# NTSB SEA91LA155: Piper PA-28R, N816CB, Milford, UT, July 4, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: July 4, 1991, 16:30 local (22:30 UTC)
- Place: Milford, UT
- Coordinates: 38.380752, -112.929817 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.3808&lon=-112.9298&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious
- Status: Completed, report February 8, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 41470
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA91LA155
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41470/pdf
- Page: https://openairdocs.org/ntsb/SEA91LA155

## Probable cause

FUEL EXHAUSTION, AND THE PILOT'S MISJUDGMENT OF PROPER DESCENT RATE. FACTORS INCLUDE INADEQUATE PREFLIGHT PLANNING, POOR IN-FLIGHT DECISION, BECOMING LOST/DISORIENTED, AND A FENCE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power(total) - nonmechanical, cruise
  - preflight planning/preparation - inadequate, pilot in command (contributing factor)
  - became lost/disoriented - inadvertent, pilot in command (contributing factor)
  - in-flight planning/decision - poor, pilot in command (contributing factor)
  - fluid,fuel - exhaustion (cause)
- Forced landing, descent - emergency
- In flight collision with object, approach - vfr pattern - final approach
  - proper descent rate - misjudged, pilot in command (cause)
  - object - fence (contributing factor)
- In flight collision with terrain/water, landing - flare/touchdown

## Analysis

THE PA-28 CLIPPED A FENCE AND IMPACTED THE GROUND DURING AN ATTEMPTED EMERGENCY LANDING, AFTER RUNNING OUT OF FUEL APPROXIMATELY 130 NAUTICAL MILES SHORT OF DESTINATION. THE PILOT STATED THAT IN ADDITION TO CIRCUMNAVIGATING WEATHER EN ROUTE, HE EXPEREINCED STRONGER THAN EXPECTED HEADWINDS AND WAS LOST/DISORIENTED WHEN HE WAS BLOWN OFF COURSE AND WAS UNABLE TO PICK UP THE VOR BY WHICH HE EXPECTED TO NAVIGATE.

## Aircraft

- Registration: [N816CB](https://openairdocs.org/deregistered/N816CB-2013-05-10), registration cancelled 2013-05-10, S/N 28R-31021, built 1969 (OpenAirDocs)
- Reported make and model: PIPER PA-28R
- Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-31021
- Engines: LYCOMING IO-360-B1E 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Less Bartlett Aviation
- Registered owner: Charles E. Fagan
- Departed: EMT, EL MONTE, CA
- Destination: PVU, PROVO, UT

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 50; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; flight hours: 200 total, 10 in this make and model, 4 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 45° at 16 knots
- Lowest ceiling: none
- Temperature: -0 °F, dew point -0 °F

## 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 19910704025989A](https://openairdocs.org/incident/19910704025989A), Jul 4, 1991: Piper PA28R180, Milford, UT, Substantial damage. Ran out of fuel short destination. Blamed weaher deviations and head winds. Blown off course to low for VOR recepti

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.

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