# NTSB ERA21LA087: Piper PA46, N662TC, Naples, FL, December 19, 2020 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: December 19, 2020, 12:16 local (17:16 UTC) - Place: Naples, FL · Gulf of Mexico - Coordinates: 26.130762, -81.817956 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.1308&lon=-81.8180&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA / FSDO, Piper Aircraft Corporation - NTSB case key (mKey): 102451 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA087 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102451/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102451 - Page: https://openairdocs.org/ntsb/ERA21LA087 ## Probable cause The inadvertent activation of the unguarded ferry tank fuel selector valve, 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. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Unintentional use/operation; cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7104605), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Design; cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=7104605), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-46-310P, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7104605), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Knowledge: knowledge of equipment](https://openairdocs.org/ntsb-findings/02032015): Personnel issues › Experience/knowledge · Pilot; cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-findings/02032015/cases.md?model=7104605), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02032015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=7104605), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-46-310P, 11 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7104605), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute: Emergency descent initiated](https://openairdocs.org/ntsb-events/130); cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-events/130/sequence.md?model=7104605), [All aircraft, 42 cases](https://openairdocs.org/ntsb-events/130/sequence.md) - [Approach: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=7104605), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis After takeoff from his home airport with about 50 gallons of fuel in each fuel tank, the pilot climbed to 7,000 ft and proceeded to his destination. When he was about halfway there, he switched from the right fuel tank to the left fuel tank. Immediately after switching fuel tanks, the engine started to sputter and lost power. The pilot switched back to the right fuel tank but there was no change. He then tried different power settings, adjusted the mixture to full rich and switched tanks again without regaining engine power. The pilot advised air traffic control (ATC) that he was having an engine problem and needed to land at the nearest airport. ATC instructed him contact the control tower at the nearest airport and cleared him to land. The pilot advised the controller that he was not going to be able to make it to the airport and that he was going to land in the water. During the water landing, the airplane came to a sudden stop. The pilot and his passenger then egressed, and the airplane sank. An annual inspection of the airplane had been completed about 2 months prior to the accident and test flights associated with the annual inspection had all been done with the fuel selector selected to the right fuel tank, and this was the first time he had selected the left fuel tank since before the annual inspection. The airplane was equipped with an engine monitor that was capable of recording engine parameters. Examination of the data revealed that around the time of the loss of engine power, exhaust gas temperature and cylinder head temperature experienced a rapid decrease on all cylinders along with a rapid decrease of turbine inlet temperature, which was indicative of the engine being starved of fuel. Examination of the wreckage did not reveal any evidence of any preimpact failures or malfunctions of the airplane or engine that would have precluded normal operation. During examination of the fuel system, the fuel selector was observed in the RIGHT fuel tank position and was confirmed to be in the right fuel tank position with low pressure air. However, when the fuel selector was positioned to the LEFT fuel tank position, continuity could not be established with low pressure air. Further examination revealed that a fuel selector valve labeled FERRY TANK was installed in the left fuel line between the factory-installed fuel selector and the left fuel tank. The ferry tank fuel selector was observed to be in the ON position, which blocked continuity from the left fuel tank to the engine. Continuity could only be established when the ferry tank fuel selector was positioned to the OFF position. With low pressure air, no continuity could be established from the ferry tank fuel line that attached to the ferry tank’s fuel selector. The ferry tank fuel selector valve was mounted between the pilot and copilot seats on the forward side of the main wing spar in the area where the pilot and copilot would normally enter and exit the cockpit. This location wassuch that the selector handle could easily be inadvertently kicked or moved by a person or object. A guard was not installed over the ferry tank fuel selector valve nor was the selector valve handle safety wired in the OFF position to deactivate the valve even though a ferry tank was not installed. Review of the airplane’s history revealed that about 3 years before the accident, the airplane had been used for an around-the-world flight by the pilot and that prior to the flight, a ferry tank had been installed. A review of maintenance records did not reveal any logbook entries or associated paperwork for the ferry tank installation and/or removal, except for a copy of the one-page fuel system schematic from the maintenance manual with a handwritten annotation (“Tank”), and hand drawn lines, both added to it in blue ink. A review of Federal Aviation Administration records did not reveal any record of a FAA Form 337 (Major Repair or Alteration) or a supplemental type certificate for installation of the ferry tank or the modification to the fuel system. ## Factual narrative On December 19, 2020, about 1216 eastern standard time, a Piper PA-46-310P; N662TC, was substantially damaged when it was involved in an accident near Naples, Florida. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated at Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida destined for Key West International Airport (EYW), Key West, Florida. The pilot reported he filed an instrument flight rules (IFR) flight plan for the flight to EYW and had the airplane towed to the fixed-base-operator’s ramp, where he conducted a preflight inspection, which included draining both tanks to check for water. No water was visible, and each fuel tank contained about 50 gallons of fuel. The fuel selector was on the right tank, and the engine started without any delay. The pilot then received his IFR clearance and took off at 1139. After takeoff, the pilot was cleared by air traffic control (ATC) to climb to 7,000 ft above mean sea level (msl) and the flight continued until it was near Southwest Florida International Airport (RSW), Fort Myers, Florida and then was cleared direct to EYW. Until this point, the engine was running smooth and was leaned to 50° lean of peak. About 1213, the pilot switched the fuel selector to the left fuel tank. Immediately after switching fuel tanks, the engine started to sputter and lost power. The pilot switched back to the right fuel tank but there was no change. He then tried different power settings, set the mixture to full rich and switched tanks again without regaining power. The pilot then advised ATC that he was having an engine problem and needed to land at the nearest airport. ATC instructed him to contact the control tower at Naples Municipal Airport (APF), Naples, Florida. APF tower then cleared him to land on runway 5 but the pilot realized that he was already well below 5,000 ft msl, so he advised the tower that he could not make it to the airport. The pilot informed the controller that he was heading for the beach and would land in the water. The pilot reported he focused on the airplane’s attitude and airspeed. The airplane touched down in the water, came to a sudden stop, and floated. Apart from the propeller, he could see no visible damage. He unlatched his seatbelt and opened the upper part of the airstair door and egressed. He then helped his passenger to egress, and they both started swimming towards the beach. The pilot saw a helicopter circling overhead, and after 10 to 15 minutes of swimming they were picked up by a boat. They were later transported to the hospital. The airplane eventually sank and came to rest in 6 ft of water and was later recovered. The pilot advised that an annual inspection of the airplane had been completed on October 15, 2020, and test flights were all done on the right fuel tank, and this was the first time he had selected the left fuel tank since before theannual inspection. The airplane was equipped with an Insight G4 Engine monitor. It was capable of monitoring engine parameters, including, but not limited to, cylinder head temperature (CHT), exhaust gas temperature (EGT), fuel flow information, and acceleration data. Data was stored on an SD memory card installed in the front panel of the device. Examination of the data revealed that about 1 hour of data was recorded for the accident flight. About 7 minutes before the end of the recorded data, exhaust gas temperature and cylinder head temperature indicated a rapid decrease in temperature on all cylinders along with a rapid decrease of turbine inlet temperature. This was indicative of the engine being starved of fuel. Examination of the wreckage, revealed that the propeller, wings, and aft fuselage, had been substantially damaged. Further examination did not reveal any evidence of any preimpact failures or malfunctions of the airplane or engine. During examination of the fuel system, the fuel selector was observed in the RIGHT fuel tank position and was confirmed to be in the right fuel tank position with low pressure air. During the fuel selector continuity check, about 3 ounces of a blue liquid consistent in color and odor of 100LL aviation type gasoline was recovered from the fuel line between the fuel selector and engine. The fuel return line to the right tank was clear of obstructions and the vapor return check valve was functional. The fuel return line to the left fuel tank was clear of obstruction and the vapor return check valve was functional. When the fuel selector was positioned to the LEFT fuel tank position, continuity could not be established with low pressure air. Further examination revealed that a fuel selector valve labeled FERRY TANK was installed in the left fuel line between the factory-installed fuel selector and the left fuel tank. The ferry tank fuel selector was observed to be in the ON position, which blocked continuity from the left fuel tank to the engine. Continuity could only be established when the ferry tank fuel selector was positioned to the OFF position. With low pressure air no continuity could be established from the ferry tank fuel line that attached to the ferry tank’s fuel selector. The ferry tank fuel selector valve was mounted between the pilot and copilot seats on the forward side of the main wing spar in the area where the pilot and copilot would normally enter and exit the cockpit. No guard was installed over the ferry tank fuel selector valve, nor was the selector valve handle safety wired in the OFF position to deactivate the valve even though a ferry tank was not installed. This configuration could not be found in the Piper Aircraft PA-46-310P/350P Maintenance Manual. And did not appear in the fuel system description or the fuel system schematic contained in Chapter 28 of the manual. Review of the airplane’s history revealed that in 2017, the airplane had been used for an around the world flight bythe pilot. In addition to other modifications, prior to the flight commencing, a Turtle-PAC ferry tank had been installed. A review of maintenance records provided by the pilot did not reveal any logbook entries or associated paperwork for the ferry tank installation and/or removal, except for a copy of the one-page Piper PA-46-310P fuel system schematic from the maintenance manual, with a handwritten annotation (“Tank”), and hand drawn lines, both added to it in blue ink. A review of Federal Aviation Administration (FAA) records also did not reveal any record of a FAA Form 337 (Major Repair or Alteration) or a supplemental type certificate for installation of the ferry tank or the modification to the fuel system. ## Aircraft - Registration: [N662TC](https://openairdocs.org/deregistered/N662TC-2022-10-03), registration cancelled 2022-10-03, S/N 468508095, built 1985 (OpenAirDocs) - Reported make and model: PIPER PA46 (310P) - Registry model: [Piper PA-46-310P](https://openairdocs.org/model/piper-pa-46-310p) (registry code 7104605) (OpenAirDocs) - Registry engine: [Continental TSIO-520-BE](https://openairdocs.org/engine/continental-tsio-520-be) (registry code 17277, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 468508095 - Year built: 1985 - Airframe hours: 3462 - Engines: CONT MOTOR TSIO-520-BE 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Plane Fun Inc Tr Trustee - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 15, 2020 - Departed: SRQ, Sarasota, FL - Destination: EYW, Key West, FL - Flight plan: IFR - Airport: APF, Naples Muni, runway 5, 6,600 × 150 ft, asphalt - Equipment: Angle of attack indicator, Auto-pilot, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Satellite tracking device, Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 8, 2019; seat: left; restraint: lap only; flight hours: 3,462 total, 890 in this make and model, 11 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 54 °F - Altimeter: 30.21 inHg - Observed at: KAPF, 3 nm away - METAR: KAPF 191653Z 07011KT 10SM CLR 22/12 A3021 RMK AO2 SLP228 T02170122 ## 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 20201219020429A](https://openairdocs.org/incident/20201219020429A), Dec 19, 2020: Piper PA-46-310P, Naples, FL, Substantial damage. During IFR flight from srq (sarasota) to eyw (key west) aircraft loss engine power at seven thousand feet altitude after switching from rt. Fuel tank to lt.… ## Docket (13 files) The files NTSB released with the investigation on January 27, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102451. 9.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14851022&FileExtension=pdf&FileName=6120_NTSB_report-c%20(1)_Redacted-Rel.pdf - Witness statements and interview summaries (item 2, PDF, 3 pages, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14852543&FileExtension=pdf&FileName=Witness%20Statements%20and%20Interview%20Summaries-Rel.pdf - Excerpts from PA-46-310P maintenance manual - fuel system description (item 3, PDF, 2 pages, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14853096&FileExtension=pdf&FileName=Excerpts%20from%20PA-46-310P%20Maintenance%20Manual%20-%20Fuel%20System%20Description-Rel.pdf - Fuel system from maintenance records (item 4, PDF, 1 page, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14853304&FileExtension=pdf&FileName=Fuel%20System%20from%20Maintenance%20Records-Rel.pdf - Flight progress strip and chronological summary of flight (item 5, PDF, 6 pages, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14852889&FileExtension=pdf&FileName=Flight%20Progress%20Strip%20and%20Chronological%20Summary%20of%20Flight-Rel.pdf - Map depicting accident location (item 6, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14853314&FileExtension=pdf&FileName=ACCIDENT%20LOCATION-Rel.pdf - Photo array (item 7, PDF, 12 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14862300&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Memorandum for record - wreckage examination (item 8, PDF, 3 pages, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14852731&FileExtension=pdf&FileName=Memorandum%20For%20Record%20-%20Wreckage%20Examination-Rel.pdf - Engine monitor specialist's factual report (item 9, PDF, 4 pages, 691 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13455910&FileExtension=pdf&FileName=ERA21LA087_G4_Final-Rel.pdf - Attachment 1 to engine monitor specialist's factual report (item 10, CSV, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13544256&FileExtension=csv&FileName=Attachment%201-Rel.csv - Statement of party representatives to NTSB investigation (item 11, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14853528&FileExtension=pdf&FileName=Signed%20Party%20Form%20(Piper)_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 2 pages, 729 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14853324&FileExtension=pdf&FileName=NTSB%20Wreckage%20Release%20-%20Signed_Redacted-Rel.pdf - Evidence control form (item 13, PDF, 1 page, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14852749&FileExtension=pdf&FileName=Evidence%20Control%20Form_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.