ERA16LA007

NTSB accident investigation · Piper PA28R · Savannah, GA · October 10, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
October 9, 2015, 20:56 local (Oct 10, 2015, 00:56 UTC)
Place
Savannah, GA
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9312NPiper PA28R
Defining event
Approach: Fuel exhaustion
Weather
Visual (VMC) · Night
Status
Completed · report June 29, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20151009020319A
Case key
92149

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

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Probable cause

The pilot's inadequate preflight fuel planning and in-flight fuel management, which resulted in fuel exhaustion and a total loss of engine power during approach. Contributing to the accident were the pilot’s failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle-of-attack, which resulted in an aerodynamic stall.

Findings · 6

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.

Planning/preparation: fuel planningPersonnel issues › Task performance · PilotPiper PA-28R-200: 2 casesAll aircraft: 719 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementPiper PA-28R-200: 3 casesAll aircraft: 1,695 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelPiper PA-28R-200: 3 casesAll aircraft: 1,695 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28R-200: 4 casesAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededPiper PA-28R-200: 2 casesAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28R-200: 29 casesAll aircraft: 9,295 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 flight service station records, the private pilot had planned a cross-country flight that was expected to be about 465 miles long and to take about 3 hours 15 minutes. The first two-thirds of the flight were uneventful, but the pilot diverted to an alternate airport because the passenger needed a rest stop. He did not purchase fuel at the diversion airport and resumed the flight. According to air traffic control records, while on final approach to the destination airport, an air traffic controller noted that the airplane was low after turning onto the final leg of the traffic pattern and advised the pilot to check his altitude; the pilot did not respond. The airplane then departed controlled flight and crashed. Neither the pilot nor the passenger could recall any events leading up to the accident. Examination of the wreckage found damage characteristics to the propeller and engine that were indicative of a loss of engine power; however, no preimpact mechanical malfunctions were found. Both fuel tanks were found compromised, but no evidence of fuel was found at the accident site. At the time of the power loss, the airplane had flown a total of about 3 hours 30 minutes. Airplane performance data revealed that the engine consumed about 10 gallons per hour, not including fuel used during taxi, takeoff, and climb. Given that the airplane did not have any fuel on board, it likely was not filled to its total capacity of 50 gallons at departure. Further, the unplanned landing increased the amount of fuel the airplane would have burned, and the pilot likely did not account for this while managing the fuel in flight. Given the evidence, it is likely that the loss of engine power resulted from fuel exhaustion. Further, once the engine lost power, the pilot did not maintain adequate airspeed and exceeded the airplane's critical angle-of-attack on approach to the airport, which resulted in an aerodynamic stall.

Factual narrative

At the time of the engine power loss, the airplane had flown about 3 hours, 30 minutes since it's initial departure from TMB, which included 2 takeoffs and climb to altitude. Review of performance data revealed that the engine consumed about 10 gallons per hour, not including fuel used during taxi, takeoff, and climb. Fueling records from October 3, 2015, the week before the accident, indicated the pilot had purchased 9.5 gallons of fuel at TMB, but no other confirmation from the pilot, passenger or any witnesses could confirm the airplane was fully fueled prior to the accident flight. According to Federal Aviation Administration (FAA) records and the airframe manufacturer, the four-seat, low wing, retractable tricycle gear airplane, serial number 28R-35012 was manufactured in 1969. It was powered by a Lycoming, IO-360-CIC 200-hp engine and equipped with a Hartzell HC-C2HK constant speed propeller. The fuel system consisted of two, 25-gallon wing tanks, each located in their respective wing for a total fuel load of 50 gallons, of which 48 gallons were usable. The fuel selector valve, located on left side panel of the floor, had three settings, left tank, right tank and off. The airplane's most recent annual inspection was completed on October 18, 2014. At that time, the engine had been operated for about 195 hours since major overhaul. The airplane had flown about 90 hours, from the time of the last annual inspection, until the accident. On October 9, 2015, about 2056 eastern daylight time, a Piper PA-28R-200, N9312N, departed controlled flight following a total loss of engine power and collided with trees while on final approach to runway 10 at Savannah, Hilton Head International Airport (SAV), Savannah, Georgia. The private pilot and passenger were seriously injured and the airplane was substantially damaged. The airplane operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night visual meteorological conditions prevailed and an instrument flight rules (IFR) flight plan was filed for the flight that departed Jacksonville Executive Airport at Craig (CRG), Jacksonville, Florida about 2001. Due to their injuries, the pilot and passenger could not recall the immediate events leading up to the accident, or the accident itself. According to flight service station records, the pilot telephoned the Miami Flight Service Station for a weather briefing at 1607, for the planned 3 hour, 15-minute flight from Miami Executive Airport (TMB), Miami, Florida, to SAV, with an estimated departure time of 1630. Flight Service reported visual flight rules conditions along the entire route of flight, with widely scattered convective activity south of Miami and near Okeechobee, but they would not interfere with the flight. Visibility was unrestricted and the winds aloft were from the northwest about 8 knots. The pilot filed an IFR flight plan for an altitude of 7,000 feet, airspeed of 125 knots, anendurance of 5 hours and an estimated enroute time of 3 hours and 15 minutes. According to air traffic control (ATC) radar data, the flight departed TMB at approximately 1700. About 2 hours after departure, at 9,000 feet mean sea level, the passenger requested a rest stop. The pilot diverted to CRG, which was approximately 125 miles south of the intended landing airport of SAV. They landed at 1930 and remained on the ground for approximately 30 minutes. The pilot then filed a new IFR flight plan from CRG to SAV and indicated an endurance of 3 hours with an enroute time of 1 hour. The pilot did not take on additional fuel at CRG and departed at 2000 EDT. After departure, the airplane made a left turn to the north and climbed to 6,900 feet. Air Traffic Control coverage tracked the airplane from TMB through CRG and SAV and showed that the entire route of flight was approximately 465 miles. Approximately 30 miles south of SAV, the pilot began his descent. He was cleared to land on runway 10. The airplane crossed over the route 95 interstate approximately 6 miles south southwest of SAV at 2,200 feet and was vectored for a right base leg to final entry into the airport traffic pattern. He turned right on to a final leg at approximately 800 feet. Shortly after turning on to a final leg, a SAV air traffic controller noticed the low altitude and advised the pilot to check his altitude. There was no response. The airplane departed controlled flight; it collided with trees and impacted the ground 2,800 feet from the approach end of runway 10. At the time of departure, flight service indicated that the entire route was VFR, with widely scattered convective activity, and unrestricted visibility for the filed route. Weather observations from TMB, were calm winds and 10 miles visibility with a temperature of 27 degrees C and a dew point of 23 degrees C. The altimeter setting was 29.97 inches Hg and winds aloft at 6,000 feet were from 310 degrees at 7 knots. Along the route of flight, conditions at Melbourne (MLB) were, winds aloft at 6,000 and 9,000 feet were from 340 degrees at 7 knots and from 290 degrees at 8 knots respectively. Conditions at Jacksonville (CRG), Florida were winds from 050 degrees at 3 knots, 10 miles visibility. Winds aloft over Jacksonville, Florida at 6,000 feet were light and variable. At SAV, winds were calm with 10 miles visibility and broken clouds at 18,000 feet. The temperature was 22 degrees C and dew point 19 degrees C. The altimeter setting was 30.03 inches Hg. According to the United States Naval Observatory, Sun and Moon Data, official sunset was at 1859 and end of civil twilight was 1924. The moonset occurred at 1718 and 10 percent of the moon disc would have been visible had the moon been above the horizon. The pilot, age 64, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His last flight review completed on June 16, 2015. He also held a third-class airman medicalcertificate issued May, 1, 2015. The pilot reported 1,550 hours of total flight time, with 454 of those hours in the same make and model as the accident airplane. According to an FAA inspector who travelled to the accident site, the airplane and all major components were accounted for at the scene. The wreckage debris was localized to the immediate vicinity of the airplane. It came through the tree canopy in a steep nose down attitude, breaking off tree limbs before striking the ground and coming to rest on an agricultural feed trough. The tail empennage was twisted and bent approximately 45 degrees to the left. On the leading edge of the right stabilator, there was a 16 inch semicircular, fore to aft accordion crush damage. The right wing separated from the fuselage at the wing root during the accident sequence. It exhibited span wise leading edge crushing and the right fuel tank was compromised. The left wing remained attached to the fuselage and was crushed up to the wing spar immediately outboard of the left fuel tank, which was also compromised. The outer 24 inches of wing were sheared off. Both main landing gear remained attached to their respective wings and were in the down position. Both propeller blades remained attached to the hub and were uniformly bent slightly aft about 10 degrees and one blade was fractured 8 inches from the tip. The fractured blade near the hub cut 9 inches through the fiberglass engine cowl in a straight line front to back and neither blade exhibited twisting or curling. The engine remained partially attached to the firewall. Many of the engine mounts were either broken or bent. The fuselage and cabin displayed damage consistent with a front end low speed impact, but the cockpit area was not compromised and retained much of its occupiable space. The engine showed little sign of damage. The throttle and propeller were fully forward and the mixture was 75 percent forward. The fuel selector switch was on left tank. The master switch, tail anti-collision lights and fuel boost pump were in the on position. The FAA inspector reported that the site was absent of any odor or evidence of fuel. There was no fuel staining on the fuselage, wings or ground. Examination of the recovered airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. Examination of the engine and system components revealed no evidence of preimpact mechanical malfunction that would preclude operation. During the examination of the engine, the No. 2 cylinder showed a compression of 20/60. The rest of the cylinders showed nominal compression. The lower compression on the No.2 cylinder would not preclude engine operations.

Aircraft

Registration
N9312N
Reported as
Piper PA28R (200)
Category
Airplane
Serial number
28R-35012
Built
1969
Airframe hours
5,785
Engine
Lycoming IO-360-C1C, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 18, 2014 · 90 hours before
Departed
CRG · Jacksonville, FL
Destination
SAV · Savannah, GA
Flight plan
IFR
Airport
SAV · Savannah/Hilton Head Intl, runway 10, 9,351 × 150 ft, asphalt
Equipment
Stall warning system, ADS-B, Handheld GPS, Auto-pilot, Electronic flight bag or handheld device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
June 13, 2015
Seat
Left
Restraint
Lap only
Flight hours
1,550 total · 454 in this make and model · 1,464 as pilot in command · 32 in the last 90 days · 6 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
0° at 0 knots
Visibility
10 statute miles
Lowest ceiling
18,000 ft broken
Temperature
72 °F, dew point 66 °F
Altimeter
30.03 inHg
Observed at
SAV, 1 nm away

Docket · 11

The files NTSB released with the investigation on March 8, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.6 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.