LAX00LA067

NTSB accident investigation · Piper PA-28-181 · Palo Alto, CA · December 2, 1999

Accident · No injuriesLimited investigationFinal report
Date
December 2, 1999, 11:24 local (19:24 UTC)
Place
Palo Alto, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4319YPiper PA-28-181
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2001
Report
Approved by Office Director
FAA report
19991202044899A
Case key
48460

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 failure of the pilot to properly calculate fuel consumption rate, and his improper in-flight planning to continue the flight to the destination airport instead of landing at a closer alternate airport. A factor was the pilot's inadequate aircraft control during the descent, which necessitated a go-around.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalCruise - normal
Fluid,fuel - exhaustionCause
Fuel consumption calculations - improperPilot in commandCause
In-flight planning/decision - improperPilot in commandCause
In flight collision with terrain/waterGo-around (vfr)
Terrain condition - swampy
Aircraft control - inadequatePilot in commandFactor
Go-around - attemptedPilot in commandFactor

Analysis

Prior to departure to return to home base, the pilot filed an IFR flight plan, conducted a preflight, and had the fuel tanks topped off. He flew on the left fuel tank for approximately 1 hour and then switched to the right fuel tank. Upon reaching his destination he noted multiple cloud layers, and requested and received an IFR clearance to his destination airport. About an hour later he switched back to the left fuel tank. He noted a drop to zero in the left fuel gage about 45 minutes later, and switched to the right tank, where he noted that the fuel gage read 5 gallons. He switched back to the left tank and the engine stopped; he switched back to the right tank and the engine restarted. He declared minimum fuel and received information on nearby airports; one 7 miles in his direction of flight, and his destination airport was 11 miles in his direction of flight. He continued the flight to the destination airport in order to lose altitude. He was at 4,000 feet, and traffic pattern altitude is 800 feet. He requested a straight in to a runway 30 even though 12 was the active runway. On short final, he initiated a go-around due to high speed, and high altitude. During the turn back to the runway the engine lost power and landed in a marshy area. There was no fuel observed in the tanks during the recovery of the airplane. During the engine examination it was noted that were was no fuel staining observed on the wings or fuselage of the airplane, and there were no leaks in the fuel system. No discrepancies were noted with the run-up.

Factual narrative

On December 2, 1999, at 1124 hours Pacific standard time, a Piper PA-28-181, N4319Y, sustained substantial damage when it lost engine power during a landing go-around at the Palo Alto, California, airport. The airplane subsequently impacted a marshy area off the departure end of runway 30. The airplane was operated by West Valley Flying Club as a personal flight under the provisions of 14 CFR Part 91. The private pilot and a passenger were not injured. Visual meteorological conditions existed at the time, and an instrument flight rules (IFR) flight plan had been filed. The flight originated at the Carlsbad-Palomar airport, Carlsbad, California, at 0736, and was scheduled to terminate at the Palo Alto airport.

At the time of the accident, Palo Alto airport was reporting winds from 150 degrees at 10 knots, and the active runway was runway 12.

The pilot reported that he rented the airplane from the flying club and was planning a trip to Carlsbad with an interim stop in Camarillo, California. Prior to departure from Palo Alto, he checked the fuel levels and noted that they were "slightly above the tabs in both wing tanks." After arrival at Camarillo, the airplane was refueled with approximately 30.5 gallons of fuel. The pilot stated that there were no problems with the airplane's performance, and the fuel burn was approximately 9.76 gallons per hour, which was what he had expected it to be.

At 1430, the airplane departed on an IFR clearance to Carlsbad, and, after landing, the pilot noted a fuel burn of 10.1 gallons per hour. The next morning, prior to departure for the return to Palo Alto, the airplane was refueled with approximately 16 gallons of fuel. The pilot performed a preflight, which included sumping the fuel tanks, with no abnormal substances found.

After receiving a clearance for departure, and climbing through 3,000 feet to 8,000 feet, the pilot requested an initial altitude of 6,000 feet to minimize the headwind that he encountered. This request was denied by ARTCC, and instead, the pilot was given 10,000 feet with an expectation of a lower altitude later. The pilot said he leaned the engine passing through 4,000 feet. He reported that he had drawn fuel off of the left tank for 1 hour 20 minutes before switching to the right tank. He noted a "normal indication" from the fuel gages of both tanks. The pilot stated that he leaned the engine per the manufacturer's 70-75 percent power tables located on the sun visor in the cockpit.

After crossing over the Gorman VOR, the pilot was cleared to descend to 8,000 feet, and he again asked the Los Angeles Air Route Traffic Control Center (ARTCC) controller for a lower altitude to minimize headwind effect; however, his request was denied. He contacted Hawthorne radio and obtained updated weather, and filed a pilot report concerning the winds aloft. He returned to the ARTCC frequency, cancelled his IFR flight plan, and requested visual flight rules (VFR) flight following.

Upon reaching San Jose, he noted multiple cloud layers. He stated that he requested and received an IFR clearance to Palo Alto. An hour later, he switched to the left tank and noted that the right fuel gage was indicating "normal." The left tank fuel gage fell "rapidly toward 0" about 45 minutes later, and he switched to the right tank where he noted that the fuel gage read approximately 5 gallons. The pilot stated that he switched to the left tank with the intent of running it for 10 minutes to ensure he had adequate fuel in the right tank for the approach. About 15 seconds later the engine stopped. He switched back to the right tank and the engine restarted. He declared minimum fuel to Bay Approach, and received information on nearby airports. The pilot stated that he continued to Palo Alto instead of landing at a closer airport (Moffett Field airport) because he had a lot of altitude to lose. He was at 4,000 feet and traffic pattern altitude is 800 feet.

The pilot noted that the right fuel gage indicator was continuing "to fall rapidly so requested straight in to 30 even though [Palo Alto] was using 12." He stated that when he broke through the clouds he switched to tower frequency. He was cleared to land; and attempted to descend rapidly to expedite landing but was unable to decrease airspeed adequately. The pilot initiated a go-around and was cleared to land on runway 12. He stated that he attempted a teardrop entry back to the runway over the San Francisco bay to avoid housing off of the right side. Halfway through the maneuver, the engine lost power. The pilot declared an emergency and was cleared to land on any runway. He made an unsuccessful attempt to restart the engine on both tanks, and landed in a marshy field off the departure end of the airport.

In a debriefing with the Chief Flight Instructor for the West Valley Flying Club, the pilot reported that approximately 40 miles from the airport he felt that he "had 10 gal in the right tank and 8 gal in the left tank." He then noted that the left tank showed empty and the right tank was showing 3 gallons. At 1113, he contacted Bay Approach and informed them that he had minimum fuel and wanted vectors to the final approach for runway 30 at Palo Alto. The pilot reported that on short final he realized he was "too fast and too high."

A witness to the accident, who was flying at the time of the accident, stated that he heard the pilot check in with Bay Approach. He heard the pilot state "I'm going to have to report minimum fuel." He heard the pilot being provided with vectors to Palo Alto, and then heard them tell the pilot that Palo Alto airport was 11 miles from his current position, and that the distance to Moffett Field was 7 miles. The witness stated that when the pilot was handed off to Palo Alto tower, he also switched to the tower. He heard the pilot state that he was on "empty."

Aircraft recovery personnel observed no fuel in the tanks during the recovery of the airplane.

Upon further inspection of the airplane, Steve's Aircraft, a Federal Aviation Administration certified repair station, noted that it had sustained substantial damage. No fuel staining was observed on the wings or fuselage of the airplane. It was also noted that there were no fuel leaks in the fuel system. The carburetor and propeller were inspected with no discrepancies noted. An engine run-up was conducted with no mechanical anomalies encountered.

The Safety Board was notified, and the incident was upgraded to an accident, on January 6, 2000.

Aircraft

Registration
N4319Y
Reported as
Piper PA-28-181
Category
Airplane
Serial number
28-8490010
Airframe hours
5,698
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
West Valley Flying Club
Registered owner
Engineering Mgt. Consultant,
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 26, 1999 · 1,518 hours before
Departed
CRQ · Carlsbad, CA
Destination
PAO
Flight plan
IFR
Airport
PAO · Palo Alto, runway 30, 2,500 × 65 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
46
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
920 total · 28 in this make and model · 920 as pilot in command · 44 in the last 90 days · 13 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 10 knots
Visibility
4 statute miles
Lowest ceiling
2,000 ft overcast
Temperature
55 °F, dew point 48 °F
Altimeter
30.00 inHg
Observed at
PAO, 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.

Other investigations on N4319Y · 1

Matched to the same aircraft by N-number and date.