# NTSB ERA17CA186: Piper PA 28-181, N8304F, Bristow, VA, May 21, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 21, 2017, 19:55 local (23:55 UTC) - Place: Bristow, VA - Coordinates: 38.721389, -77.538055 - Nearby events: https://openairdocs.org/map.md?lat=38.7214&lon=-77.5381&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 15, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA / FSDO - NTSB case key (mKey): 95210 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17CA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95210/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95210 - Page: https://openairdocs.org/ntsb/ERA17CA186 ## Probable cause The flight instructor’s and pilot’s mismanagement of the available fuel, which resulted in exhaustion of the fuel in the selected fuel tank and a subsequent total loss of engine power. ## 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 management (probable cause); cases with it: [Piper PA-28-181, 20 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102807), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 10 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102807), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [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-28-181, 10 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102807), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [Piper PA-28-181, 21 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102807), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot; cases with it: [Piper PA-28-181, 21 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102807), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-181, 7 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102807), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: [Piper PA-28-181, 3 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=7102807), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Approach-VFR pattern downwind: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-28-181, 26 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102807), [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-28-181, 23 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102807), [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-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor was working with the private pilot on his flight review. Before the flight, the pilot checked the fuel and observed that the fuel level in both fuel tanks was below the tabs and that the right fuel tank had less fuel in it then the left fuel tank. After departing and maneuvering in the local area, the pilot and the flight instructor returned to the airport, landed, then taxied back for another takeoff. After completing two traffic pattern circuits, on the third takeoff, the engine stopped producing power at 800 ft mean sea level (msl) on the upwind leg of the traffic pattern. The pilot lowered the airplane's nose, and the engine started running again. The flight instructor then took over control of the airplane as they started on the right crosswind leg for the runway, and at 900 ft msl, the engine lost power again. After deciding that the airplane did not have sufficient altitude to reach the runway, the flight instructor advised the air traffic control tower that they were going to attempt a landing in a field near the airport. She then checked the mixture, throttle, and ignition, without results, but neither she nor the private pilot attempted to switch from the right fuel tank to the left fuel tank. During the off-airport landing, the airplane went through an electric fence and spun around about 180°. The nose landing gear sheared off, which resulted in substantial damage to the airframe. Examination of the engine revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. Examination and draining of the fuel system revealed that the fuel strainer bowl, the line from the fuel strainer to the carburetor, and the carburetor float bowl were absent of fuel. The right fuel tank also contained only about 1 pint of fuel, whereas the left fuel tank contained about 3 gallons of fuel. Review of flight school records revealed that the airplane had flown 4.7 hours since it was last refueled. When asked, the flight instructor advised that she had not observed the pilot as he performed his preflight inspection, did not know when the airplane had last been refueled, and did not remember asking the pilot about the fuel quantity before they departed. ## Factual narrative The flight instructor was working with the private pilot on his flight review. Prior to the flight, the pilot checked the fuel and observed that the fuel level in both fuel tanks was below the tabs, and that the right fuel tank had less fuel in it then the left fuel tank. After departing, maneuvering in the local area, the pilot and the flight instructor returned to the airport, landed, then taxied back for another takeoff. After completing two traffic pattern circuits, on the third takeoff the engine stopped producing power at 800 ft. msl, on the upwind leg of the traffic pattern. The private pilot lowered the airplane's nose and the engine started running again. The flight instructor then took over control of the airplane as they started on the right crosswind leg for the runway, and at 900 ft. msl, the engine lost power again. After deciding that the airplane did not have enough altitude, to make the runway, she advised the air traffic control tower that they were going to attempt a landing in a field near the airport. She then checked the mixture, throttle, and ignition, without result, but neither she nor the private pilot, attempted to switch from the right fuel tank to the left fuel tank.During the off-airport landing, the airplane went through an electric fence, spun around about 180 degrees. The nose landing gear sheared off, resulting in substantial damage to the airframe. Examination of the engine revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. Examination and draining of the fuel system, revealed that the fuel strainer bowl, the line from the fuel strainer to the carburetor, and the carburetor float bowl were absent of fuel. The right fuel tank also contained only about 1 pint of fuel, while the left fuel tank contained about 3 gallons of fuel. Review of flight school records revealed that the airplane had flown 4.7 hours since it was last refueled. When asked, the flight instructor advised that she had not observed the private pilot as he performed his preflight inspection, did not know when the airplane had last been refueled, and did not remember asking the private pilot about the fuel quantity before they departed. ## Aircraft - Registration: [N8304F](https://openairdocs.org/deregistered/N8304F-2020-02-03), registration cancelled 2020-02-03, S/N 28-8390012, built 1982 (OpenAirDocs) - Reported make and model: PIPER PA 28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8390012 - Year built: 1982 - Airframe hours: 6204 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Dulles Aviation Inc - Registered owner: Dulles Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 18, 2016, 90 hours before - Departed: HEF, Manassas, VA - Destination: HEF, Manassas, VA - Flight plan: VFR - Airport: HEF, Manassas Rgnl/Harry P Davis Fi, runway 16R, 3,715 × 100 ft, asphalt - Equipment: Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 53; injuries: none; airline transport, commercial; airplane ratings: single-engine sea, multi-engine land, single-engine land, multi-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review June 15, 2016; seat: right; restraint: 3-point; flight hours: 7,500 total, 200 in this make and model, 30 in the last 30 days - Pilot; age 56; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review July 13, 2014; seat: left; restraint: 3-point; flight hours: 225 total, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 54 °F - Altimeter: 30.20 inHg - Observed at: KHEF, 1 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 20170521005849A](https://openairdocs.org/incident/20170521005849A), May 21, 2017: Piper PA-28-181, Bristow, VA, Substantial damage. CFI was giving a flight review to a private pilot. After the third take-off from rwy 16R, the engine quit at about 800 feet MSL. The CFI took control of the… ## Docket (6 files) The files NTSB released with the investigation on October 30, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95210. 6.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457435&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457436&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Master.PDF - Flight Times Provided by Operator (item 3, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457437&FileExtension=.PDF&FileName=Flight%20Times%20Provided%20by%20Operator-Master.PDF - Excerpts from Piper PA-28-181 Information Manual - Fuel, Fueling, and Fuel System Information (item 4, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457440&FileExtension=.PDF&FileName=Excerpts%20from%20Piper%20PA-28-181%20Information%20Manual%20-%20Fuel,%20Fueling,%20and%20Fuel%20System%20Information-Master.PDF - Weather Reports and Records - KHEF METARs (item 5, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457443&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-%20KHEF%20METARs-Master.PDF - Photo Array (item 6, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457445&FileExtension=.PDF&FileName=Photo%20Array-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.