NYC08FA020

NTSB accident investigation · Piper PA-28-181 · Boynton Beach, FL · October 28, 2007

Accident · FatalField investigationFinal report
Date
October 27, 2007, 20:12 local (Oct 28, 2007, 00:12 UTC)
Place
Boynton Beach, FL
Injuries
2 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8155CPiper PA-28-181
Weather
Visual (VMC) · Night
Status
Completed · report May 6, 2010
Report
Approved by Office Director
Parties
Piper Aircraft, FAA FSDO, Lycoming Engines
FAA report
20071027824309A
Case key
66967

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A total loss of engine power due to fuel starvation as a result of the pilots' improper in-flight fuel management.

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
Fuel management - inadequatePilot in command(cfi)Cause
Fuel management - inadequateDual studentCause
Forced landingEmergency descent/landing
Emergency procedure - improperPilot in command(cfi)
Emergency procedure - improperDual student
Light condition - night
In flight collision with objectEmergency descent/landing
Object - tree(s)

Analysis

Shortly before the end of a planned 2-hour night instructional instrument flight, at an altitude of about 1,000 feet above the ground, the airplane’s engine lost power. The certificated flight instructor directed the certificated private pilot to perform a forced landing to a golf course, but while on final approach the airplane impacted trees and cartwheeled. Postaccident examination of the airplane revealed that the right fuel tank was intact but empty. The left fuel tank was breached but contained approximately 6 gallons of fuel, and an accident site soil analysis indicated a fuel spill of approximately 20 to 30 gallons. The electric fuel pump switch was found in the “on” position and the fuel selector valve was found with right fuel tank selected. Performance data indicated that the flight would have consumed approximately 25 gallons, or about half of the total fuel on board when the airplane took off. The surviving passenger reported that after the loss of engine power, both pilots were concentrating on finding a suitable landing spot, which was difficult due to the darkness, rather than troubleshooting the loss of engine power. The pilot operating handbook states that any time fuel starvation is suspected during flight, the fuel selector should immediately be positioned to the other tank and the electric fuel pump switched to the “on” position.

Factual narrative

History of flight

On October 27, 2007, about 2012 eastern daylight time, a Piper PA-28-181, N8155C, operated by Rohan Aviation, Incorporated, doing business as Kemper Aviation, was substantially damaged when it impacted trees and terrain in Boynton Beach, Florida following a loss of engine power. The certificated flight instructor (CFI) and the certificated private pilot receiving instrument instruction were fatally injured, and the passenger was seriously injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the instructional flight, which was operating under the provisions of 14 Code of Federal Regulations Part 91.

According to Federal Aviation Administration (FAA) air traffic control (ATC) information, radar contact with the accident airplane was initially established about 1813, shortly after the airplane departed its base at Palm Beach County Park Airport (LNA), Lantana, Florida. The pilots then conducted four practice instrument approaches at four different airports in Florida. These included Kendall-Tamiami Executive Airport (TMB), Miami, Opa-Locka Executive Airport (OPF), Miami, Ft. Lauderdale Executive Airport (FXE), Ft. Lauderdale, and Pompano Beach Airpark (PMP), Pompano Beach.

Communications between the PMP air traffic control tower (ATCT) and the airplane indicated that the pilots planned to conduct a low approach to runway 15 at PMP, followed by the missed approach and then the very high frequency omnidirectional radio range (VOR) approach to return to LNA. About 1956, the pilots initiated the missed approach. The ground track derived from ATC radar data initially depicted the airplane when it was approximately 4 1/2 miles northwest of PMP, and proceeding to the northwest. The airplane maintained this track at an altitude of 2,700 feet for approximately 4 miles, and then flew in a more northerly direction for another 4 miles. About 1957, PMP ATCT instructed the pilots to contact Palm Beach Approach once they were "established northeast bound." About 2001, the pilots contacted Palm Beach Approach, and were initially cleared "direct Lantana." The pilots responded that they wanted the "full VOR" approach, and about 2002 the Palm Beach Approach controller instructed the pilots to "proceed direct [to the] Palm Beach" VOR, and to "maintain VFR at two thousand five hundred for now."

About 2003, the airplane turned to the northeast, towards the VOR. About the same time, the pilots radioed that they needed to descend to 2,000 feet to remain in visual meteorological conditions, and were approved to do so by the controller. About 2006, the ground radar data indicated that the airplane departed 2,000 feet and began a descent of approximately 300 feet per minute (fpm). There were no communications from the airplane regarding this descent. About 2009, when the airplane was at an altitude of approximately 1,000 feet, the pilots reported to the controller that "we have engine problems, we need to land as soon as possible." The controller first responded with a query as to whether the pilots preferred to "come to Palm Beach or go to Lantana?" After 10 seconds and two unsuccessful attempts to communicate their preference, the pilots radioed that they were "unable to maintain altitude" and that they did "not know how long the engine is gonna hold for us." The controller advised the pilots that "Lantana airport is twelve o'clock and four miles you just want to land there?" There was no response, and eight seconds later the controller repeated the transmission. The pilots responded, but the transmissions were only partially intelligible. The final transmission from the airplane was received 1 minute and 35 seconds after the initial declaration of the engine problem, and appeared to indicate that the pilots intended to land on a road. Radar data indicated that during this period, the airplane flew to the northeast, then turned north, and then turned to the east, all while it was in a continuous descent. The final four radar data points depicted a flight path that nearly reversed course to the west in a sharp right turn, and descended from an altitude of 500 feet. The last radar data point indicated an airplane altitude of 100 feet, at a time of 2011.

Several persons on the ground either heard or saw an airplane in the area with engine problems. Most of these witnesses reported that unusual engine noises drew their attention to the airplane; almost uniformly, the witnesses described the engine as "sputtering." Two individuals who were located in a house approximately 300 feet from the impact point heard the impact, but when they stepped outside and visually scanned the area, they did not see the wreckage.

According to FAA communications transcripts, about 2010 the Palm Beach controller solicited the assistance of another airplane in the area to locate the accident airplane. About 2014, another airplane contacted the controller and offered search assistance, and about 2017 the pilot of that airplane reported receiving an emergency locator transmitter (ELT) signal. In the ensuing hour, several other airplanes assisted in the search, and were able to determine the general location of the ELT signal. About 2129, a Palm Beach County Sheriff's Office helicopter reported to the controller that it had located the wreckage.

Several months after the accident, the surviving passenger was interviewed about the accident flight. The passenger had approximately 23 total hours of flight experience, all in Cessna 152 airplanes, and he had been invited along on the flight as an observer by the pilot. He was seated in the rear seat, on the right side of the airplane, and could hear and communicate with the two pilots in the front via his headset. He could also hear the ATC communications. According to the passenger, the airplane was headed back to LNA when "the engine quit." He said that the pilots immediately notified ATC that they had an engine problem, and that both pilots were focused exclusively on looking for a place to land, but that it was difficult due to the darkness. He could not recall either pilot making any attempt to diagnose the reason for the engine failure, or taking any actions to restart the engine. The passenger recalled that at some point, the pilot pointed out a road on the left side of the airplane as a suitable landing area, but that the CFI countered the suggestion with a decision to have the pilot land on a golf course. The passenger said that the airplane hit trees and "cartwheeled" during the attempted landing on the golf course. When he was asked about it in the interview, the passenger could not recall any in-flight discussion by the pilots regarding fuel management, and was he not aware of the pilot switching fuel tanks during the flight.

Personnel information

The pilot in the left seat held a private pilot certificate with airplane single engine land (ASEL) rating. His most recent first-class medical was dated November 15, 2006. He began his flight training in December 2006. According to his logbook, the pilot had approximately 360 hours of flight experience, including 42 hours of night experience, and received 180 hours of flight instruction. The pilot had accrued approximately 17 hours of flight time in the 30 days prior to the accident. The accident flight was the pilot's first flight since October 22, 2007. The pilot's toxicology report noted that no screened compounds were detected.

The CFI in the right seat began instructing at the flight school in June 2007. His most recent second-class medical was dated April 24, 2007. He held an Airline Transport Pilot certificate with ASEL and airplane multiengine land (AMEL) ratings, a Flight Instructor certificate with ASEL, AMEL and instrument airplane ratings, and a Ground Instructor certificate with advanced and instrument ratings. He reported approximately 12,500 hours of total flight experience on his last medical ap

Aircraft

Registration
N8155C
Reported as
Piper PA-28-181
Category
Airplane
Serial number
28-8090236
Airframe hours
5,200
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Kemper Aviation
Registered owner
Day Trippin Airlines
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 3, 2007 · 95 hours before
Departed
LNA · West Palm Beach, FL
Destination
LNA · Boynton Beach, FL
Airport
LNA · Palm Beach County Park Airport

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
18
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Last flight review
June 20, 2007
Seat
Left
Toxicology
Performed
Flight hours
360 total · 17 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Age
46
Injuries
Fatal
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 30, 2007
Seat
Right
Toxicology
Performed
Flight hours
12,133 total · 10,463 as pilot in command

Weather

Conditions
Visual (VMC) · Night
Wind
70° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 70 °F
Altimeter
30.02 inHg
Observed at
KPBI, 10 nm away

Docket · 26

The files NTSB released with the investigation on December 4, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.