ERA20LA270

NTSB accident investigation · Piper PA31 · Sumter, SC · August 1, 2020

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 1, 2020, 10:00 local (14:00 UTC)
Place
Sumter, SC
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
C-GXKSPiper PA31
Defining event
Maneuvering-low-alt flying: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Lycoming, Piper, FAA/FSDO
Case key
101719

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 fuel mismanagement during flight, which resulted in a total loss of engine power from both engines due to fuel starvation.

Findings · 2

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.

Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotAll aircraft: 1,391 cases
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementAll aircraft: 1,695 cases

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 pilot, he and the copilot were flying low-level mapping flights in the twin-engine airplane. Although the copilot was not multi-engine rated, he and the pilot regularly switched control of the airplane during the mapping flights. On the accident flight, the pilot was seated in the right seat; the copilot was seated in the left seat; and they were flying the airplane at an altitude of about 300 ft above ground level. According to the pilot, they flew for about 2 hours before he, who was the pilot flying at the time, switched fuel tanks from the inboard tanks to the outboard tanks. The pilot did not tell the copilot he had switched fuel tanks. About 1.5 hours later, while the copilot was the pilot flying, the left engine started to surge and lose power. The pilot began the steps of the emergency procedure for an engine failure in cruise flight starting with moving the fuel selectors to the inboard tanks. Power was not restored; the airplane immediately began losing altitude; and the pilot took over control of the airplane. The copilot stated that at the time the pilot took over control, he looked at the fuel tank quantity gauges, and they both displayed zero. The pilot reported that the airplane stalled just above the ground during the emergency landing in a field. The right wing struck first, and within a couple of seconds, the right outboard fuel tank exploded. The pilot and copilot egressed out the rear door. Examination of the wreckage revealed that neither engine exhibited evidence of power at impact. The left outboard fuel tank was found completely full of fuel, and the left inboard fuel tank was empty. Both right wing tanks were fire damaged, and the fuel quantity in the tanks at impact could not be determined. Further examination revealed that the fuel crossfeed valve was in the “crossfeed/open” position. No fuel was observed in the valve or attached fuel lines during disassembly. The left fuel selector valve was found in the “OFF” position, and no fuel was observed within the fuel line between the valve and gascolator. The right fuel selector valve was damaged by fire, and its position at impact could not be determined. No other anomalies were noted in the engines or airframe. According to the pilot, all fuel tanks were full before the flight. According to the pilot’s operating manual, the airplane likely consumed about 33.1 gallons of fuel per hour or a total of about 115 gallons of fuel during the 3.5-hour flight. Given that the inboard fuel cells held 56 gallons each (112 gallons total), that the left inboard tank was found empty, and that the copilot noticed that the fuel gauges were reading zero just before impact, it is likely that each engine was drawing fuel from its respective inboard tank throughout the flight until those tanks were empty. The left engine lost power first, and the right engine likely lost power just before impact. The postaccident positions of the crossfeed valve (on) and the left fuel selector(off) did not correspond to the pilot’s statements regarding his positioning of the fuel selector valves during the flight. The fuel panel was located between and behind the pilots’ seats and required the pilots to look down and back in order to see the panel when making changes to the panel; therefore, it is likely the pilot misconfigured the valves when he switched tanks 2 hours into the flight, when he switched tanks after the left engine lost power, or on both occasions. It is unlikely the copilot would have been able to see an incorrect switch selection on the fuel panel due to the location of the panel, and he would have been unlikely to look at the 2-hour point as the pilot did not verbalize that a change to the panel had been made.

Factual narrative

On August 1, 2020, about 1000 eastern daylight time, a Piper PA-31-325, Canadian registration C-GXKS, was substantially damaged when it was involved in an accident near Sumter, South Carolina. The pilot and copilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. According to the pilot, he and the copilot had been flying mapping flights for the United States Geological Survey. The pilot stated that they had scanners weighing about 800 lbs on board and that they would fly about 300 ft above ground level in a grid pattern while mapping. He further stated that he personally fueled the inboard and outboard fuel tanks the day before the accident flight. On the accident flight, the pilot was seated in the right seat, and the copilot was seated in the left seat. They departed Santee Cooper Regional Airport (MNI), Manning, South Carolina about 0630 and planned on returning to the same airport. After 2 hours of flight time, the pilot, who was the pilot flying, switched from the inboard fuel tanks to the outboard fuel tanks. The pilot stated he did not verbalize to the copilot that he had switched the tanks. The pilot further stated the pilot flying will commonly request the other pilot to assist with the tank switching procedure since the tank selectors are behind the pilots’ seats and are not visible without looking behind and downwards. About 1.5 hours later, while the copilot was flying, the left engine started “surging” and rapidly began to lose power. The pilot reported that he began the memory items for an engine failure in cruise flight starting with moving the fuel selectors to the inboard tanks. The airplane immediately began to lose altitude, and shortly after, they had descended below the tree level. The pilot took control of the airplane and turned to a field just ahead of them. The airplane stalled just above the ground, and the right wing contacted the ground first. The pilot stated both side windows shattered during impact; and within 2 seconds, the right outboard fuel tank exploded; and a postimpact fire ensued. Both pilots egressed through the rear door. The copilot stated he was training in the airplane and did not have a multiengine rating. He stated he did not have any official hours flying the airplane with an instructor but had flown the airplane for about 200 hours. His description of the accident flight was consistent with that provided by the pilot. He further stated that when he turned over control of the airplane to the pilot during the last few seconds of flight, he looked at the fuel tank quantity gauges, and they were both reading “zero.” Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the airplane impacted the ground with the right wing first and slid sideways through the field. Both engines were fractured off, and neither engine exhibited evidence of power at the time of impact. Thefuselage and right wing were consumed by fire. The left wing was still attached to the fuselage. The left outboard fuel tank was completely full of fuel, and the inboard tank was empty. Further examination of the airplane revealed that the crossfeed valve was found in the “crossfeed/open” position. No fuel was observed in the valve or attached fuel lines during disassembly. A functional field test was performed on the valve with low pressure air, with no anomalies were noted. The left fuel selector valve was found in the “OFF” position, and the control cables were secured. No fuel was observed within the fuel line between the valve and gascolator. The right fuel selector valve was thermally damaged and could not be examined or functionally tested. No other anomalies were noted in the engines or airframe that would have precluded normal operation before impact. The fuel system consisted of four flexible fuel cells, two in each wing. The outboard fuel cells held 40 gallons each, and the inboard fuel cells held 56 gallons each. The right and left fuel systems were independent of each other and were connected only when the crossfeed system was activated. The airplane also had nacelle tanks installed, one 27-gallon capacity tank in each engine nacelle. The fuel management controls were located in the fuel system control panel mounted between the front seats on the forward edge of the wing spar carry-through cover. Located on the fuel control panel were the fuel tank selectors, fire wall fuel shutoffs, and the crossfeed control. Two fuel gauges were mounted in the overhead switch panel. The right gauge indicated the fuel quantity in the right-wing fuel cells, and the left gauge indicated the fuel quantity in the left-wing fuel cells. The gauges were connected electrically to the fuel selector and indicated the fuel quantity of the cell selected. The PA-31-325 Pilot’s Operating Manual (POM) states the following: During normal operation of the fuel system, each engine is supplied with fuel from its respective fuel supply. Selection of the controls on the right side of the control panel provides fuel from the right inboard or outboard fuel cells to the right engine and left fuel control selection provides fuel from the left inboard or outboard fuel cells to the left engine. For emergencies, fuel from one system can supply the opposite engine through the use of the crossfeed system. The crossfeed valve is located at the inboard rib assembly of the left wing butt area and is intended for emergency use only, (See Airplane Flight Manual). The crossfeed is controlled by a knob in the center of the fuel control panel, and under all normal conditions should be in the off position. NOTE - The crossfeed system is not intended for normal operation. When the crossfeed valve is on, be certain the fuel selector valve on the tank not in use is off, and the procedures outlined in the Airplane Flight Manual are followed. The accident fight was about 3.5 hours induration. According to the POM, the estimated fuel burn at normal (245 brake horsepower) power was 33.1 gal/hr.

Aircraft

Registration
C-GXKS
Reported as
Piper PA31 (325)
Category
Airplane
Serial number
31-7512038
Built
1975
Airframe hours
12,038
Engines
Lycoming TIO-540f2BDL, 325 horsepower, reciprocatingLycoming TIO-540f2BDL, 325 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Aerial observation · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 23, 2020 · 22.2 hours before
Departed
MNI · Manning, SC
Destination
MNI · Manning, SC
Flight plan
Company VFR
Equipment
Stall warning system, Satellite tracking device, Electronic multifunction display, ADS-B

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
23
Injuries
Minor
Certificates
Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
June 20, 2020
Seat
Right
Restraint
3-point
Flight hours
1,625.4 total · 550 in this make and model · 1,181.5 as pilot in command · 138.8 in the last 90 days · 77.5 in the last 30 days · 5.9 in the last 24 hours
Role
Co-pilot
Injuries
Minor
Certificates
Private, Commercial
Airplane ratings
Single-engine sea, Single-engine land
Medical
Class 1
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 73 °F
Altimeter
29.97 inHg
Observed at
KSSC, 7 nm away

Docket · 9

The files NTSB released with the investigation on September 21, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.7 MB in all.