuries: none; 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 - Pilot; age 22; injuries: minor; 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 ## 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 20150204000819A](https://openairdocs.org/incident/20150204000819A), Feb 4, 2015: Piper PA-18-150, Gladys, VA, Substantial damage. After taking off from brookneal airport (0V4), and while returning to lynchburg (lyh) at about 1,000 ft AGL, the engine started surging. Pilot selected a… ## Docket (7 files) The files NTSB released with the investigation on August 4, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90691. 7.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Flight Instructor (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430463&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Flight%20Instructor-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Pilot Rated Student (item 2, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430464&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Pilot%20Rated%20Student-Redacted.PDF - Memorandum of Record – Telephone Conversation with Federal Aviation Inspector (item 3, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430465&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20%E2%80%93%20Telephone%20Conversation%20with%20Federal%20Aviation%20Inspector-Master.PDF - Memorandum of Record – Actions Taken After Accident by Operator (item 4, .PDF, 502 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430466&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20%E2%80%93%20Actions%20Taken%20After%20Accident%20by%20Operator-Master.PDF - Liberty University Piper PA-18-150 checklist (item 5, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430467&FileExtension=.PDF&FileName=Liberty%20University%20Piper%20PA-18-150%20checklist-Master.PDF - Photo 1 - Resting Position of Airplane (Photo Courtesy of Virginia State Police) (item 6, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430468&FileExtension=.PDF&FileName=Photo%201%20-%20Resting%20Position%20of%20Airplane%20(Photo%20Courtesy%20of%20Virginia%20State%20Police)-Master.PDF - Photo 2 - Fuel Sight Gauge (Photo Courtesy of Operator) (item 7, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430469&FileExtension=.PDF&FileName=Photo%202%20-%20Fuel%20Sight%20Gauge%20(Photo%20Courtesy%20of%20Operator)-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.