# NTSB ERA20FA026: Piper PA32R, N181AG, Paducah, KY, November 1, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 31, 2019, 19:26 local (Nov 1, 2019, 00:26 UTC) - Place: Paducah, KY - Coordinates: 37.103332, -88.817222 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.1033&lon=-88.8172&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Piper, Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 100516 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20FA026 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100516/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100516 - Page: https://openairdocs.org/ntsb/ERA20FA026 ## Probable cause The pilot’s failure to fully seat the fuel selector in the proper tank position during the descent for landing, which resulted in fuel starvation and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [New Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7104308), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [New Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7104308), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [New Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7104308), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [New Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=7104308), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [New Piper PA-32R-301T, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7104308), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The pilot was conducting a visual, straight-in approach for landing when he reported to the tower controller that the airplane had lost engine power. The airplane subsequently impacted trees and terrain short of the runway and was destroyed by impact and a post-impact fire. Examination of the wreckage confirmed flight control continuity and revealed no preimpact mechanical anomalies. Examination of the fuel selector revealed that the fuel selector control lever was near the right fuel tank position; however, examination of the fuel selector valve revealed that the selector plate was out of the detent and not fully seated in any tank position. Impact marks on the selector plate showed the detent ball was closest to the left fuel tank and the out-of-position plate occluded the fuel port. The first step of the manufacturer’s approach and landing checklist was, “Fuel Selector – Proper Tank.” Given the lack of other mechanical anomalies found during the examination, it is likely that the pilot moved the fuel selector at some point during the descent and approach, but failed to fully seat the selector in position, and the restricted fuel flow was likely less than what was needed to sustain engine power. Following the loss of engine power, the remaining altitude was insufficient to provide gliding distance to the runway. ## Factual narrative The first step of the Approach and Landing Checklist contained in the airplane’s operating handbook stated: Fuel Selector Proper Tank On October 31, 2019, at 1926 central daylight time, a Piper PA32R-301T, N181AG, was destroyed when it was involved in an accident near Paducah, Kentucky. The private pilot was fatally injured. The flight was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A representative from the fixed base operator at the departure airport stated that the accident airplane arrived on October 27, 2019, and he serviced the airplane with 31 gallons of fuel, which filled the tanks. He further commented on the smoothness of the engine as the airplane approached the fuel pumps. In an interview at the accident site, the local air traffic controller said that he was familiar with the pilot and the accident airplane. He said that the pilot established contact on the tower frequency and he provided the pilot with the current altimeter, wind, and active runway information. The pilot informed him that he was "lined up" for a straight-in landing to runway 14 and requested that runway, which the controller approved. Radar data depicted the airplane in a steady descent aligned with runway 14. The controller advised the airplane was "cleared to land" which the pilot acknowledged. About 1.5 minutes later, the pilot advised, "I've lost power." The controller asked the pilot if he thought the airplane would reach the runway, and the pilot responded, "Yes." At that time, the airplane was about 1,000 ft above ground level (agl) and 4 miles from the landing threshold of the runway. Soon after, the pilot advised, "I'm not going to make it, I'm in the trees." There were no further communications from the accident airplane. The airplane collided with trees and terrain, about 1.5 miles from the runway 14 threshold. The Western Kentucky Medical Examiner’s Office performed an autopsy on the pilot and determined the cause of death as blunt force trauma. The FAA Forensic Sciences Laboratory performed toxicological testing for the pilot. The results were negative for the presence of drugs and alcohol. The airplane wreckage was examined at the site, and all major components were accounted for at the scene. The wreckage path was oriented about a 140° heading and was about 100 ft in length. The initial tree strike was about 60 ft above the ground, where the outboard 8 ft of the left wing remained suspended. The main wreckage came to rest adjacent to a railbed on an approximate 090° heading. The baggage compartment, cockpit, cabin area, the inboard sections of each wing, and the empennage were consumed by post-crash fire. Flight control continuity was verified to all flight control surfaces except where controls were damaged consistent with impact and fire. The engine was rotated by hand at the propeller, and continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed on allcylinders using the "thumb" method. Borescope examination of each cylinder revealed signatures consistent with normal wear and lubrication. The magnetos sustained thermal damage. They were removed and rotated by hand, but neither produced spark. The fuel pump was removed, actuated with a drill, and drew and expelled air into the intake port and out of the output port. The fuel inlet screen and the fuel injector nozzles were clear and absent of debris. The turbocharger was removed, and both the compressor and exhaust impellers rotated freely and displayed no visible damage. The fuel lines were consumed by fire and the fuel selector valve exhibited thermal damage. The fuel selector control lever was observed near the right fuel tank position. However, examination of the fuel selector valve revealed the selector plate was out of the detent and not fully seated in the right fuel tank position. The fuel selector valve's bowl was thermally damaged, and its filters were consumed by fire. Figure 1 – View of Fuel Selector Plate as Found Further examination of the selector valve revealed that its lever was seized in position. Upon disassembly, the selector plate indicated an intermediate selector valve position. During disassembly, when the selector valve could be rotated and was placed in the left or right fuel tank position detent, it was noted that the associated ports were unobstructed. Figure 2 – View of Selector Plate Position Transfer Marks ## Aircraft - Registration: [N181AG](https://openairdocs.org/deregistered/N181AG-2022-08-24), registration cancelled 2022-08-24, S/N 3257416, built 2006 (OpenAirDocs) - Reported make and model: Piper PA32R (301T) - Registry model: [New Piper PA-32R-301T](https://openairdocs.org/model/new-piper-pa-32r-301t) (registry code 7104308) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AH1A](https://openairdocs.org/engine/lycoming-tio-540-ah1a) (registry code 42003, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3257416 - Year built: 2006 - Airframe hours: 1588.7 - Engines: Lycoming TIO-540-AH1A 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Cloud Hugger Transportation Llc - Registered owner: Cloud Hugger Transportation Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 19, 2019 - Departed: MHE, Mitchell, SD - Destination: PAH, Paducah, KY - Airport: PAH, Barkley Rgnl, runway 14, 5,499 × 150 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3; seat: left; toxicology performed; flight hours: 567.2 total, 447.2 in this make and model ## Weather - Conditions: Visual (VMC), Night - Wind: 250° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 27 °F - Altimeter: 30.27 inHg - Observed at: PAH, 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 20191031017419A](https://openairdocs.org/incident/20191031017419A), Oct 31, 2019: New Piper Aircraft Inc PA-32R-301T, Paducah, KY, Destroyed, 1 fatal. Aircraft was destroyed during a forced landing, resulting from complete loss of engine power. During landing, the aircraft impacted a tree, removing the outer… ## Docket (14 files) The files NTSB released with the investigation on November 17, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100516. 90.7 MB in all. - Air traffic control memorandum for record (item 1, PDF, 1 page, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11691563&FileExtension=pdf&FileName=Memorandum%20for%20Record%20John%20Oates%20-Rel.pdf - Approach track (item 2, PDF, 1 page, 532 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684639&FileExtension=pdf&FileName=Approach%20track-Rel.pdf - Air traffic control radar raw data (item 3, PDF, 42 pages, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11685019&FileExtension=pdf&FileName=N181AG%20Track%20Data-Rel.pdf - Air traffic control package (item 4, PDF, 64 pages, 31.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684450&FileExtension=pdf&FileName=ACCIDENT%20PACKAGE%20N181AG_Redacted-Rel.pdf - Line technician statement and fuel receipts (item 5, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684649&FileExtension=pdf&FileName=Line%20Technician%20Statement%20and%20Fuel%20Receipts_Redacted-Rel.pdf - Flight instructor statement (item 6, PDF, 2 pages, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684271&FileExtension=pdf&FileName=Flight%20Instructor%27s%20Statement_Redacted-Rel.pdf - Before-landing checklist (Piper) (item 7, PDF, 1 page, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684597&FileExtension=pdf&FileName=Checklist-Rel.pdf - Fuel selector exam (annotated photos provided by Piper) (item 8, PDF, 6 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684861&FileExtension=pdf&FileName=Fuel%20Selector%20Exam-Rel.pdf - Maintenance records (item 9, PDF, 2 pages, 27.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11685341&FileExtension=pdf&FileName=MX%20Records_Redacted-Rel.pdf - Toxicological report (item 10, PDF, 1 page, 350 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11684871&FileExtension=pdf&FileName=Pilot%20Tox_Redacted-Rel.pdf - Photo array (item 11, PDF, 7 pages, 22.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11686138&FileExtension=pdf&FileName=ERA20FA026%20Photo%20Array-Rel.pdf - Autopsy report memorandum (item 12, PDF, 1 page, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11685047&FileExtension=pdf&FileName=Autopsy%20Memo%20for%20Record-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 955 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11685838&FileExtension=pdf&FileName=N181AG%20-%20Wreckage%20Release_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 2 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12080301&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.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.