# NTSB ERA22LA144: Piper PA-28-150, N5208W, Savannah, GA, February 26, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: February 26, 2022, 10:43 local (15:43 UTC) - Place: Savannah, GA · Water/Swamp - Coordinates: 32.12758, -81.20213 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1276&lon=-81.2021&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/Atlanta - NTSB case key (mKey): 104724 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA144 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104724/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104724 - Page: https://openairdocs.org/ntsb/ERA22LA144 ## Probable cause The student pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation. ## 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-28-150, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=7102804), [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 · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-150, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102804), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-28-150, 1 case](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102804), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-150, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102804), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The student pilot was conducting a solo flight and was on the base leg of the traffic pattern at the conclusion of the flight when the engine lost total power. The pilot determined that he could not reach the runway and chose a river for the forced landing, during which the airplane sustained substantial damage. Examination of fueling and dispatch records revealed that at the time of the accident, the airplane had logged 4.1 hours of flight since it was most recently fueled to capacity, which would have provided about 5.3 hours of endurance in a nominal cruise flight configuration of 75% power with a fuel consumption rate of about 9 gallons per hour (gph). Interviews with the student pilot and his flight instructor, as well as a review of surveillance video of the preflight inspection, revealed that the student pilot did not visually inspect the fuel quantity. Although the instructor performed a visual inspection, the fuel quantity measuring device for the airplane “was broken” and was not used. Recovery and examination of the airplane revealed that the fuel tanks were intact. The right fuel tank contained about 1 gallon of fuel, and the left fuel tank contained about 2 to 3 gallons of fuel. There was no evidence of fuel spillage in the water at the accident site. The fuel selector was found in the right tank position. There was no evidence found of mechanical deficiencies with the airplane that would have precluded normal operation. Examination of data downloaded from the airplane’s engine data monitor revealed fuel flow rates at or above 10 gph for about 21 minutes of the 1.1-hour flight. Given the position of the fuel selector, the small amount of fuel found in the right tank, and the lack of mechanical anomalies, it is likely that the loss of engine power was the result of fuel starvation when the fuel supply in the right tank was exhausted. ## Factual narrative On February 26, 2022, at 1043 eastern standard time, a Piper PA-28-150, N5208W, was substantially damaged when it was involved in an accident in Savannah, Georgia. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 solo instructional flight. According to the student pilot, he was on short final for landing on runway 01 at his home airport at the conclusion of a solo flight when the tower controller instructed him to discontinue his approach, turn right, and enter the left downwind leg of the traffic pattern for runway 28. Once established on the downwind leg, the pilot completed a right 360° turn as directed by the controller before he continued the downwind leg and turned left onto the base leg of the airport traffic pattern. When approaching the turn onto the final approach leg of the traffic pattern, the engine lost power. According to the pilot, the engine “sputtered,” and the engine rpm “dropped, then came back up” before it reduced to 300 rpm. Engine rpm was never restored, and the pilot chose to perform a forced landing in the Savannah River. According to Federal Aviation Administration (FAA) and maintenance records, the airplane was manufactured in 1961 and was equipped with two 25-gallon wing tanks of which 24 gallons in each tank were usable. The manufacturer’s Owner’s Handbook stated that the airplane’s fuel consumption rate at 75% power was 9 gallons per hour (gph). The consumption rate at cruise does not include fuel consumed during engine start, taxi, takeoff, and climb. The airplane was recovered from the Savannah River under the supervision of an FAA inspector. The airplane’s left wing was substantially damaged. Flight control continuity was established from the flight controls to all flight control surfaces. The fuel selector was found in the right tank position. Twenty gallons of liquid were drained from the airplane’s fuel tanks of which “maybe 3 or 4 gallons” were fuel and the rest water. According to the recovery specialist, “About 75% of that was from the left tank. There [were] about 5 gallons in the right tank, and maybe a gallon of that was fuel.” When asked if the fuel tanks were breached, he replied, “No, when the diver went down there were no ‘rainbows’ going to the surface or any evidence of fuel leaking. There were no ‘rainbows’ on the surface either.” The engine was examined at an aircraft recovery facility in Jacksonville, Florida. The spark plugs were removed; the engine was rotated by hand at the propeller; and water was pumped from the cylinders. During rotation, continuity was confirmed from the powertrain to the valvetrain and the accessory section. Compression was confirmed using the thumb method. The magnetos were removed and dried with compressed air. When actuated with a drill, they produced spark at all terminal leads. The carburetor was removed and disassembled and contained no water or fuel. The fuel inlet screen was intact and unobstructed.The engine driven fuel pump was removed, contained no water or fuel, and pumped fluid when actuated by hand. The electric fuel pump was removed, contained no fuel, and operated when powered by a battery. Review of company dispatch and fueling records revealed that, before the accident flight, the airplane had flown 4.1 hours since it was fueled to capacity. At the nominal cruise fuel consumption rate of 9 gph, the airplane would have consumed 27 gallons of fuel in 3.0 hours, and the amount of fuel remaining in the tanks would have been about 21 gallons. An interview with the pilot’s flight instructor revealed that the normal convention was to refuel airplanes before departure based on the planned mission. The instructor estimated that the airplane was adequately fueled for the planned solo flight and that the fuel quantity on board was about 34 gallons. Review of surveillance video revealed that the instructor visually inspected the fuel tanks while the student conducted his preflight inspection, but the student pilot did not. The instructor explained that the fuel quantity measuring device for the airplane was not used during the preflight inspection as “it was broken.” The student pilot stated that he “believes he departed on the “Left” tank position, switched to the “Right” tank position, and that the selector remained in that position throughout the remainder of the flight. Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that, on the accident flight, the airplane climbed to traffic pattern and/or cruise flight altitude four times. Examination of data downloaded from the airplane’s engine data monitor revealed fuel flow rates at or above 10 gph for about 21 minutes of the 1.1-hour flight. ## Aircraft - Registration: [N5208W](https://openairdocs.org/deregistered/N5208W-2023-10-19), registration cancelled 2023-10-19, S/N 28-244, built 1961 (OpenAirDocs) - Reported make and model: PIPER PA-28-150 - Registry model: [Piper PA-28-150](https://openairdocs.org/model/piper-pa-28-150) (registry code 7102804) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-244 - Year built: 1961 - Airframe hours: 4030 - Engines: Lycoming O-320-A2B 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: FlyCorps Aviation - Registered owner: Pointblank Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, January 18, 2022, 47 hours before - Departed: TBR, Statesboro, GA - Destination: Same as departure - Equipment: Stall warning system, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 20; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; restraint: 4-point; flight hours: 24 total, 24 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 39 °F - Altimeter: 30.33 inHg - Observed at: SAV - METAR: KSAV 261553Z 32003KT 10SM FEW038 SCT250 19/04 A3033 RMK AO2 SLP270 T01940039 ## 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 20220226002619A](https://openairdocs.org/incident/20220226002619A), Feb 26, 2022: Piper PA-28-150, Savannah, GA, Substantial damage. On February 26, 2022, at approximately 10:50 local time, the student pilot of N5208W, a PA28 aircraft, was turning base to final for runway 28 at ksav when he… ## Other investigations on N5208W (1) 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. - [NTSB LAX72DVA64](https://openairdocs.org/ntsb/LAX72DVA64), Mar 24, 1972: Piper PA-28 (N5208W), Bakersfield, CA, substantial damage ## Docket (11 files) The files NTSB released with the investigation on November 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104724. 12.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903534&FileExtension=pdf&FileName=NTSB%20Form%206120_Redacted-Rel.pdf - Pilot's statement (item 2, PDF, 1 page, 507 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903689&FileExtension=pdf&FileName=Pilot%20Statement_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 3, PDF, 2 pages, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903470&FileExtension=pdf&FileName=ERA22LA144%20Joshua%20Ymbras-Rel.pdf - Memorandum for record flight instructor (item 4, PDF, 2 pages, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903341&FileExtension=pdf&FileName=ERA22LA144%20Rebecca%20Spencer-Rel.pdf - FAA inspector's statement memorandum for record (item 5, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903699&FileExtension=pdf&FileName=ERA22LA144%20Rodney%20Hood%20FAA%20Inspector-Rel.pdf - Aircraft dispatch record (item 6, PDF, 1 page, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903198&FileExtension=pdf&FileName=Dispatch%20Record-Rel.pdf - Last fuel receipt (item 7, PDF, 1 page, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903544&FileExtension=pdf&FileName=Last%20Fueling%20before%20Accident%20Flight_Redacted-Rel.pdf - Engine data monitor plots (item 8, PDF, 3 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14903109&FileExtension=pdf&FileName=ERA22LA144%20JPI%20EDM-700%20plots-Rel.pdf - Docket photo array (item 9, PDF, 3 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14902332&FileExtension=pdf&FileName=LA144%20Docket%20Photo%20Array-Rel.pdf - Engine data monitor - specialist's factual report (item 10, PDF, 8 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14919748&FileExtension=pdf&FileName=ERA22LA144%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report (item 11, CSV, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14919314&FileExtension=csv&FileName=ERA22LA144%20Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv 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.