# NTSB FTW01FA007: Piper PA-23-160, N3390P, Cotulla, TX, October 10, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 10, 2000, 15:22 local (20:22 UTC) - Place: Cotulla, TX - Coordinates: 28.430608, -99.230857 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.4306&lon=-99.2309&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report January 16, 2003 - Report: Approved by Office Director - Parties: Textron Lycoming, The New Piper Aircraft, Inc., FAA FSDO - NTSB case key (mKey): 50441 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW01FA007 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/50441/pdf - Page: https://openairdocs.org/ntsb/FTW01FA007 ## Probable cause The pilot's failure to refuel the airplane which resulted in fuel exhaustion and subsequent loss of engine power. Also contributing to the accident was the pilot's failure to feather the engine. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, cruise - 1 engine - fluid,fuel - exhaustion (contributing factor) - refueling - not performed, pilot in command (contributing factor) - propeller feathering - not performed, pilot in command (contributing factor) - Forced landing, descent - emergency - Loss of control - in flight, emergency descent/landing - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis During the day cross-country flight in instrument meteorological conditions (IMC), the pilot reported a loss of left engine power and then reported he was unable to maintain altitude. The controller provided the pilot with a vector to the nearest airport. The pilot descended the airplane, reported he was in visual meteorological conditions, and reported the airport in sight. There were no further transmissions from the pilot. The initial ground scar measurements at the accident site were consistent with the length of the right wing, the right engine cowling, and the nose of the airplane. The right wing leading edge and the nose were crushed aft, upward, and to the right. The pilot had logged a total of 24 hours in actual IMC, of which 3.9 hours (.8-hour in the make and model of the accident airplane) were during the 30 days prior to the accident. A maintenance entry stated in part: "disconnected aux fuel cells and capped and plugged lines, fastened fuel covers for aux tanks down and placarded "DO NOT FILL AUX TANKS" placarded fuel console "AUX FUEL NOT AVAILABLE." Examination of the airplane confirmed the aux tanks were unusable. The main fuel tank capacity was 72 gallons total. The integrity of the fuel system was not compromised, continuity was confirmed from the main fuel tanks to the respective engines, and no discrepancies were found that would have precluded operation of the system prior to the accident. An estimated 2 ounces of blue colored fuel was found in the left main fuel sump. Five and one-half quarts of blue colored fuel were drained from the right main fuel tank. By rotating the crankshaft manually, continuity was confirmed from the crankshaft flange to the rear accessory case gears, and thumb compression was obtained on all the cylinders on both engines. Both left propeller blades were found against the stop locks (non-feather position), and the blades exhibited no physical evidence of rotation. A test run was conducted for the left engine, and no discrepancies were found that would indicate the engine was incapable of producing power prior to the impact. ## Factual narrative HISTORY OF FLIGHT On October 10, 2000, approximately 1522 central daylight time, a Piper PA-23-160, twin-engine airplane, N3390P, impacted the terrain in an uncontrolled descent near Cotulla, Texas, following a loss of left engine power. The commercial pilot received serious injuries, and the passenger was fatally injured. The airplane sustained substantial damage. The airplane was owned by a private individual and leased to the Mesquite Flight Center, Inc., at Mesquite, Texas. Instrument meteorological conditions (IMC) prevailed for the 14 Code of Federal Regulations Part 91 business flight, and an instrument flight rules (IFR) flight plan was filed. The flight departed Hebbronville approximately 1416 with a planned destination of San Antonio, Texas. According to personnel at the Mesquite Flight Center, they were contacted by the director of flight operations for the National Institute for Community Banking, Inc., for rental of the aircraft, and the pilot was contacted independently of the Mesquite Flight Center. Personnel at Mesquite Flight Center reported the airplane departed Mesquite (HQZ) early on the day of the accident. Acquaintances of the passenger reported that the passenger boarded the airplane at Addison (ADS), Texas, for the business flight to Hebbronville (HBV), Texas. The passenger was the principal and managing director for the National Institute Community for Banking, Inc., and was to meet with banking personnel at Hebbronville. To their knowledge, the passenger had not taken previous flights with the pilot nor Mesquite Flight Center. The air traffic control data and transcripts were reviewed and all times converted to central daylight time unless otherwise noted. At 0704 on the morning of the accident, the pilot contacted Houston Air Route Traffic Control Center (HOU ARTCC), reported the airplane level at 4,000 feet msl, en route from ADS to HBV and requested flight following to the destination. The flight arrived at HBV at 0800. At 1252, the pilot called the San Angelo Automated Flight Service Station (SJT AFSS) and received a standard weather briefing for an IFR flight from HBV to Stinson Municipal Airport (SSF), San Antonio, Texas, and filed an IFR flight plan. At 1355, the pilot was issued the following clearance: N3390P, cleared from HBV to Cotulla (COT), leming one arrival to SSF, maintain 3,000 (feet msl), squawk (transponder code) 4710, void if not off by 1410, contact center (HOU ARTCC) 127.8 Megahertz (MHz) on departure. At 1416:39, radar contact with the airplane was verified by the HOU ARTCC controller, and the controller issued the altimeter setting of 30.38 inches of Mercury (Hg). At 1421:18, the airplane was cleared to 4,000 feet msl. Approximately 1424:57, the pilot reported that the airplane was level at 4,000 feet msl, that he was having trouble with the mode C altitude, and the controller requested that the pilot turn off the mode C on the transponder. At 1426:44, the controller cleared the airplane to 5,000 feet msl. At 1435:29, the flight was cleared direct COT direct SSF. At 1448:28, the controller's radar indicated that the airplane "was drifting all over the sky", and the controller instructed the pilot to turn the airplane left to a heading of 020 degrees for radar vectors to SSF. At 1456:02, the pilot was instructed to contact HOU ARTCC on 134.6 MHz. Approximately 1509:46, the pilot reported a loss of power on the left engine, declared an emergency, and was cleared to descend the airplane to 3,000 feet msl. At 1510:08, the pilot was instructed to turn the airplane left to a heading of 255 degrees for radar vectors to the Cotulla-LaSalle County Airport (COT). At 1513:09, the controller issued the pilot the 1450 COT surface weather observation: wind 320 degrees at 6 knots, visibility 7 statute miles, ceiling 1,000 broken, 2,500 overcast, temperature 9 degrees Celsius (C.), dew point 7 degrees C., and the altimeter 30.34 inches Hg. Approximately, 1514:10, the controller issued the heading of 260 degrees, and the pilot told the controller that the airplane would not maintain altitude, and requested a descent to VFR conditions. The minimum sector altitude to which the controller could descend the airplane was 2,400 feet msl. At 1515:02, the pilot declared an emergency, and was informed that the COT airport was at the 12 o'clock position at about 18 nautical miles. At 1517:53, the pilot reported that the engine started on its own. At 1518:31, the pilot reported that engine power was fluctuating coming on and off, on and off, and he requested a descent to visual meteorological conditions (VMC). Under the pilot's emergency discretion, he descended the airplane to 1,000 feet msl. Approximately 1521:48, the pilot transmitted that the airplane was in VMC and he had the airport in sight. There were no additional transmissions by the pilot. Approximately 1528:28, an emergency locator transmitter (ELT) was heard over the emergency frequency 121.5 MHz, the controller initiated search and rescue, and the airplane was located by Cotulla-La Salle County Airport personnel. A witness reported to the NTSB investigator-in-charge (IIC), that the airplane "sounded as if it had run out of fuel." Airport personnel and local authorities reported finding the master switch and both fuel pump switches in the "ON" position and no evidence of fuel at the site. PERSONNEL INFORMATION The pilot logbooks and the FAA records, reviewed by the NTSB IIC, showed that on April 29, 1996, the pilot was issued, on the basis of his India Pilot License, an FAA commercial pilot certificate with the airplane single-engine land rating, with the limitation in part: Not valid for the carriage of persons or property for compensation or hire. On July 15, 1998, the pilot added the instrument airplane rating (US Test Passed) to his FAA commercial pilot certificate. On January 21, 1999, the pilot satisfactorily completed his second re-examination for the commercial pilot certificate (US Test Passed) with the airplane-single-engine land and instrument ratings. On August 31, 2000, the pilot added the airplane multiengine land rating. On March 1, 2000, the pilot satisfactorily completed a re-examination of the entire flight portion for the flight instructor certificate with the airplane single-engine land rating. On April 24, 2000, the pilot added the instrument airplane rating to his flight instructor certificate. On May 1, 2000, the pilot satisfactorily completed his second re-examination for the addition of the airplane multiengine land rating to the flight instructor certificate. The pilot held a first class medical certificate issued on July 5, 2000. There were no limitations on the medical certificate. The pilot received a ground and flight check (0.8-hour) in the accident airplane on October 9, 2000, and during both portions of the check, the flight instructor explained the fuel system (72 gallons usable instead of 108 gallons, because the auxiliary tanks were placarded "DO NOT FILL"). According to the flight instructor, who checked out the pilot in the accident airplane, "the pilot was checked out per Mesquite Flight Center policy and found competent to operate N3390P at that time." The pilot's accumulated flight time was 1,140 hours of which 100 hours were in multiengine airplanes (46.2 hours in the make and model of the accident airplane). The pilot's accumulated instrument flight time was 99 hours with 24 hours in actual instrument meteorological conditions (IMC). During the 30 days prior to the accident, the pilot logged 9.7 hours in the make and model of the accident airplane, and in actual IMC 3.9 hours (.8-hour in the make and model of the accident airplane). AIRCRAFT INFORMATION FAA records for the Piper PA-23 aircraft, serial number 23-1353, indicated the airworthiness certificate was issued on April 9, 1958. There were no maintenance ## Aircraft - Registration: [N3390P](https://openairdocs.org/deregistered/N3390P-2001-04-03), registration cancelled 2001-04-03, S/N 23-1353 (OpenAirDocs) - Reported make and model: Piper PA-23-160 - Registry model: [Piper PA-23-160](https://openairdocs.org/model/piper-pa-23-160) (registry code 7102304) (OpenAirDocs) - Category: Airplane - Serial number: 23-1535 - Airframe hours: 4193 - Engines: Lycoming O-320B 160 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Mesquite Flight Center, Inc., - Registered owner: Tracy Arnold - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 20, 2000 - Departed: HBV, Hebbronville, TX - Destination: SSF, San Antonio, TX - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: serious; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review May 1, 2000; seat: left; flight hours: 1,140 total, 46 in this make and model, 954 as pilot in command, 260 in the last 90 days, 120 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 6 knots - Visibility: 7 statute miles - Lowest ceiling: 1,000 ft broken - Temperature: 48 °F, dew point 45 °F - Altimeter: 30.34 inHg - Observed at: COT, 17 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 20001010015649A](https://openairdocs.org/incident/20001010015649A), Oct 10, 2000: Piper PA23160, Cotulla, TX, Destroyed, 1 fatal. (-23) On October 10, 2000, at approx. 1525 CDT, a Piper PA-23-160 twin engine airplane, N3390P, was destroyed during landing following reported loss of engine… 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.